Clinical value of tumor markers for early detection of recurrence in patients with cervical adenocarcinoma and adenosquamous carcinoma

Utility of vaginal vault cytology in the local recurrence of cervical cancer

BACKGROUND

In Japan, 8000 women were newly diagnosed with cervical cancer in 2018. The healthcare insurance policy in Japan allows physicians to utilize vaginal volt cytology tests and serum biomarker measurement at every visit and imaging analysis at an adequate interval with screening for recurrence after initial treatment. However, the major surveillance guidelines published in the United States and European countries recommend focusing on pelvic examinations and symptom reviews to avoid unnecessary tests. This study aimed to reassess the benefits of standard surveillance methods adopted in this study by retrospective analysis.

METHODS

From January 2009 to December 2015, the medical records of patients with recurrence who were initially diagnosed with International Federation of Gynecology and Obstetrics stage I-III cervical cancer were collected for this study. Clinicopathological data were statistically analyzed to identify significant factors. In the first 2 years, the patients underwent regular surveillance, including pelvic examination, serum tumor marker tests, vaginal vault cytology every 1-3 months, and imaging analysis at 6- to 12-month intervals. In the following 2 years, the patients received a regular check with the same methods every 4 months and an annual imaging analysis. Afterward, the patients had regular screening every 6 to 12 months.

RESULTS

In the study period, 84 of the 981 patients experienced recurrence, and 88.1% had an asymptomatic recurrence. The disease-free interval was not related to the recurrence site. In univariate analysis, primary treatment, recurrence site, and diagnostic method were significant factors for survival outcomes. In contrast, multivariate analysis indicated that only primary treatment was a significant factor. In patients with local recurrence, multivariate analysis demonstrated that radiation as salvage therapy was an independent predictive factor for overall survival after recurrence.

CONCLUSIONS

In this retrospective study, routine imaging analysis and serum biomarker measurement did not contribute to patient prognosis after recurrence. In contrast, vaginal vault cytology can improve survival after recurrence in some patients. Tailored surveillance methods based on individual disease conditions and treatment modalities can improve post-recurrent survival outcomes.

The serum squamous cell carcinoma antigen level in inverted sinonasal papilloma and nasal polyps patients

Objective

To clarify whether the serum squamous cell carcinoma antigen (SCCA) levels of patients with inverted papilloma (IP) are different from patients with nasal polyps (NP) and rhinitis.

Materials and methods

Serum SCCA levels were measured in 30 patients with IP and 30 patients with NP at one day before surgery and seven days after surgery and measured in 28 patients with rhinitis.

Results

Elevated serum SCCA levels (>1.5 ng/ml) were found in 80.0% of patients in the IP group, 6.7% of patients in the NP group and 14.3% of patients in the rhinitis group, which was a significant difference. The medians of serum SCCA levels in the IP, NP and rhinitis groups were 3.9, 0.8 and 1.1 ng/ml, respectively, which was a significant difference. The SCCA level in IP group was not significantly correlated according to Krouse Staging. There was a significant difference in serum SCCA levels between the pre- and postoperative stages in the IP group, at 3.9 and 0.8 ng/ml, respectively, while in the NP group the levels were 0.8 and 1.0 ng/ml, not significantly different. With regard to the IP diagnosis in the IP and NP group based on the SCCA level (>1.5 ng/ml), sensitivity and specificity was 80.0% and 93.3%, respectively.

Conclusions

The serum SCCA level in patients with IP was elevated and then it decreased after surgery. This was different from NP and rhinitis patients who mostly had normal levels, which did not change.

Plasma levels of M-CSF and VEGF in laboratory diagnostics and differentiation of selected histological types of cervical cancers

Background

The search of useful serum biomarkers for the early detection of cervical cancers has been of a high priority. The activation of Macrophage-Colony Stimulating Factor (M-CSF) and Vascular Endothelial Growth Factor (VEGF) is likely involved in the pathogenesis and spread of cancer. We compared the plasma levels of M-CSF and VEGF to the ones of commonly accepted tumor markers CA 125and SCC-Ag in three groups of patients: 1. the cervical cancer group (patients with either squamous cell carcinoma or adenocarcinoma); 2. the cervical dysplasia group; 3. the control group.

Methods

This cohort study included 100 patients with cervical cancer and 55 patients with cervical dysplasia. The control group consisted of 50 healthy volunteers. The plasma levels of VEGF and M-CSF were determined using ELISA, while CA 125 and SCC-Ag concentrations were obtained by the chemiluminescent microparticle immunoassay (CMIA).

Results

The median levels of M-CSF and VEGF as well as CA 125 and SCC-Ag in the entire group of cervical cancer patients, were significantly different compared to the healthy women group. In case of both the squamous cell carcinoma and the adenocarcinoma groups, plasma levels of M-CSF and VEGF were higher compared to the control group. No significant differences in the studied parameters between the squamous cell carcinoma and the adenocarcinoma group were observed. The highest sensitivity and specificity were obtained for VEGF (81.18 and 76.00%, respectively) and SCC-Ag (81.18%; 74.00%) in the squamous cell carcinoma group and for VEGF (86.67%; 76.00%) in the adenocarcinoma group. The area under the ROC curve for VEGF was the largest in the adenocarcinoma group followed by the squamous cell carcinoma group (0.9082 and 0.8566 respectively).

Conclusions

Obtained results indicate a possible clinical applicability and a high diagnostic power for the combination of MSC-F, VEGF, CA 125 and SCC-Ag in the diagnosis of both studied types of cervical cancer.

Clinical value of serum HMGB1 levels in early detection of recurrent squamous cell carcinoma of uterine cervix: comparison with serum SCCA, CYFRA21-1, and CEA levels

AIM

To evaluate the clinical value of serum high mobility group box chromosomal protein 1 (HMGB1) levels in making the early diagnosis of recurrent cervical squamous cell carcinomas (CSCC) and compare it with the value of serum squamous cell carcinoma antigen (SCCA), cytokeratin fragment (CYFRA) 21-1, and carcinoembryonic antigen (CEA) levels.

METHODS

Immunohistochemical staining of tissue from 64 patients with recurrent CSCCs, 72 patients with non-recurrent carcinoma, and 28 healthy participants was performed to determine the expression of HMGB1 protein. The serum levels of the 4 markers in 112 patients with recurrent CSCC, 174 patients with non-recurrent disease, and 128 healthy participants were measured by enzyme-linked immunosorbent assay. The receiver operating characteristic (ROC) curves were constructed and the area under the curve (AUC) was calculated.

RESULTS

Higher immunostaining score was found in recurrent CSCC tissue sections than in non-recurrent CSCC sections. Serum HMGB1 levels in patients with recurrent CSCC were significantly higher than in patients with non-recurrent disease and healthy controls. The AUC of HMGB1, SCCA, CYFRA21-1, and CEA was 0.816, 0.768, 0.703, and 0.625, respectively. HMGB1 had the best specificity and positive likelihood ratio (78.0% and 3.25, respectively), whereas SCCA had the best sensitivity and negative likelihood ratio (76.3% and 0.34, respectively). Parallel combined measurements increased the diagnostic sensitivity and serial combination increased the specificity. High serum HMGB1 levels were inversely correlated with disease-free survival (P=0.009, Pearson chi(2) test) and overall survival (P=0.018).

CONCLUSION

HMGB1 was overexpressed in recurrent CSCCs. Serum HMGB1 level could be a useful and specific marker for evaluating the disease recurrence and predicting prognosis in patients with CSCC. Serial combined measurements of serum HMGB1, SCCA, and CYFRA21-1 increased the diagnostic specificity, and parallel combined testing increased the diagnostic sensitivity.

The serum assay of tumour markers in the prognostic evaluation, treatment monitoring and follow-up of patients with cervical cancer: a review of the literature

Pre-treatment serum squamous cell carcinoma antigen [SCC] levels are elevated in 28-88% of patients with squamous cell cervical cancer, and are related to tumour stage, tumour size, depth of stromal invasion, lymph-vascular space status, parametrial involvement and lymph node status. The clinical relevance of pre-treatment serum SCC assay is still debated. Some authors reported that it has no prognostic value, some others found that it is related to survival at univariate analysis, and some others detected that is an independent prognostic variable for survival. Serial SCC measurements reflect both the tumour response to treatment and the clinical outcome of patients. Increasing SCC levels can precede the clinical diagnosis of recurrent disease in 46-92% of the cases, with a mean lead time ranging from 2 to 8 months. According to some authors serum SCC assay during the follow-up does not improve the cure rate of patients who will ultimately develop a recurrence. However, it has been recently reported that the performance of a positron emission tomography [PET] in patients with asymptomatic SCC elevation can sometimes allow an earlier diagnosis of relapse with a survival benefit. SCC is a more sensitive serum tumour marker than CYFRA 21-1 for squamous cell cervical cancer in most series. Pre-treatment CA 125 levels are raised in 20-75% of patients with cervical adenocarcinoma, and reflect tumour stage, tumour size, histological grade, cervical stromal invasion, lymph-vascular space status and lymph node status. Elevated serum CA 125 has been also detected in patients with squamous cell cervical cancer, but with a positivity rate lower than that found in patients with cervical adenocarcinoma. Pre-treatment CA 125 levels appear to have a prognostic value, and rising serum CA 125 during follow-up may precede or be coincident with the clinical diagnosis of recurrent cervical adenocarcinoma. Serum levels of vascular endothelial growth factor [VEGF] are often elevated in patients with cervical cancer, and decrease significantly after successful treatment. However, the clinical relevance of serum VEGF assay is still investigational.

Biochemical prognostic factors and risk of relapses in patients with cervical cancer

No validated tumor marker is currently available for the management of patients with cervical cancer. However, some tumor-associated antigens have been measured in the sera from patients with this malignancy and have been related to the clinical course of disease. Squamous cell carcinoma antigen (SCC) is more sensitive than CYFRA 21-1 for squamous cell cervical cancer. Serum SCC levels are elevated in 28-88% of patients with this malignancy, and correlate with tumor stage, tumor size, cervical stromal invasion, lymph-vascular space involvement, and lymph node status. Some authors reported that pre-treatment serum SCC has no prognostic value, whereas others found that it is related to disease-free survival and/or overall survival at univariate analysis or at multivariate analysis. Serial SCC measurements correlate with tumor response to radiotherapy and/or chemotherapy and the clinical outcome of patients. Increasing serum SCC can precede the clinical diagnosis of relapse in 46-92% of cases, with a median lead time ranging from 2 to 8 months. According to some authors serum SCC assay during the follow-up does not improve the cure rate of patients who will ultimately develop a recurrence. However, it has been recently reported that the performance of a PET in asymptomatic patients with serum SCC elevation can sometimes allow an earlier diagnosis of relapse with a survival benefit. Serum CA 125 levels are raised in 20-75% of patients with cervical adenocarcinoma, and reflect tumor stage, tumor size, histological grade, cervical stromal invasion, lymph-vascular space involvement, and lymph node status. Pre-treatment CA 125 levels appear to have a prognostic value, and rising serum CA 125 may precede or be coincident with the clinical diagnosis of recurrent cervical adenocarcinoma.

Positron emission tomography in gynecologic cancer

Most positron emission tomography (PET) imaging studies in gynecologic cancer are performed using (18)F-fluorodeoxyglucose (FDG). It contributes valuable information in primary staging of untreated advanced cervical cancer, in the post-treatment surveillance with unexplained tumor marker (such as squamous cell carcinoma antigen [SCC-Ag]) elevation or suspicious of recurrence, and restaging of potentially curable recurrent cervical cancer. Its value in early-stage resectable cervical cancer is questionable. In ovarian cancer, FDG-PET provides benefits for those with plateaued or increasing abnormal serum CA 125 (>35 U/mL), computed tomography and/or magnetic resonance imaging (CT-MRI) defined localized recurrence feasible for local destructive procedures (such as surgery, radiotherapy, or radiofrequency ablation), and clinically suspected recurrent or persistent cancer for which CT-guide biopsy cannot be performed. The role of FDG-PET in endometrial cancer is relatively less defined because of the lack of data in the literature. In our prospective study, FDG-PET coupled with MRI-CT may facilitate optimal management of endometrial cancer in well-selected cases. The clinical impact was positive in 29 (48.3%) of the 60 scans, 22.2% for primary staging, 73.1% for post-therapy surveillance, and 57.1% after salvage therapy, respectively. Scant studies have been reported in the management of vulvar cancer using FDG-PET. More data are needed. Gestational trophoblastic neoplasia is quite unique in biological behavior and clinical management. Our preliminary results suggest that FDG-PET is potentially useful in selected gestational trophoblastic neoplasia by providing a precise metastatic mapping of tumor extent up front, monitoring response, and localizing viable tumors after chemotherapy. The evaluation of a diagnostic tool, such as PET, is usually via comparing the diagnostic efficacy (sensitivity, specificity, etc), by using a more sophisticated receiver operating curve method, or the proportion of treatment been modified. Evaluating PET by clinical benefit is specific to the individual tumor and an attractive new endpoint.

Serum tumor markers in the management of ovarian, endometrial and cervical cancer

CA 125 is the most reliable serum marker for ovarian carcinoma. Whereas its role in the screening of the malignancy is controversial, serum CA 125 assay is very useful for both the differential diagnosis of ovarian masses, particularly in postmenopause, and the monitoring of the response to chemotherapy and follow-up of patients with histologically proven ovarian carcinoma. Tumor-associated antigens other than CA 125, such as CA 19.9, CA 15.3 and TAG.72, firstly identified in gastro-intestinal or breast malignancies, have been detected also in tissue and serum samples from patients with ovarian carcinoma. In particular CA19.9 offers the advantage of high sensitivity for mucinous histotype, which often fails to express CA 125. Serum CA 125 correlates with the clinical course of disease better than the other antigens, and in patients with positive CA 125 assay at diagnosis the concomitant evaluation of CA 19.9 or CA 72.4 or CA 15.3 does not offer any additional benefit for monitoring ovarian carcinoma. Conversely, the serial measurements of these other antigens may represent an interesting biochemical tool for the management of patients with negative CA 125 assay. Serum alphaFP and betaHCG are very useful in the preoperative evaluation and management of nondysgerminomatous ovarian germ cell tumors, whereas elevated serum inhibin levels can be detected in patients with granulosa cell tumors of the ovary. As for endometrial carcinoma, preoperative serum CA 125 levels correlate with stage, depth of myometrial invasion, histologic grade, cervical invasion, peritoneal cytology, lymph node status and clinical outcome. Moreover, serial CA 125 assay is a good indicator of disease activity and a useful biochemical tool for post-treatment surveillance of patients with endometrial carcinoma. SCC is the most reliable serum marker for squamous cell cervical carcinoma, and in patients with this malignancy pretreatment SCC levels are related to tumor stage, tumor size, depth of cervical invasion, lymph-vascular space involvement, lymph node status and clinical outcome. Serial SCC measurements parallel the response to radiotherapy and chemotherapy as well as the clinical course of disease after the completion of treatment. Serum CYFRA 21.1 seems to be less sensitive than serum SCC for squamous cell cervical carcinoma. Elevated CA 125 levels can be often detected in patients with cervical adenocarcinoma. The future for tumor marker research is represented by the emerging technologies of transcriptional profiling and proteomics.

Clinical value of serum squamous cell carcinoma antigen in the management of sinonasal inverted papilloma

BACKGROUND

Although sinonasal inverted papilloma (IP) is a rare benign tumor, it has a tendency to recur and is sometimes associated with squamous cell carcinoma (SCC). Therefore, postoperative long-term follow-up of these patients is recommended. We previously reported that serum SCC antigen might be a useful tumor marker for sinonasal IP. In this study, we investigated whether serum SCC antigen level has a correlation with disease status and is useful in the early detection of recurrent disease.

METHODS

Blood samples for the analysis of serum SCC antigen were taken from 28 IP patients before and after surgical treatment.

RESULTS

Twenty-five (89%) of 28 cases showed evaluated serum SCC antigen levels above the upper limit. This marker level decreased in all cases after surgical resection. Four of these patients had a recurrence. None of the patients with recurrent tumor showed symptoms at the time of detection of their recurrent tumor, and recurrence was discovered from elevated levels of SCC antigen.

CONCLUSIONS

Serum SCC antigen level has a correlation with disease status of IP and has a potential to serve as a useful tool for monitoring the course of disease. SCC antigen is a reliable tumor marker in the management of sinonasal IPs.

Factors predicting disease outcome in early stage adenocarcinoma of the uterine cervix

CONTEXT

Adenocarcinoma (AC) and adenosquamous carcinoma (ASC) comprise the second principal histological types of cervical carcinoma. As compared with the squamous cell cancer (SCC), these lesions are far less frequent, and their epidemiology, natural history and prognostic determinants are less well understood.

OBJECTIVE

Patients with an early stage AC of the uterine cervix diagnosed in our clinic were subjected to detailed analysis for the prognostic determinants.

STUDY SUBJECTS

A series of 94 women with early stage (adenocarcinoma in situ (AIS) to IIB) cervical ACs or ASCs diagnosed and treated in our department during 1995-1999 and subsequently followed-up for a mean of 43.1 +/- 16.2 (S.D.) months.

MAIN OUTCOME MEASURES

Patients were examined by colposcopy, Papanicolaou (PAP) smear and biopsy. The stage of the disease (FIGO) and tumour histology in operative specimens were recorded, and univariate (Kaplan-Meier) and multivariate survival analysis (Cox) were run to explore the factors predicting disease outcome.

RESULTS

Mean age of the women was 44.2 +/- 2.5 (S.D.) years (range 24-81 years), which is significantly (P=0.000) lower than that (49.9 +/- 14.2) of 464 SCC patients in our material. Minority of the women (38.2%) reported any clinical symptoms, but these correlated with the stage (P=0.041). Screening history was acceptable (i.e. screening interval 3 to 4 years) in 56 women, whereas 28 (29.8%) had no previous PAP smear taken. Interpretation errors were established in 17 (23.6%) and sampling errors in 6 (8.3%) of the 72 smears available for re-screening. No colposcopic lesions were found in 29 (30.9%) women. Follow-up data were available from 72 patients, of whom the disease progressed in four (one died), whereas 68 patients are alive and well at the moment. Patient's age (P=0.000), screening history (P=0.0127), FIGO stage (P=0.001), mode of therapy (P=0.0187), and presence of co-existent squamous cell lesions (P=0.0184) were significant prognostic indicators in univariate survival analysis. Cox's multivariate survival analysis disclosed FIGO stage (P=0.001) and screening history (P=0.006) as the only significant independent predictors of the disease outcome.

CONCLUSIONS

The present data emphasise the importance of early cervical AC as a disease of younger women, making early detection of its precursors (AIS) by regular PAP smear screening mandatory in prevention of disease progression. This can only be achieved by increasing the sensitivity of the PAP smear in detecting abnormal glandular cells in asymptomatic women.