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Significance of serum SCC antigen as a tumor marker in patients with squamous cell carcinoma of the vulva
GYNECOLOGIC
ONCOLOGY
35, 227-232
(1989)
Significance of Serum SCC Antigen as a Tumor Marker in Patients with Squamous Cell Carcinoma of the Vulva’ R. VAN DER SIJDE, H. W. A. DE BRUIJN,’ M. KRANS, J. BOUMA, AND J. G. AALDERS Department
of Obstetrics
crnd Gynecology,
University
ReceivedAugust The significance of serum SCC antigen as a tumor marker was investigated in 94 women with squamous cell carcinoma of the vulva. The incidence of elevated serum SCC levels varied from 10% in FIG0 stage I to 40% in FIG0 stage IV. We did not observe a correlation between elevated pretreatment SCC values and the presence of lymph node metastases. During follow-up, elevated serum SCC values were observed in 8 of 19 patients (42%) with recurrent or progressive disease. It is concluded that the determination of serum SCC levels does not provide additional information in the staging of squamous cell vulvar carcinoma, but can be useful for the early detection of recurrent diseaseduring follow-up in some patients. However, elevated serum SCC levels were also found in 25% of patients without demonstrable tumor activity during follow-up and benign skin disorders were recognized as a cause of false-positive SCC results. co 1989 Academic PRESS, Inc.
INTRODUCTION Squamous cell carcinoma of the vulva is a fairly rare tumor that is diagnosed mainly in elderly women. The tumor incidence is 2: 100,000. Ninety-five percent of all malignant tumors of the vulva are squamous cell carcinomas. It has been suggested that the incidence of squa-
mous cell carcinoma is increasing and that the tumor is being diagnosed more often in younger women [I]. The primary route of dissemination is to the inguinal lymph nodes and secondarily to the pelvic lymph nodes. Hematogenic spread is observed mainly in the more advanced stages. Radical vulvectomy with bilateral inguinal and femoral lymphadenectomy en bloc is generally accepted as the treatment of choice. Until now the results of radiotherapy and chemotherapy have been disappointing. The prognosis
in early-stage
disease depends
largely
by the Praeventiefonds,Grant No. reprint requests should be addressed.
Groningen,
The Netherlwds
30. 1988
marker that is sufficiently sensitive and specific and that correlates with the tumor burden may be useful in determining the primary treatment method, in monitoring the clinical course of the disease, and in detecting tumor recurrence early. No such tumor marker for squamous cell carcinoma of the vulva has yet been reported. In 1977 Kato and Torigoe isolated an antigen, tumor antigen 4 (TA-4), from squamous cell carcinoma of the cervix [3]. The SCC antigen, a purified subfraction of TA-4, a protein with a molecular weight of 45,000, shows antigenic similarities to the other TA-4 subfractions. Measured by radioimmunoassay, the SCC antigen acts as an index of total TA-4 activity. Elevated serum SCC levels are found in patients with squamous cell carcinoma of the cervix, as well as in some patients with squamous cell carcinoma of other origin, such as the bronchus and nasopharynx, and sporadically in healthy volunteers and patients with tumors of other histologic origin [4]. Kato et al. recently showed that the degree of increase in SCC level correlates well with tumor dissemination status and course of disease in patients with squamous cell carcinoma of the cervix [5-71. We have been able to confirm this correlation between serum SCC level and tumor dissemination in patients with squamous cell carcinoma of the cervix [8]. The present study was conducted to investigate the value of SCC antigen as a tumor marker in patients with squamous cell carcinoma of the vulva. PATIENTS
AND METHODS
The University Clinic for Obstetrics and Gynecology in Groningen functions as the gynecological-oncological center for the northern provinces of The Netherlands. Between 1978 and 1985, 94 patients with squamous cell carcinoma of the vulva underwent primary treatment at our clinic. Pretreatment serum samples from these patients were stored at the serum bank. In 32 cases one or more serum samples were obtained during follow-up.
on
whether the lymph nodes are involved [2]. A tumor ’ Supported ’ To whom
Hospital,
28-1478. 227
0090-8258189 $1.50 Copyright0 1989by AcademicPress.Inc. All rights of reproduction
in any form reserved.
228
VAN
DER SIJDE ET AL.
These sera were also included in the analysis. All samples were stored at -60°C. Tumors were classified in accordance with the FIG0 staging system. The diagnosis was confirmed histopathologically in all cases. Standard treatment consisted of radical vulvectomy with bilateral inguinal and femoral lymphadenectomy en bloc in 69 of 94 patients. Seven patients were subjected to pelvic lymphadenectomy. Less radical procedures were carried out in 10 patients who had an increased risk for operation or as palliative treatment at an advanced stage. Two patients underwent an excenterative operation. Five patients with inoperable, local, bulky tumors were treated with radical radiotherapy, in two cases in combination with bleomycin chemotherapy. One patient received treatment only to relieve her symptoms. Radiotherapy was applied as adjuvant treatment in 26 patients with histopathologically confirmed positive lymph node metastases. All patients were followed up at our outpatient department every 3 months during the first year, every 4 months during the second year, every 6 months during the third year, and once a year thereafter. The duration of follow-up varied from 2 months to 8 years. Patients who were subjected to radical treatment and were free of disease during the entire follow-up period, with a minimum of 3 months after completion of primary treatment, were defined as having a complete remission. Recurrent disease was defined as tumor activity within the area of primary treatment 3 months or more after completion of radical treatment. Patients who were subjected to nonradical treatment or showed tumor activity within the area of treatment within 3 months of completion of primary treatment were regarded as having residual disease. Statistical analysis was performed using the x2 test. Serum SCC antigen analysis was carried out using a double-antibody SCC radioimmunoassay kit (Dainabot Co. Ltd., Tokyo) which was developed from a subfraction of a purified TA-4 preparation, isolated from liver metastases of a squamous cell carcinoma of the cervix. The sensitivity of the assay is 0.7 rig/ml. A control serum sample was prepared at our laboratory and analyzed during each run. The reproducibility was 26.5 + 2.0 rig/ml (mean + SD, n = 32); the coefficient of variation was 7.5%.
Sera collected from 85 healthy women with a normal Pap smear prior to laparoscopic sterilization were used as a control group. The distribution of serum SCC levels in these control samples is shown in Table 1. A serum level of 2.5 rig/ml, being the 95th percentile in these samples, was taken to be the upper limit of a normal serum SCC value. During follow-up, sera from those women who either had elevated serum SCC levels before treatment or dem-
TABLE 1 Serum XC in Control Samples (n = 85) Serum SCC (w/ml)
n
%
1.1-1.5
17 26
20 30.6
I .6-2.0 2.1-2.5 2.6-3.0 3.1-3.5 3.6-4.0
29 9 3 0 I
34.1 10.6 3.5 1.2
SI.0
onstrated tumor activity after primary treatment were analyzed. As a control, serum samples from four women who had normal pretreatment serum SCC levels and who did not show signs- of tumor activity during follow-up were used. All samples were thawed for the first time for analysis and the analyses were carried out in duplicate. RESULTS Elevated pretreatment serum SCC levels were measured in 24 of 94 (26%) patients with squamous cell carcinoma of the vulva, as compared with 4 of 85 (4.7%) control samples (x2 = 14.7, P < 0.001). The incidence of elevated pretreatment SCC levels in FIG0 stage I and II disease did not differ significantly from that in the control samples (see Table 2). Fifty-three percent of the patients with stage III vulvar cancer had elevated serum SCC values; in FIG0 stage IV, the incidence was 40%. Quantitative data on serum SCC values in patients with squamous cell carcinoma of the vulva are shown in Fig. 1. Pretreatment
Serum SCC and Lymph Node Metastases
Regional lymph nodes were surgically removed in 86 of 94 patients and histopathologically examined in all 86 TABLE 2 Incidence of Pretreatment Serum SCC Increase in Patients with Squamous Cell Carcinoma of the Vulva in Relation to the FIG0 Stage
Group
n
Control Stage I Stage II Stage III Stage IV
85 22 37 30 5
Number of see values >2.5 rig/ml
Serum SCC @g/ml) Median
P
0.7-17.4 0.7-24.1
I.5 I .85 1.6 2.65
ns. n.s.
0.7-6.9
2.5
‘co.002
Range
4 ( 5%)
0.7-
2 (10%)
0.7- 3.5
4 (11%) 16 (53%)
2 (40%)
3.7
SERUM
SCC
IN
VULVAR
progression. The remaining 16 patients were in complete remission. These groups are discussed separately.
SCC rig/ml 25
20
I
15-
Patients in Complete Remission
. .
I
.
IOc
controls
I
II
III
FIG. 1. Pretreatment serum SCC levels cell carcinoma of the vulva (n = 94).
Ip in patients
with
squamous
cases. An overall incidence of lymph node metastases was found in 35 of 86 cases (41%): 17% in stage I, 26% in stage II, 64% in stage III, and 100% in stage IV disease. Elevated serum SCC levels are found in 37% of the patients with positive lymph nodes as compared with 16% of the patients with negative lymph nodes (all stages) (x2 = 4.14, P < 0.05); however, stage by stage no significant differences could be calculated (Table 3). Neither could any predictive value be attributed to the SCC values within FIG0 stages I and II, with 20% false-negative and 40% false-positive results. Serum SCC and Course
TABLE 3 Incidence of Pretreatment Serum SCC Values in Relation to Lymph Node Metastases
FIG0
n
SCC
Positive
nodes
2!iF \ I?
NO EVIDENCE OF DISEASE
RECURRENT AND PROGRESSIVE DISEASE
z 20-
15-
> 2.5 rig/ml
n
SCC
lo-
5
2.5
nodes > 2.5 rig/ml
P
Stage
I
15
2 (13%)
3
Stage Stage Stage
II III IV
26 10 -
I ( 4%) 6 (60%) -
9 18 5
2 (22%) 9 (50%) 2 (40%)
n.s. n.s. n.s.
51
9 (18%)
35
13 (37%)
0.05
Total
Of the 16 patients without demonstrable tumor activity during follow-up, 8 had elevated serum SCC levels prior to treatment. The highest level measured was 24.1 rig/ml. The serum marker trends of these patients are shown in Fig. 2 (left). All 8 patients demonstrated a drop in serum SCC levels following primary treatment; however, during follow-up, serum SCC levels were still above the cutoff value of 2.5 rig/ml in 4 patients. In 2 of these 4 patients the serum SCC elevation was incidental. One patient demonstrated a stabilization of the serum SCC concentration at a level of 3.5 rig/ml for several months prior to her death from a stroke. The remaining patient with a stage III carcinoma of the vulva underwent radical vulvectomy with bilateral inguinal and femoral lymphadenectomy, followed by adjunctive radiotherapy because of positive lymph nodes. During follow-up severe lymphedema was diagnosed. In addition the patient dem-
of Disease
In 35 selected patients serum samples were obtained and analyzed for SCC antigen during follow-up. Nineteen patients experienced recurrent disease or local tumor
Negative
229
CANCER
-
1\ FIG. 2. (Left) Serum SCC course in 16 patients with squamous cell carcinoma of the vulva, without clinically demonstrable tumor activity during follow-up (mean follow-up 28 months). (Right) Serum SCC course in I9 patients with squamous cell carcinoma of the vulva and tumor activity during follow-up (mean follow-up 15 months). A = pretreatment serum SCC, B = last serum SCC during follow-up.
230
VAN
DER SIJDE ET AL.
onstrated recurrent erysipelas despite long-term treatment with Penidural. This patient is still alive, more than 3 years after primary treatment without evidence of vulvar cancer. The serum SCC levels during follow-up showed a remarkable course with peak values greater than 2.5 rig/ml, according to the clinical course of the infection (see Fig. 3). In eight patients with normal pretreatment serum SCC values, no elevated levels were encountered during follow-up.
VULVECTOMY
151 r \-c F
I
t I
RADIOTHERAPY
z IO
1
Patients with Progressive or Recurrent Disease during Follow-up Follow-up serum SCC analyses were carried out in 19 patients in whom signs of tumor activity were observed during follow-up. Serum marker trends of these patients are shown in Fig. 2 (right). Palliative therapy was delivered to 12 patients. In 7 of 19 cases the primary treatment was intended to be curative. In one of the 7 patients who underwent radical treatment, the pretreatment serum SCC value normalized after treatment (Fig. 4). Five of the seven patients developed a locoregional recurrence. Increasing serum SCC levels were observed in 2 of these 5 cases (Figs. 4 and 5). Two other patients developed metastases, without locoregional recurrence. Both patients had normal pretreatment serum SCC values and only one of these patients demonstrated an incidental elevation during follow-up. Six of the seven patients died of cancer. The other patient is still alive following radical excision of a small local recurrence 3 years after primary treatment. All of the SCC values for this patient were normal during the VULVECTOMY
I 4
I 0
I 12
I 16
II 20
I 28
24
I 32
I 36
I amonths
FIG. 4. Serum SCC in a 53-year-old woman with FIG0 stage III carcinoma of the vulva with regional recurrence 28 months after primary radical vulvectomy and bilateral groin lymphadenectomy, followed by radiotherapy for positive lymph nodes. ESR indicates the time at which the erythrocyte sedimentation rate became elevated.
whole course of her disease. Of the 12 patients who underwent palliative treatment, 8 had elevated pretreatment serum SCC levels. In 4, the SCC levels returned to normal following treatment (Figs. 6 and 7). During follow-up, SCC values greater than 2.5 rig/ml were measured in 5 of 12 cases, whether incidentally (2 cases) or consecutively (3 cases). All 12 patients demonstrated locoregional recurrence during follow-up. In 2 of 12 cases distant metastases were also present; both patients had normal SCC levels during follow-up. Only one of these 12 patients is still alive, with local tumor growth and a marginal serum SCC value of 2.5 rig/ml 9 months after primary treatment. All other patients died of cancer. No relationship between serum
t I
LYMPHOGENIC METASTASIS
LOCAL RECURRENCESI3xl
NED 1
I
I 4
I 8
II 12
16
II 20
24
II 28
32
II 36
LO
Lo I 44months
FIG. 3. Serum SCC and antistreptolysin titer in a 72-year-old patient with squamous cell carcinoma of the vulva, FIG0 stage III, with recurrent erysipelas, without evidence of tumor activity during followup. Primary therapy consisted of radical vulvectomy, bilateral inguinal lymphadenectomy and left pelvic lymphadenectomy, followed by radiotherapy for positive lymph nodes. NED, no evidence of disease.
I
I L
I 8
I 12
I 16
I 20
I 24
I 2Bmonths
FIG. 5. Serum SCC in an 82-year-old woman with FIG0 stage IV carcinoma of the vulva with locoregional recurrence after primary radical vulvectomy and bilateral groin lymphadenectomy.
SERUM SCC IN VULVAR VULVECTOMY
i
1
RADIOTHERAPY
t
--
RADKITHERAPY
15.
t
I
F F : lo-
GROIN LYMPHNWE I
15
I I
231
CANCER
'-
E 4 G 1
VULVECTOMY
I
I 2
I L
I 6
I E
I M
I 12
I 1L
I 16
I 18
I B
I 22
1 2L
l26manths
5
2 5-
FIG. 8. Serum SCC in an 87.year-old woman with FIG0 stage I carcinoma of the vulva with inguinal lymph node recurrence after primary vulvectomy without lymphadenectomy.
---------. I
4
I
0
I
12
I
16 months
FIG. 6. Serum SCC in a 79-year-old woman with FIG0 stage IV carcinoma of the vulva with progression after palliative vulvectomy, followed by radiotherapy.
cases with tumor activity for whom three or more followup serum samples were available. DISCUSSION
SCC level and site of tumor growth could be demonMany reports have confirmed the value of SCC as a strated. As is shown in the Figs. 4 to 8, serum SCC did useful marker in the staging, treatment, and follow-up not follow the clinical course of the disease in a number of patients with carcinoma of the cervix. Elevated serum of patients. The serum SCC value only increased in one SCC values have been reported in patients with maligpatient prior to the clinical manifestation of a recurrence nancies of other origin such as squamous cell carcinoma (Fig. 8). of the lung. The serum SCC levels in these cases are It should be realized that the number of study subjects fairly low [4,9]. was small and that the number of available serum samImmunohistochemistry has demonstrated that SCC is ples per patient may have given rise to a biased picture: produced by normal, premalignant, and malignant cervix elevated serum SCC values were found in 70% of the tissue and that a relationship appears to exist between the amount of SCC production on the one hand and the CHEMOTHERAPY seriousness of the disorder and degree of squamous cell differentiation on the other [ 10-121. Maruo et al. [ 131 t VULVECTOMY I found that in squamous cell cervical carcinoma cell cult I RADIOTHERAPY tures, the production of SCC antigen increased under RELAPSE the influence of epidermal growth factor (EGF). rData on the possible significance of SCC antigen as tumor marker for squamous cell carcinoma of the vulva are scarce. Crombach and Wuerz [9] have reported increased serum SCC values in 42% of their group of 12 patients with tumor burden. In our study on 94 patients with squamous cell carcinoma of the vulva, the overall incidence of elevated pretreatment serum SCC levels was 26%. Elevated serum SCC levels were more frequently observed in patients with advanced stage tumors: 53% in stage III and 40% in stage IV disease. These findings confirm the observation made by Crombach and Wuerz. 25The incidence of increased serum SCC levels in stage I and II disease did not differ from the incidence observed I I I I I in control samples. The degree of elevation of serum 2Omonths L 0 12 16 SCC levels found in our study group was generally lower FIG. 7. Serum SCC in a B-year-old woman with a bulky FIG0 than that found in patients with squamous cell carcinoma stage III carcinoma of the vulva with progression after preoperative chemotherapy (bleomycin) followed by nonradical surgery and of the cervix, even at a very advanced stage of the disease. radiotherapy.
232
VAN DER SIJDE ET AL.
It was not possible to demonstrate a relationship between increased pretreatment serum SCC levels and lymph node metastases. Apparently, SCC is produced by squamous cell carcinoma of the vulva. The factors that determine the expression of the antigen and its presence in the circulation remain to be discovered. These factors may be different from those that play a part in carcinoma of the cervix. Elevated serum KC levels were found in 4 of 16 patients with complete remission during follow-up. The use of a cutoff point of 4 rig/ml could avoid these apparent false-positive values in three patients. One patient with erysipelas during follow-up demonstrated a remarkable course of the SCC level. Several consecutive values greater than 2.5 rig/ml alternated with values less than 2.5 rig/ml. This observation indicates that nonmalignant disorders of squamous cell epithelium may be related to elevated serum SCC levels. The underlying mechanism is still unknown. It is possible that factors such as raised cell metabolism and circulatory changes play a part here. The increase in SCC production under the influence of EGF found by Maruo et al. [13] also deserves further research in this respect. Increasing serum SCC levels were observed in our study group during follow-up in 47% of the patients who had recurrent or progressive disease. We could not find a relationship between elevated serum SCC levels and the site of the tumor. Notably, in only two of four patients with hematogenic metastases were elevated serum SCC levels found. As shown by our data, increasing serum SCC levels can be demonstrated in vulvar carcinoma patients, in accordance with the biological behavior of the tumor. In only one patient did the serum SCC level increase prior to clinical manifestation of a recurrence.
CONCLUSIONS 1. SCC is produced by squamous cell carcinoma tissue of the vulva and is observed particularly in the circulation of patients with FIG0 stage III and IV disease. 2. Analysis of serum SCC levels in patients with squamous cell carcinoma of the vulva has no clinical significance for the staging of the tumor. 3. The analysis of serum SCC values in squamous cell carcinoma of the vulva is not related to the presence of lymph node metastases, stage by stage. 4. In a number of cases the analysis of serum SCC levels can be useful during follow-up for following the course of the disease, even if pretreatment levels were not elevated. 5. In interpretation of an elevated serum SCC level, it is important to consider the possible presence of other
diseases that might have caused the increase, such as skin disorders. 6. Further in vitro research as well as clinical and immunohistochemical investigation is necessary to isolate the factors that determine the expression of SCC antigen and its presence in the circulation. REFERENCES 1. Kneale, B. L. G., Elliott, P. M., and McDonald, A. M. Micro invasive carcinoma of the vulva: Clinical features and management, in Gynecologic oncology (M. Coppleson, Ed.), Churchill Livingstone, Edinburgh, pp. 320-328 (1981). 2. Disaia, P. J., and Creasman, W. T. Invasive cancer of the vulva, in Clinical gynecologic oncology, Mosby, St. Louis, MO, pp. 185206 (1981). 3. Kato, H., and Torigoe, T. Radio-immunoassay for tumor-antigen of human cervical squamous cell carcinoma, Cancer 40, 1621-1628 (1977). 4. Kato, H., Miyauchi, M., Morioka, H., Fujino, T., and Torigoe, T. Tumor antigen of human cervical squamous cell carcinoma. Correlation of circulating levels with disease progress, Cancer 45, 585-590 (1979). 5. Kato, H., Morioka, H., Tsutsui, H., Aramaki, S., and Torigoe, T. Value of tumor-antigen (TA-4) of squamous cell carcinoma in predicting the extent of cervical cancer, Cancer SO, 1294-1296 (1982). 6. Kato, H., Tamai, K., Morioka, H., Magai, M., Nagaya, T., and Torigoe, T. Tumour antigen, TA-4, in the detection of recurrence in cervical squamous cell carcinoma, Cancer 54, 1544- 1546(1984). 7. Maruo, T., Shibata, K., Kimura, A., Hoshina, M., and Mochizuki, M. Tumor associated antigen, TA-4, in the monitoring of the effects of therapy for squamous cell carcinoma of the uterine cervix. Serial determinations and tissue localization, Cancer 56, 302-308 (1985). 8. De Bruijn, H. W. A., Bouma, J., Krans, M., Boonstra, H., van der Sijde, R., and Aalders, J. G. SCC antigen: A useful tumor marker in patients with squamous cell carcinoma of the cervix, in SCC Antigen in the management of squamous cell carcinoma (H. Kato, H. W. A. de Bruijn, W. Ebert, R. B. Herberman, and J. T. Johnson, Eds.), Excerpta Medica, Princeton, pp. 18-33 (1987). 9. Crombach, G.. and Wuerz, H. Serum concentrations of SCC antigen in patients with cervical cancer, in SCC Antigen in the muttagement of squamous ceil carcinoma (H. Kato, H. W. A. de Bruijn, W. Ebert, R. B. Herberman, and J. T. Johnson, Eds.), Excerpta Medica, Princeton, pp. 54-63 (1987). 10. Suehiro, Y., Kato, H., Magai, M., and Torigoe, T. Flow cytometric analysis of tumor antigen TA-4 in gynecologic tumors, Cancer 57, 1380-1384 (1986). 11. Hoshina, M., Kimura, A., Shibata, K., Maruo, T., and Mochizuki, M. Immunocytological distribution of the tumor antigen TA-4: Expression during carcinogenesis and maturation of squamous epithelium of human uterine cervix, Asia-Oceania J. Obstet. Gynaecol. 12, 119-126 (1986). 12. Hussa, R. O., Maruro, T., Strobe], J. L., Patillo, R. A., and Mochizuki, M. Production of tumor associated antigen, TA-4, by the Ca Ski cervical carcinoma cell-line, Obstet. Gynecol. 67, 802-805 (1986). 13. Maruo, T., Matsuo, H., Nishino, R., Hussa, R. O., Strobe], J. L., Patillo, R. A., and Mochizuki, M. Discordant induction of tumorassociated antigen, TA-4, and chorionic gonadotropin B in cultured cervical carcinoma cells, Acta Obstet. Gynaecol. Japan. 39, 291296 (1987).
ONCOLOGY
35, 227-232
(1989)
Significance of Serum SCC Antigen as a Tumor Marker in Patients with Squamous Cell Carcinoma of the Vulva’ R. VAN DER SIJDE, H. W. A. DE BRUIJN,’ M. KRANS, J. BOUMA, AND J. G. AALDERS Department
of Obstetrics
crnd Gynecology,
University
ReceivedAugust The significance of serum SCC antigen as a tumor marker was investigated in 94 women with squamous cell carcinoma of the vulva. The incidence of elevated serum SCC levels varied from 10% in FIG0 stage I to 40% in FIG0 stage IV. We did not observe a correlation between elevated pretreatment SCC values and the presence of lymph node metastases. During follow-up, elevated serum SCC values were observed in 8 of 19 patients (42%) with recurrent or progressive disease. It is concluded that the determination of serum SCC levels does not provide additional information in the staging of squamous cell vulvar carcinoma, but can be useful for the early detection of recurrent diseaseduring follow-up in some patients. However, elevated serum SCC levels were also found in 25% of patients without demonstrable tumor activity during follow-up and benign skin disorders were recognized as a cause of false-positive SCC results. co 1989 Academic PRESS, Inc.
INTRODUCTION Squamous cell carcinoma of the vulva is a fairly rare tumor that is diagnosed mainly in elderly women. The tumor incidence is 2: 100,000. Ninety-five percent of all malignant tumors of the vulva are squamous cell carcinomas. It has been suggested that the incidence of squa-
mous cell carcinoma is increasing and that the tumor is being diagnosed more often in younger women [I]. The primary route of dissemination is to the inguinal lymph nodes and secondarily to the pelvic lymph nodes. Hematogenic spread is observed mainly in the more advanced stages. Radical vulvectomy with bilateral inguinal and femoral lymphadenectomy en bloc is generally accepted as the treatment of choice. Until now the results of radiotherapy and chemotherapy have been disappointing. The prognosis
in early-stage
disease depends
largely
by the Praeventiefonds,Grant No. reprint requests should be addressed.
Groningen,
The Netherlwds
30. 1988
marker that is sufficiently sensitive and specific and that correlates with the tumor burden may be useful in determining the primary treatment method, in monitoring the clinical course of the disease, and in detecting tumor recurrence early. No such tumor marker for squamous cell carcinoma of the vulva has yet been reported. In 1977 Kato and Torigoe isolated an antigen, tumor antigen 4 (TA-4), from squamous cell carcinoma of the cervix [3]. The SCC antigen, a purified subfraction of TA-4, a protein with a molecular weight of 45,000, shows antigenic similarities to the other TA-4 subfractions. Measured by radioimmunoassay, the SCC antigen acts as an index of total TA-4 activity. Elevated serum SCC levels are found in patients with squamous cell carcinoma of the cervix, as well as in some patients with squamous cell carcinoma of other origin, such as the bronchus and nasopharynx, and sporadically in healthy volunteers and patients with tumors of other histologic origin [4]. Kato et al. recently showed that the degree of increase in SCC level correlates well with tumor dissemination status and course of disease in patients with squamous cell carcinoma of the cervix [5-71. We have been able to confirm this correlation between serum SCC level and tumor dissemination in patients with squamous cell carcinoma of the cervix [8]. The present study was conducted to investigate the value of SCC antigen as a tumor marker in patients with squamous cell carcinoma of the vulva. PATIENTS
AND METHODS
The University Clinic for Obstetrics and Gynecology in Groningen functions as the gynecological-oncological center for the northern provinces of The Netherlands. Between 1978 and 1985, 94 patients with squamous cell carcinoma of the vulva underwent primary treatment at our clinic. Pretreatment serum samples from these patients were stored at the serum bank. In 32 cases one or more serum samples were obtained during follow-up.
on
whether the lymph nodes are involved [2]. A tumor ’ Supported ’ To whom
Hospital,
28-1478. 227
0090-8258189 $1.50 Copyright0 1989by AcademicPress.Inc. All rights of reproduction
in any form reserved.
228
VAN
DER SIJDE ET AL.
These sera were also included in the analysis. All samples were stored at -60°C. Tumors were classified in accordance with the FIG0 staging system. The diagnosis was confirmed histopathologically in all cases. Standard treatment consisted of radical vulvectomy with bilateral inguinal and femoral lymphadenectomy en bloc in 69 of 94 patients. Seven patients were subjected to pelvic lymphadenectomy. Less radical procedures were carried out in 10 patients who had an increased risk for operation or as palliative treatment at an advanced stage. Two patients underwent an excenterative operation. Five patients with inoperable, local, bulky tumors were treated with radical radiotherapy, in two cases in combination with bleomycin chemotherapy. One patient received treatment only to relieve her symptoms. Radiotherapy was applied as adjuvant treatment in 26 patients with histopathologically confirmed positive lymph node metastases. All patients were followed up at our outpatient department every 3 months during the first year, every 4 months during the second year, every 6 months during the third year, and once a year thereafter. The duration of follow-up varied from 2 months to 8 years. Patients who were subjected to radical treatment and were free of disease during the entire follow-up period, with a minimum of 3 months after completion of primary treatment, were defined as having a complete remission. Recurrent disease was defined as tumor activity within the area of primary treatment 3 months or more after completion of radical treatment. Patients who were subjected to nonradical treatment or showed tumor activity within the area of treatment within 3 months of completion of primary treatment were regarded as having residual disease. Statistical analysis was performed using the x2 test. Serum SCC antigen analysis was carried out using a double-antibody SCC radioimmunoassay kit (Dainabot Co. Ltd., Tokyo) which was developed from a subfraction of a purified TA-4 preparation, isolated from liver metastases of a squamous cell carcinoma of the cervix. The sensitivity of the assay is 0.7 rig/ml. A control serum sample was prepared at our laboratory and analyzed during each run. The reproducibility was 26.5 + 2.0 rig/ml (mean + SD, n = 32); the coefficient of variation was 7.5%.
Sera collected from 85 healthy women with a normal Pap smear prior to laparoscopic sterilization were used as a control group. The distribution of serum SCC levels in these control samples is shown in Table 1. A serum level of 2.5 rig/ml, being the 95th percentile in these samples, was taken to be the upper limit of a normal serum SCC value. During follow-up, sera from those women who either had elevated serum SCC levels before treatment or dem-
TABLE 1 Serum XC in Control Samples (n = 85) Serum SCC (w/ml)
n
%
1.1-1.5
17 26
20 30.6
I .6-2.0 2.1-2.5 2.6-3.0 3.1-3.5 3.6-4.0
29 9 3 0 I
34.1 10.6 3.5 1.2
SI.0
onstrated tumor activity after primary treatment were analyzed. As a control, serum samples from four women who had normal pretreatment serum SCC levels and who did not show signs- of tumor activity during follow-up were used. All samples were thawed for the first time for analysis and the analyses were carried out in duplicate. RESULTS Elevated pretreatment serum SCC levels were measured in 24 of 94 (26%) patients with squamous cell carcinoma of the vulva, as compared with 4 of 85 (4.7%) control samples (x2 = 14.7, P < 0.001). The incidence of elevated pretreatment SCC levels in FIG0 stage I and II disease did not differ significantly from that in the control samples (see Table 2). Fifty-three percent of the patients with stage III vulvar cancer had elevated serum SCC values; in FIG0 stage IV, the incidence was 40%. Quantitative data on serum SCC values in patients with squamous cell carcinoma of the vulva are shown in Fig. 1. Pretreatment
Serum SCC and Lymph Node Metastases
Regional lymph nodes were surgically removed in 86 of 94 patients and histopathologically examined in all 86 TABLE 2 Incidence of Pretreatment Serum SCC Increase in Patients with Squamous Cell Carcinoma of the Vulva in Relation to the FIG0 Stage
Group
n
Control Stage I Stage II Stage III Stage IV
85 22 37 30 5
Number of see values >2.5 rig/ml
Serum SCC @g/ml) Median
P
0.7-17.4 0.7-24.1
I.5 I .85 1.6 2.65
ns. n.s.
0.7-6.9
2.5
‘co.002
Range
4 ( 5%)
0.7-
2 (10%)
0.7- 3.5
4 (11%) 16 (53%)
2 (40%)
3.7
SERUM
SCC
IN
VULVAR
progression. The remaining 16 patients were in complete remission. These groups are discussed separately.
SCC rig/ml 25
20
I
15-
Patients in Complete Remission
. .
I
.
IOc
controls
I
II
III
FIG. 1. Pretreatment serum SCC levels cell carcinoma of the vulva (n = 94).
Ip in patients
with
squamous
cases. An overall incidence of lymph node metastases was found in 35 of 86 cases (41%): 17% in stage I, 26% in stage II, 64% in stage III, and 100% in stage IV disease. Elevated serum SCC levels are found in 37% of the patients with positive lymph nodes as compared with 16% of the patients with negative lymph nodes (all stages) (x2 = 4.14, P < 0.05); however, stage by stage no significant differences could be calculated (Table 3). Neither could any predictive value be attributed to the SCC values within FIG0 stages I and II, with 20% false-negative and 40% false-positive results. Serum SCC and Course
TABLE 3 Incidence of Pretreatment Serum SCC Values in Relation to Lymph Node Metastases
FIG0
n
SCC
Positive
nodes
2!iF \ I?
NO EVIDENCE OF DISEASE
RECURRENT AND PROGRESSIVE DISEASE
z 20-
15-
> 2.5 rig/ml
n
SCC
lo-
5
2.5
nodes > 2.5 rig/ml
P
Stage
I
15
2 (13%)
3
Stage Stage Stage
II III IV
26 10 -
I ( 4%) 6 (60%) -
9 18 5
2 (22%) 9 (50%) 2 (40%)
n.s. n.s. n.s.
51
9 (18%)
35
13 (37%)
0.05
Total
Of the 16 patients without demonstrable tumor activity during follow-up, 8 had elevated serum SCC levels prior to treatment. The highest level measured was 24.1 rig/ml. The serum marker trends of these patients are shown in Fig. 2 (left). All 8 patients demonstrated a drop in serum SCC levels following primary treatment; however, during follow-up, serum SCC levels were still above the cutoff value of 2.5 rig/ml in 4 patients. In 2 of these 4 patients the serum SCC elevation was incidental. One patient demonstrated a stabilization of the serum SCC concentration at a level of 3.5 rig/ml for several months prior to her death from a stroke. The remaining patient with a stage III carcinoma of the vulva underwent radical vulvectomy with bilateral inguinal and femoral lymphadenectomy, followed by adjunctive radiotherapy because of positive lymph nodes. During follow-up severe lymphedema was diagnosed. In addition the patient dem-
of Disease
In 35 selected patients serum samples were obtained and analyzed for SCC antigen during follow-up. Nineteen patients experienced recurrent disease or local tumor
Negative
229
CANCER
-
1\ FIG. 2. (Left) Serum SCC course in 16 patients with squamous cell carcinoma of the vulva, without clinically demonstrable tumor activity during follow-up (mean follow-up 28 months). (Right) Serum SCC course in I9 patients with squamous cell carcinoma of the vulva and tumor activity during follow-up (mean follow-up 15 months). A = pretreatment serum SCC, B = last serum SCC during follow-up.
230
VAN
DER SIJDE ET AL.
onstrated recurrent erysipelas despite long-term treatment with Penidural. This patient is still alive, more than 3 years after primary treatment without evidence of vulvar cancer. The serum SCC levels during follow-up showed a remarkable course with peak values greater than 2.5 rig/ml, according to the clinical course of the infection (see Fig. 3). In eight patients with normal pretreatment serum SCC values, no elevated levels were encountered during follow-up.
VULVECTOMY
151 r \-c F
I
t I
RADIOTHERAPY
z IO
1
Patients with Progressive or Recurrent Disease during Follow-up Follow-up serum SCC analyses were carried out in 19 patients in whom signs of tumor activity were observed during follow-up. Serum marker trends of these patients are shown in Fig. 2 (right). Palliative therapy was delivered to 12 patients. In 7 of 19 cases the primary treatment was intended to be curative. In one of the 7 patients who underwent radical treatment, the pretreatment serum SCC value normalized after treatment (Fig. 4). Five of the seven patients developed a locoregional recurrence. Increasing serum SCC levels were observed in 2 of these 5 cases (Figs. 4 and 5). Two other patients developed metastases, without locoregional recurrence. Both patients had normal pretreatment serum SCC values and only one of these patients demonstrated an incidental elevation during follow-up. Six of the seven patients died of cancer. The other patient is still alive following radical excision of a small local recurrence 3 years after primary treatment. All of the SCC values for this patient were normal during the VULVECTOMY
I 4
I 0
I 12
I 16
II 20
I 28
24
I 32
I 36
I amonths
FIG. 4. Serum SCC in a 53-year-old woman with FIG0 stage III carcinoma of the vulva with regional recurrence 28 months after primary radical vulvectomy and bilateral groin lymphadenectomy, followed by radiotherapy for positive lymph nodes. ESR indicates the time at which the erythrocyte sedimentation rate became elevated.
whole course of her disease. Of the 12 patients who underwent palliative treatment, 8 had elevated pretreatment serum SCC levels. In 4, the SCC levels returned to normal following treatment (Figs. 6 and 7). During follow-up, SCC values greater than 2.5 rig/ml were measured in 5 of 12 cases, whether incidentally (2 cases) or consecutively (3 cases). All 12 patients demonstrated locoregional recurrence during follow-up. In 2 of 12 cases distant metastases were also present; both patients had normal SCC levels during follow-up. Only one of these 12 patients is still alive, with local tumor growth and a marginal serum SCC value of 2.5 rig/ml 9 months after primary treatment. All other patients died of cancer. No relationship between serum
t I
LYMPHOGENIC METASTASIS
LOCAL RECURRENCESI3xl
NED 1
I
I 4
I 8
II 12
16
II 20
24
II 28
32
II 36
LO
Lo I 44months
FIG. 3. Serum SCC and antistreptolysin titer in a 72-year-old patient with squamous cell carcinoma of the vulva, FIG0 stage III, with recurrent erysipelas, without evidence of tumor activity during followup. Primary therapy consisted of radical vulvectomy, bilateral inguinal lymphadenectomy and left pelvic lymphadenectomy, followed by radiotherapy for positive lymph nodes. NED, no evidence of disease.
I
I L
I 8
I 12
I 16
I 20
I 24
I 2Bmonths
FIG. 5. Serum SCC in an 82-year-old woman with FIG0 stage IV carcinoma of the vulva with locoregional recurrence after primary radical vulvectomy and bilateral groin lymphadenectomy.
SERUM SCC IN VULVAR VULVECTOMY
i
1
RADIOTHERAPY
t
--
RADKITHERAPY
15.
t
I
F F : lo-
GROIN LYMPHNWE I
15
I I
231
CANCER
'-
E 4 G 1
VULVECTOMY
I
I 2
I L
I 6
I E
I M
I 12
I 1L
I 16
I 18
I B
I 22
1 2L
l26manths
5
2 5-
FIG. 8. Serum SCC in an 87.year-old woman with FIG0 stage I carcinoma of the vulva with inguinal lymph node recurrence after primary vulvectomy without lymphadenectomy.
---------. I
4
I
0
I
12
I
16 months
FIG. 6. Serum SCC in a 79-year-old woman with FIG0 stage IV carcinoma of the vulva with progression after palliative vulvectomy, followed by radiotherapy.
cases with tumor activity for whom three or more followup serum samples were available. DISCUSSION
SCC level and site of tumor growth could be demonMany reports have confirmed the value of SCC as a strated. As is shown in the Figs. 4 to 8, serum SCC did useful marker in the staging, treatment, and follow-up not follow the clinical course of the disease in a number of patients with carcinoma of the cervix. Elevated serum of patients. The serum SCC value only increased in one SCC values have been reported in patients with maligpatient prior to the clinical manifestation of a recurrence nancies of other origin such as squamous cell carcinoma (Fig. 8). of the lung. The serum SCC levels in these cases are It should be realized that the number of study subjects fairly low [4,9]. was small and that the number of available serum samImmunohistochemistry has demonstrated that SCC is ples per patient may have given rise to a biased picture: produced by normal, premalignant, and malignant cervix elevated serum SCC values were found in 70% of the tissue and that a relationship appears to exist between the amount of SCC production on the one hand and the CHEMOTHERAPY seriousness of the disorder and degree of squamous cell differentiation on the other [ 10-121. Maruo et al. [ 131 t VULVECTOMY I found that in squamous cell cervical carcinoma cell cult I RADIOTHERAPY tures, the production of SCC antigen increased under RELAPSE the influence of epidermal growth factor (EGF). rData on the possible significance of SCC antigen as tumor marker for squamous cell carcinoma of the vulva are scarce. Crombach and Wuerz [9] have reported increased serum SCC values in 42% of their group of 12 patients with tumor burden. In our study on 94 patients with squamous cell carcinoma of the vulva, the overall incidence of elevated pretreatment serum SCC levels was 26%. Elevated serum SCC levels were more frequently observed in patients with advanced stage tumors: 53% in stage III and 40% in stage IV disease. These findings confirm the observation made by Crombach and Wuerz. 25The incidence of increased serum SCC levels in stage I and II disease did not differ from the incidence observed I I I I I in control samples. The degree of elevation of serum 2Omonths L 0 12 16 SCC levels found in our study group was generally lower FIG. 7. Serum SCC in a B-year-old woman with a bulky FIG0 than that found in patients with squamous cell carcinoma stage III carcinoma of the vulva with progression after preoperative chemotherapy (bleomycin) followed by nonradical surgery and of the cervix, even at a very advanced stage of the disease. radiotherapy.
232
VAN DER SIJDE ET AL.
It was not possible to demonstrate a relationship between increased pretreatment serum SCC levels and lymph node metastases. Apparently, SCC is produced by squamous cell carcinoma of the vulva. The factors that determine the expression of the antigen and its presence in the circulation remain to be discovered. These factors may be different from those that play a part in carcinoma of the cervix. Elevated serum KC levels were found in 4 of 16 patients with complete remission during follow-up. The use of a cutoff point of 4 rig/ml could avoid these apparent false-positive values in three patients. One patient with erysipelas during follow-up demonstrated a remarkable course of the SCC level. Several consecutive values greater than 2.5 rig/ml alternated with values less than 2.5 rig/ml. This observation indicates that nonmalignant disorders of squamous cell epithelium may be related to elevated serum SCC levels. The underlying mechanism is still unknown. It is possible that factors such as raised cell metabolism and circulatory changes play a part here. The increase in SCC production under the influence of EGF found by Maruo et al. [13] also deserves further research in this respect. Increasing serum SCC levels were observed in our study group during follow-up in 47% of the patients who had recurrent or progressive disease. We could not find a relationship between elevated serum SCC levels and the site of the tumor. Notably, in only two of four patients with hematogenic metastases were elevated serum SCC levels found. As shown by our data, increasing serum SCC levels can be demonstrated in vulvar carcinoma patients, in accordance with the biological behavior of the tumor. In only one patient did the serum SCC level increase prior to clinical manifestation of a recurrence.
CONCLUSIONS 1. SCC is produced by squamous cell carcinoma tissue of the vulva and is observed particularly in the circulation of patients with FIG0 stage III and IV disease. 2. Analysis of serum SCC levels in patients with squamous cell carcinoma of the vulva has no clinical significance for the staging of the tumor. 3. The analysis of serum SCC values in squamous cell carcinoma of the vulva is not related to the presence of lymph node metastases, stage by stage. 4. In a number of cases the analysis of serum SCC levels can be useful during follow-up for following the course of the disease, even if pretreatment levels were not elevated. 5. In interpretation of an elevated serum SCC level, it is important to consider the possible presence of other
diseases that might have caused the increase, such as skin disorders. 6. Further in vitro research as well as clinical and immunohistochemical investigation is necessary to isolate the factors that determine the expression of SCC antigen and its presence in the circulation. REFERENCES 1. Kneale, B. L. G., Elliott, P. M., and McDonald, A. M. Micro invasive carcinoma of the vulva: Clinical features and management, in Gynecologic oncology (M. Coppleson, Ed.), Churchill Livingstone, Edinburgh, pp. 320-328 (1981). 2. Disaia, P. J., and Creasman, W. T. Invasive cancer of the vulva, in Clinical gynecologic oncology, Mosby, St. Louis, MO, pp. 185206 (1981). 3. Kato, H., and Torigoe, T. Radio-immunoassay for tumor-antigen of human cervical squamous cell carcinoma, Cancer 40, 1621-1628 (1977). 4. Kato, H., Miyauchi, M., Morioka, H., Fujino, T., and Torigoe, T. Tumor antigen of human cervical squamous cell carcinoma. Correlation of circulating levels with disease progress, Cancer 45, 585-590 (1979). 5. Kato, H., Morioka, H., Tsutsui, H., Aramaki, S., and Torigoe, T. Value of tumor-antigen (TA-4) of squamous cell carcinoma in predicting the extent of cervical cancer, Cancer SO, 1294-1296 (1982). 6. Kato, H., Tamai, K., Morioka, H., Magai, M., Nagaya, T., and Torigoe, T. Tumour antigen, TA-4, in the detection of recurrence in cervical squamous cell carcinoma, Cancer 54, 1544- 1546(1984). 7. Maruo, T., Shibata, K., Kimura, A., Hoshina, M., and Mochizuki, M. Tumor associated antigen, TA-4, in the monitoring of the effects of therapy for squamous cell carcinoma of the uterine cervix. Serial determinations and tissue localization, Cancer 56, 302-308 (1985). 8. De Bruijn, H. W. A., Bouma, J., Krans, M., Boonstra, H., van der Sijde, R., and Aalders, J. G. SCC antigen: A useful tumor marker in patients with squamous cell carcinoma of the cervix, in SCC Antigen in the management of squamous cell carcinoma (H. Kato, H. W. A. de Bruijn, W. Ebert, R. B. Herberman, and J. T. Johnson, Eds.), Excerpta Medica, Princeton, pp. 18-33 (1987). 9. Crombach, G.. and Wuerz, H. Serum concentrations of SCC antigen in patients with cervical cancer, in SCC Antigen in the muttagement of squamous ceil carcinoma (H. Kato, H. W. A. de Bruijn, W. Ebert, R. B. Herberman, and J. T. Johnson, Eds.), Excerpta Medica, Princeton, pp. 54-63 (1987). 10. Suehiro, Y., Kato, H., Magai, M., and Torigoe, T. Flow cytometric analysis of tumor antigen TA-4 in gynecologic tumors, Cancer 57, 1380-1384 (1986). 11. Hoshina, M., Kimura, A., Shibata, K., Maruo, T., and Mochizuki, M. Immunocytological distribution of the tumor antigen TA-4: Expression during carcinogenesis and maturation of squamous epithelium of human uterine cervix, Asia-Oceania J. Obstet. Gynaecol. 12, 119-126 (1986). 12. Hussa, R. O., Maruro, T., Strobe], J. L., Patillo, R. A., and Mochizuki, M. Production of tumor associated antigen, TA-4, by the Ca Ski cervical carcinoma cell-line, Obstet. Gynecol. 67, 802-805 (1986). 13. Maruo, T., Matsuo, H., Nishino, R., Hussa, R. O., Strobe], J. L., Patillo, R. A., and Mochizuki, M. Discordant induction of tumorassociated antigen, TA-4, and chorionic gonadotropin B in cultured cervical carcinoma cells, Acta Obstet. Gynaecol. Japan. 39, 291296 (1987).