J Cancer Res Clin Oncol (1988) 114:394-398

Jo0m~lol

Cancer mesearch Clinical ©neology O Springer-Verlag 1988

Glycoprotein tumour markers in head and neck neoplasms- a consecutive study on CA-50, CA 19-9, and CEA *

Hans Gustafsson, Lars Franz6n, Kjell Grankvist, Matti Anniko, and Roger Henriksson Departments of Oncology, Otorhinolaryngology, Head and Neck Surgery, and Clinical Chemistry, Ume~ University Hospital, S- 90185 UmeS_, Sweden

Summary. Serum levels of three glycoprotein tumour antigens (carcino-embryonic antigen, CEA; cancer- associated antigen 50, CA-50; gastrointestinal cancer- associated antigen, CA 19-9) were determined on 125 consecutive patients with tumours of the head and neck region. Elevated CEA values (> 5 units/ml) were found in 13/70 squamous cell carcinomas, 3/21 benign and 4/18 malignant salivary gland neoplasms. Ele- vated CA-50 values (> 17 units/ml) were found in 19/ 70 squamous cell carcinomas, 6/18 malignant and 1/21 benign salivary neoplasms. CA 19-9 displayed higher values (> 37 units/ml) in 9/68 squamous cell carcino- mas, 4/18 malignant and none of 21 benign salivary gland tumours. Combination of CEA and CA-50 analyses increased the proportion of elevated values to 30/70 in squamous cell carcinomas and 10/18 in sali- vary gland malignancies. In squamous cell carcinomas no correlation between staging or grading and serum levels was detected for any of the markers. Among malignant salivary gland tumours, CA-50 displayed enhanced serum values in 4/6 mucoepidermoid carci- nomas. The mean values for CA-50 and CA 19-9 serum levels were significantly higher for malignant salivary gland neoplasms compared to benign tu- mours. There was a close correlation between CA-50 and CA 19-9 serum levels. Although, the results sug- gest that at present none of the tumour markers tested have a place alone in the routine examination of pa- tients with tumours affecting the head and neck re- gion, further studies on salivary gland neoplasms and combinations of the tumour markers are justified.

Key words: Tumour marker, Carbohydrate antigen, squamous cell carcinoma, salivary gland neoplasm

* This study was supported by grants from the Swedish Society for Cancer Research and Lions Research Foundation, Ume~ Sweden

Offprint requests to: Roger Henriksson, Department of Oncology, University of Umegt, S-901 85 Umefi, Sweden

Introduction

The role of serum tumour markers in staging and as an adjuvant in prognosis of patients with head and neck neoplasms has attracted considerably less inter- est, compared to other tumours (Neville 1985). This may partially be due to the fact that the most common antigens and antibodies have been detected and devel- oped from other types of neoplasms in other regions of the body. Carcino-embryonic antigen (CEA), cancer-associated antigen 50 (CA-50) and gastrointes- tinal cancer-associated antigen (GICA, CA 19-9) are identified by monoclonal antibodies defining different tumour- associated carbohydrate antigens on cell membranes (Hammarstr6m 1985). They were primar- ily detected in colorectal carcinomas. However, CEA has been detected in salivary gland tumour tissue (McDicken and Scott 1981; Caselitz et al. 1981), and also in sera of patients with squamous cell carcinomas (Schr6der and Meyer 1986; Airoldi et al. 1986). CA 1%9 has been detected in oral squamous cell carcino- mas (Airoldi et al. 1986) and CA-50 is present in nor- mal rat mucosa tissue (Geterud et al. 1987).

The aim of the present study was to consecutively scan the serum levels of the glycoprotein antigens CEA, CA-50 and CA 19-9 in patients with tumours of the head and neck region in order to evaluate their possible application for screening or follow-up.

Materials and methods Patients

Serum samples were obtained from 150 patients with suspected or confirmed head and neck tumours. Patient consent was obtained be- fore blood sampling. In 125 cases the diagnosis was microscopically confirmed and analysis of CEA, CA-50 and CA 19-9 performed. There were 75 male patients and 50 female, 34 were smokers and 13 ex-smokers. Tumour diagnoses are shown in Table 1. Tumour local- izations for squamous cell carcinomas are described in Table 3. In 49 cases of squamous cell carcinoma TNM staging (Table 2 a) and grad- ing (Table 2b) was performed.

H. Gustafsson et al.: Glycoprotein tumour markers 395

Analysis

Serum CEA was determined using an enzyme-linked immunosor- bent assay (Enzymun-Test CEA) from Boehringer-Mannheim GmbH, Mannheim, FRG. Serum CA-50 was determined using the CanAg Ca-50 RIA inhibition test from Stena Diagnostics, Gothen- burg, Sweden. The test is based on the ability of serum containing elevated levels of the CA-50 antigen to inhibit the binding of CA-50 monoclonal antibodies to plastic absorbed purified CA-50 ganglio- side antigen (Lindholm and Johansson 1985). Serum CA 19-9 was determined using a solid phase radioimmunoassay from Abbot Diagnostics Products GmbH, Wiesbaden-Delkenheim, FRG. The limit of detection for CEA was 2.5 units/ml, and for CA-50 10 units/ ml. In calculations, estimated values (for CEA 1.0 unit/ml, and for CA-50 5.0 units/ml) were used for subliminal values. In the calcula- tions CEA values > 5.0 units/ml, CA-50 values > 17 units/ml and CA 19-9 >37 units/mI were regarded as positive serum samples. These were based on results from the respective manufacturers: for CEA 95 % of 640 healthy individuals displayed values between 0 and 4.9 units/ml; for CA-50 in 500 healthy persons the mean + 2 SD was 17 units/ml; and for CA 19-9 1539 healthy subjects had values >37 units/ml.

Table 2. Proportion of positive sera in relation to stage and grade of squamous cell carcinoma

a)

Stage q CEA CA-50 CA/19-9 >5 >17 >37

units/ml

T1 1i ] 4 4 0

12/49 T2 2 4 2 T3 15 4 3 3 T4 11 l 1 4 1

NO 36 ] 8 13 4 N1 8 / 4 9 3 2 1 N3 5 0 0 1

b)

Grade CEA CA-50 CA/19-9 >5 >17 >37

Statistics

The X 2 test, the FisheFs exact test and the Pearson correlation coef- ficient were used for comparison of individual turnout types.

Results

The serum levels of CEA, CA-50 CA 19-9 are depicted in Fig. I a-c. The proportions of elevated serum levels for these turnout markers in individual tumour types are shown in Table 1.

CEA values higher than 5 units/ml were found in 21 cases in the total sample, in 13 out of 70 squamous cell carcinomas (19%), in three of 21 benign (16%) and 4 of 18 (22%) malignant salivary neoplasms. Ele- vated CA-50 values ( > 17 units/roll were found in 19/ 70 squamous cell carcinomas (27%), and 6/18 malig- nant salivary neoplasms (33 %), while only 2 of 21 be- nign salivary neoplasm had an elevated serum value. Levels of CA l 9-9 displayed a similar distribution to the CA-50 values; however, the proportion of positive samples ( > 37 units/ml) was markedly lower; 9/68 of

Table 1. Number of patients with elevated serum levels of the tumour markers for the different diagnose

units/ml

Well- 14 4 6 1 differentiated

Moderately 43 9 11 8 differentiated

Poorly 6 1 1 0 differentiated

Table 3. Proportion of positive sera in relation to the localization of the tumour in squamous cell carcinoma

Local t/ CEA CA-50 CA/I 9-9 >5 >17 >37

units/ml

Oral cavity 23 3 7 4 Otopharynx 2 1 0 0 Epipharynx 6 0 1 1 Hypopharynx 5 1 0 0 Nasal cavity 2 0 0 0 Sinus 3 0 1 1 Larynx 18 6 8 1 Lymphoid glands 5 2 1 0 Skin 4 0 0 1 Oesophagus 2 0 1 1

Diagnosis r/ CEA CA-50 CA/19-9 >5 >17 >37

units/ml

Squamous cell carcinoma 70 13 Benign salivary neoplasm 21 3 Malignant salivary neoplasm 18 4 Lymphoma 5 0 Nasal papilloma 3 1 Melanoma 4 0 Others 4 0

Total 125 21

19 9 2 0 6 4 0 0 0 0 1 0 0 0

28 13

squamous cell carcinomas were increased (13.2%), none of 21 benign salivary neoplasms and 4 of 18 of salivary malignancies (22%).

Of the 5 lymphomas, 3 nasal papillomas, 4 mela- nomas, 1 sarcoma, 1 metastatic seminoma and 2 tran- sitional cell carcinomas of the nose, only i nasal papil- loma was positive for CEA, and only 1 melanoma was slightly positive for CA-50.

For squamous cell carcinomas no correlation be- tween staging or tumour grade and serum levels were detected for any of the markers (Table 2 a and b). In

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o Fig. 1. Concentrations of tumour antigens in serum for different di- agnoses a) careino-embryonie antigen (CEA), b) cancer-associated antigen 50 (CA-50), e) gastrointestinal cancer-associated antigen (CA 19-9). The upper normal limits are indicated by dotted lines

H. Gustafsson et al.: Glycoprotein tumour markers 397

Table 4. Proportion of positive sera in salivary neoplasm

Salivary neoplasm r/ CEA CA-50 CA/19-9 >5 >17 >37

units/ml

Mucoepidermoid carcinoma 6 0 4 2 Adenoid cystic carcinoma 3 1 1 1 Acinic cell carcinoma 3 1 1 1 Malignant mixed tumour 3 1 0 0 Adenocarcinoma 2 1 0 0 Salivary duct carcinoma 1 0 0 0

Malignant salivary neoplasm 18 4 6 4

Benign salivary neoplasms 21 4 2 0

Table 5. Mean_+ SEM for the different markers in salivary gland neoplasms

q CEA CA-50 CA-19/9

Benign 21 2.4-+0.6 9.5-+1.8 10.9-+1.5 tumours

Malignant 18 3.5_+1.0 16.9+2.9" 24.1_+4.9" tumours

* P<0.05

Table 6. Correlation of the tested markers to each other - coeffi- cients of correlation

Diagnosis Pearsons Fishers P value correlation test coefficient

Squamous cell carcinoma CEA vs CA-50 0.04 0.82 0.82 CA-50 vs CA/19-9 0.59 6.8 0,002 CEA vs CA/19-9 -0 .13 1.04 0.31

Benign salivary neoplasm CEA vs CA-50 0.00 0.051 0.64 CA-50 vs CA/19-9 0.40 - - CEA vs CA/I%9 -0 .08 -

Malignant salivary neoplasm CEA vs CA-50 -0 .17 1.13 0.15 CA-50 vs CA/19-9 0.78 6.06 0.007 CEA vs CA/19-9 - 0 . 1 4 0.28 0.37

Table 7. The mean value __+ SEM of the different markers with regard to sex

Marker Men Female P value

CEA 2.8_-4-0.3 2.8_+0.3 0.80 CA-50 15.2±0.9 12.4_+ 1.1 0.14 CA/19-9 18.4_+2.1 13.8 -+ i .3 0.08

none of the patients were distant metastasis observed. The proportions of positive samples in different local- izations are shown in Table 3. Of laryngeal carcino- mas, 6 were positive for CEA, and also 8/18 for CA- 50. Of 23 oral carcinomas, 7 were CA-50 positive, otherwise no other localizations had more than 2 posi- tive sera for any of the markers.

For malignant salivary gland tumours CA-50 dis- played the highest proportion of positive sera (6/18). Of 6 mucoepidermoid carcinomas, 4 were positive for CA- 50 (Table 4). The mean values for CA-50 and CA 19-9 were significantly higher for malignant salivary gland neoplasms as compared to benign tumours (Table 5). CEA did not differ significantly between malignant and benign tumours.

Fishers exact test showed a correlation between positive CA-50 and positive CA 19-9 values in both squamous cell carcinomas and malignant salivary gland neoplasms (Table 6). Benign salivary neoplasms could not be tested as no positive CA 19-9 values were seen. Positive CEA values were not related to other positive serum levels. Pearson correlation coefficients showed a similar correlation for the absolute serum values. Addition of CEA assay to CA-50 determina- tion increased the proportion of positive findings from 19 to 30/70 in squamous cell carcinomas and from 6 to 10/18 in malignant salivary gland neoplasms.

There were no significant differences between sexes, although CA 19-9 showed a tendency to higher values in men (Table 7). Only CEA displayed a posi- tive correlation to smoking, with a significantly higher proportion of positive sera in smokers (corrected Z 2 test 1.8; P<0.05).

Discussion

The present study displayed a low positive predictive value for the glycoprotein tumour markers CEA, CA- 50 and CA 19-9 with regard to head and neck tu- mours. Although maybe of only limited diagnostic value, CA 19-9 and CA-50 demonstrated interesting differences between malignant and benign salivary gland tumours.

CEA has been shown to be present in tissue samples from both benign and malignant salivary gland tumours (Caselitz et al. 1982; McDicken and Scott 1981). In particular, glandular differentiated tu- mours displayed a high prevalence of CEA staining. This suggested the possibility of post-operative moni- toring of saliva and plasma particularly where residual tumour, metastasis or recurrences were considered likely. Even though the present study includes a limited number of cases, it supports previous views that serum levels of CEA cannot be used to separate malignant from and benign neoplasms (Silverman et

398 H. Gustafsson et al.: Glycoprotein tumour markers

al. 1976; Schrtder and Meyer 1986). In this respect, however, CA-50, may be useful. High proportions of positive sera were found in mucoepidermoid carcino- mas. Acinic cell carcinomas and adenoid cystic carci- nomas also displayed some positive values, whereas none of the 6 cases of adenocarcinomas and salivary duct carcinomas were positive. However, it has to be noted that the time of sampling was at diagnosis. A higher proportion of positive sera might perhaps be found in metastatic tumours when the tumour burden is larger.

An interesting observation, with regard to the lo- calization of the tumour and tumour size, was the rel- atively high proportion of positive sera in the larynx carcinomas, tumours which are often detected early, still having a small volume. The rationale for this is not evident but indicates that squamous cell carci- noma of the larynx may differ in biological character- istics from carcinomas of other localizations. There were no other differences, with regard to TNM classi- fication or differentiation of the squamous cell carci- nomas.

Although the antigens are not identical, both CA- 50 and CA 19-9 are known to be related to the Lewis blood group antigen (Hammarstrtm 1985). This study confirms the close relationship between the gly- coprotein markers CA-50 and CA 19-9 (Hammar- strtm 1985; Paganuzzi et al. 1985). In our study and in others (Bruhn et al. 1985), CA-50 seemed to display a higher sensitivity, suggesting that CA-50 in general is to be preferred over CA 19-9. In contrast, CEA did not correlate with any of the other markers tested, and might thus be a complement to any of the other markers in serum assays. In fact, addition of CEA as- say markedly increased the fraction of positive sera as compared to CA-50 determination alone.

In conclusion, at present none of the markers tested deserve a place in the routine examination of patients with tumours affecting the head and neck re-

gion. However, combination of antigens might be more fruitful. Furthermore, CA 19-9 and especially CA-50 seem to have an interesting connection with malignant salivary gland neoplasms, and, thus, fur- ther studies are justified.

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Received January 18, 1988/Accepted February 24, 1988