CYFRA 21-1 [cytokeratin 19 fragment] and C-reactive proteins [CRP] were separately reported to be associated with prognosis of head and neck squamous cell carcinoma. The combined roles of CYFRA 21-1 and CRP levels were rarely investigated in oral squamous cell carcinoma [OSCC]. The purpose of the present study was to analyze the relationship between preoperative levels of both CYFRA 21-1 and CRP, with clinicopathological factors and prognosis in OSCC patients.
Methods
A retrospective study was performed on 130 OSCC patients between December 2010 and June 2013. Their serum CYFRA 21-1 and CRP levels were measured preoperatively.
Results
CYFRA 21-1 level of ≥3.3 ng/mL and CRP level of ≥5.0 mg/L were significantly associated with pathological tumor status [P < 0.001], tumor depth [>10 vs. ≤10 mm, P = 0.001], bone invasion [P = 0.001], skin invasion [P = 0.006], pathologic nodal metastasis [P = 0.012], and disease-free survival [P = 0.009]. Higher CYPFRA 21-1 and CRP levels were also associated with higher risks of distant metastasis [log-rank test, P = 0.013, [HR [95 % CI]] 1.692 [1.097–2.414]].
Conclusions
Preoperative CYFRA 21-1 and CRP levels are probable candidates as biomarkers for risk stratification in OSCC.
Background
Oral cavity cancer is one of the commonest cancers in the world but shows wide geographical variation due to habitual consumption of cigarette, alcohol, and areca quid [AQ]. The incidence of oral cavity cancer ranks fifth among the types of cancer in Taiwan []. Search for significant biomarkers predicting tumor behaviors and patients’ prognosis may help clinicians choose appropriate treatment for those patients [–]. Newer markers that can help us better and more precisely predict patients’ prognosis are needed clinically.
In oral squamous cell carcinoma [OSCC], to early detect tumor, it usually links to the squamous cell component of cancer. Cytokeratins are structural proteins forming the subunits of epithelial intermediary filaments. In the literature, 20 different cytokeratin polypeptides have been identified. Cytokeratin 19 is expressed by normal and benign epithelial cells and various carcinomas, particularly the lung cancer. CYFRA 21-1 is the serum soluble fragment of cytokeratin 19 and was first described in the mid 1990s []. Increased concentration of CYFRA 21-1 was shown to be associated with poorer prognosis in patients with lung cancer [, ]. The measurement of CYFRA 21-1 in patients with squamous cell carcinoma of the head and neck [HNSCC] is also an established tumor marker and prognosticator [, –]. CYFRA 21-1 serum levels are significantly higher in patients with HNSCC compared to a healthy or control group []. Sawant et al. [] reported a sensitivity of 84 % and a specificity of 93 % of CYFRA 21-1 in patients with oropharyngeal cancer. They found the serum marker reduced significantly after surgical therapy of the primary tumor.
A second potentially significant marker is the acute phase protein CRP, which has also been shown to correlate with survival in human cancers [, –]. We previously demonstrated that C-reactive protein [CRP] elevation in OSCC is associated with poor survival and tumor invasiveness [, ]. Elevated CRP could be a marker for chronic inflammation in the tumor microenvironment, with chronic inflammation itself also acts as a stimulus for angiogenesis, cell proliferation, and tumorigenesis [–]. However, the relationship between CYFRA 21-1 and CRP, and their potential combined value as prognostic markers of survival, has not been previously explored in OSCC. In this study, we retrospectively analyzed 130 OSCC patients who were primarily treated with radical excision in our institution. The aim of this study was to evaluate the importance of CYFRA 21-1 and CRP as tumor markers in patients with OSCC at the time of initial diagnosis in correlation with tumor size, histologic grading, and lymph node metastasis.
Methods
Patients and staging workup
We retrospectively reviewed 130 consecutive OSCC patients who had undergone primary radical surgery and were subsequently followed at Chang Gung Memorial Hospital from December 2010 to June 2013. The serum samples were obtained prior to surgery. All patients underwent radical surgery with curative intent. The follow-up for each patient began at the time of cancer treatment and ended at the time of death or last time clinic follow-up, whichever came first.
The patients in this series underwent an extensive preoperative survey, which included a detailed medical history and a complete physical examination, and computed tomography [CT] or magnetic resonance imaging [MRI] scans of the head and neck. Abdominal sonography and bone scan or positron emission tomography [PET] were also included in preoperative tumor survey. The guidelines of the 2010 American Joint Committee on Cancer [AJCC] [tumor-node-metastasis [TNM] classification] were employed for clinical staging []. Patients who were initially diagnosed of a distant metastasis were excluded from the analysis.
Treatment
One hundred twenty-seven participants underwent a wide excision of the primary tumors with 1-cm safe margins [both peripheral and deep margins], which were cryosectioned to ensure that the margin was free from the tumor tissue. Supraomohyoid or modified radical neck dissection was performed according to patients’ clinical nodal status. All histological parameters including the depth of infiltration, bone, skin invasion, lymph node extracapsular spread [ECS], and grade of differentiation were recorded.
Postoperative radiotherapy [RT] was performed in patients who presented a stage pT4 tumor, pathologically positive lymph nodes, or pathologically close margins [≤4 mm]. Concomitant chemoradiotherapy [CCRT] with cisplatin-based agents was administered to patients with ECS or pathological multiple lymph node metastases [, ]. Three patients received CCRT first, and received salvage radical surgery due to persistence of disease.
Follow-up
All of the patients had a checkup every month during the first 6 months after treatment, every 2 months during the following 6 months, every 3 months during the second year, and every 6 months thereafter. All the patients were subjected to a hemogram, blood chemistry, chest X-ray, and CT scan or MRI in the first 3 and 6 months and then annually afterward. Patients with abnormal clinical symptoms/signs or laboratory data during follow-up would receive a bone scan and liver ultrasound.
Measurement of CYFRA 21-1
Cytokeratin 19 fragments were detected by the monoclonal antibodies KS 19.1 and BM 19.21; these antibodies are specific for two different epitopes of cytokeratin 19 []. The measurement of CYFRA 21-1 was completed in electrochemiluminescent immunoassay [ECLIA] using the CYFRA 21-1 reagent kit. The CYFRA 21-1 concentration of each sample was automatically calculated in a Roche Analytics E170 immunology analyzer. The calculated concentration of CYFRA 21-1 was expressed in ng/mL, and the cut-off level of 3.3 ng/mL was used according to the manufacturer’s instructions [Roche Diagnostics, Mannheim, Germany] []. CYFRA 21-1 serum levels were determined for each patient at the time of initial diagnosis.
Measurement of CRP
Preoperative serum CRP levels were checked at the time of tissue diagnosis before any medical intervention or antibiotic treatment to minimize intra-individual differences. A fresh blood sample was collected and sent to the laboratory for testing. Serum CRP levels were detected using an auto-analyzer [Hitachi 7600-210, Hitachi Medico, Tokyo]. The cut-off point for serum CRP was set at 5.0 mg/L, which is internationally adopted for inflammation [, , ].
Ethics
The study was approved by the Institutional Review Board [103-3590B] of Chang Gung Memorial Hospital, Linkou, Taiwan, ROC.
Results
Patient characteristics
Table shows the clinicopathological characteristics of the 130 OSCC patients [114 males and 16 females]. The tongue [N = 58, 44.6 %] and the buccal mucosa [N = 44, 33.8 %] were the most common primary tumor sites. The tumor stage distribution was 28 [21.5 %] in stage I, 17 [13.1 %] in stage II, 23 [17.7 %] in stage III, and 62 [47.7 %] in stage IV. The median follow-up period was 19.0 months. All patients received radical surgeries, and the adjuvant therapies were listed in Table . All patients were followed in clinic at least 6 months after treatment.
Table 1 Characteristics of the 130 oral cavity squamous cell carcinoma patients
Full size table
CRP levels, clinicopathological variables, and prognosis
Elevated CRP levels [CRP ≥5.0 mg/L] were found to be associated with the skin invasion [P = 0.009], bone invasion [P < 0.001], tumor depth [≥10 vs.