Scandinavian Journal of Clinical & Laboratory Investigation, 2015; Early Online: 1–7
ORIGINAL ARTICLE
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Comparison of tumor markers and inflammatory biomarkers in chronic obstructive pulmonary disease (COPD) exacerbations
NIKOLAOS BAROUCHOS1,2,3, ATHANASIA PAPAZAFIROPOULOU4, NICOLETTA IACOVIDOU5, NIKOLAOS VRACHNIS6, NEKTARIOS BAROUCHOS1, ELENI ARMENIAKOU1,2, VASILIKI DIONYSSOPOULOU2, ALEXANDROS G. MATHIOUDAKIS1,3, ELENI CHRISTOPOULOU1,3, SPIRIDOULA KOLTSIDA1 & ELENI BASSIAKOU1 1National
and Kapodistrian University of Athens, Medical School, Athens, 2Intensive Care Unit, 3Pulmonary Department, and 43rd Pathology Department – Diabetes Center, General Hospital of Nikaia “St. Panteleimon”, Piraeus, 52nd Department of Obstetrics and Gynecology, Neonatal Division, National and Kapodistrian University of Athens, Medical School, Athens, Greece, and 62nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Medical School, Athens, Greece
Abstract Objective. The aim of the present study was: (a) to measure levels of the tumor markers, Carcinoembryonic antigen (CEA), Cancer antigen 19-9 (CA19-9), Cancer antigen 125 (CA125), Neuron specific enolase (NSE) and Cytokeratin fragments 19 (CYFRA21-1); (b) to investigate any correlation between them and the inflammatory biomarkers C-reactive protein (CRP), Erythrocyte sedimentation rate (ESR) and white blood cells count (WBC), in patients with chronic obstructive pulmonary disease (COPD) exacerbation, who belong in groups of severity C and D, as classified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD); (c) and finally, to compare these results in these two groups. Material and methods. Fifty-two patients with COPD exacerbation [35 male/17 female, mean age ( SD) 68.3 6.4 years] were the study subjects, and were classified in severity groups C (n 27) and D (n 25), based on the spirometric classification, the number of exacerbations in the preceding year and the assessment of their symptoms by GOLD. Results. CEA and CA125 were increased in group D. In group C, there was a significant correlation between CRP and CA125 (p 0.05). In group D, there was a significant correlation between WBC and NSE (p 0.02), between CRP and CA19-9 (p 0.02) and NSE (p 0.001), and between the ESR and NSE (p 0.03). CA125 (p 0.01) and CA19-9 (p 0.01) were significantly higher in group D compared to group C. In contrast, there was no significant difference in two groups for NSE, CEA and CYFRA21-1. Conclusion. Certain tumor markers were increased and were associated with increased levels of inflammatory biomarkers and with the disease severity. Inflammation might have a key pathogenetic role linking the above tumor markers with the severity of COPD. Key Words: Blood sedimentation, chronic obstructive pulmonary disease, C-reactive protein, disease exacerbation, leukocytes, tumor markers
Introduction Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide with a great impact on health economics and the society as its prevalence increases progressively over the last years [1–3]. COPD exacerbations are one of the most common causes of hospitalization among these patients
[4–6]. Based on the spirometric classification, on the number of exacerbations in the preceding year and on the assessment of symptoms, patients with COPD are classified in four groups of severity (A, B, C, D) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) [7–10]. Several studies so far have shown that in COPD exacerbation, inflammatory biomarkers such as
Correspondence: Nikolaos Barouchos, MD, MSc, Medical School of National and Kapodistrian University of Athens, 75 Mikras Asias Street, 115 27 Athens, Greece. Tel: 30 21057 49479. E-mail: [email protected] (Received 8 July 2014 ; accepted 25 November 2014 ) ISSN 0036-5513 print/ISSN 1502-7686 online © 2015 Informa Healthcare DOI: 10.3109/00365513.2014.992944
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C-reactive protein (CRP), White blood cells count (WBCs) and Erythrocyte sedimentation rate (ESR) are increased [11–14]. Additionally, it has been observed that tumor markers, Cancer antigen 19-9 (CA19-9) and Cancer antigen 125 (CA125) are increased in relation to the severity of COPD [15]. However, the existing literature data regarding the prognostic value of several tumor markers on lung diseases are conflicted. It has been shown that serum levels of other tumor markers, such as Carcinoembryonic antigen (CEA), Neuron specific enolase (NSE) and Cytokeratin fragments 19 (CYFRA21-1), did not differ between patients with lung cancer compared to patients with non-neoplastic lung diseases, such as acute pneumonia, COPD and interstitial lung diseases [16,17]. However, the existing literature data regarding the pathogenetic role of tumor markers in COPD exacerbations are limited. Therefore, the aim of the present study was to evaluate the serum levels of aforementioned tumor markers (CA125, CA19-9, CEA, NSE and CYFRA21-1) in patients with COPD exacerbation, who belong in severity groups C and D by GOLD and to investigate whether a correlation, between them and the inflammatory biomarkers (CRP, ESR and WBCs) exists. We also aimed at comparing these results in the two groups under investigation.
Materials and methods Ninety-nine patients with COPD exacerbation were enrolled in the study. Exclusion criteria were: lung [18–20], pancreatic [21], ovarian [22,23] and colorectal cancer [24,25], or any other kind of known neoplasia, using data obtained from their medical history. Patients with heart failure were excluded as well as existing studies suggest that tumor markers CA19-9 and CA125 are increased in patients suffering from this condition [26]. Patients with pneumonia, cystic fibrosis or with a known collagen disease [17,20], and with any other inflammatory or infectious diseases which increase inflammatory biomarkers CRP, ESR and WBC were also excluded. Finally, we did not include patients of severity groups A and B, because they are at low risk and have a lower risk for exacerbation [7] and only a small percentage of them may present in the emergency department with COPD exacerbation. On final evaluation (clinical and laboratory) 47 of them were excluded; 12 had various kinds of malignancy, seven had acute pneumonia, three had collagen disease with pulmonary involvement, 16 had heart failure and nine after classification of COPD severity by GOLD belonged in groups A and B. Finally, 52 patients with acute exacerbation of COPD fulfilled the inclusion criteria [35 males/17 females, mean age ( standard deviation) 68.3 6.4 years] and were included. They were hospitalized (from October 2012 to April 2013) in the Pulmonary
Department of the General Hospital of Nikaia “St. Panteleimon”, Piraeus, until the remission of exacerbation and discharge from the hospital. General Hospital of Nikaia is a tertiary hospital with 40,000 admissions approximately annually and covering about one million people in the greater area of Piraeus. All patients gave informed consent prior to their participation in the study. The study was approved by the Hospital’s Ethics Committee. Patients were classified in severity groups C and D by GOLD based on spirometric classification, on the number of exacerbations in the preceding year, using data obtained from medical history and on the assessment of symptoms especially of dyspnea using the modified British Medical Research Council (mMRC) questionnaire [7–10]. On the admission day the following investigations were performed: arterial blood gases determination and blood pH (arterial blood gas analyzer Nova-Biomedical, Start Profile, Critical Care Xpress-UK). Arterial oxyhemoglobin saturation (SpO2) was measured non-invasively by pulse oximetry (Nonin GO2 LCD-USA). Measurement of inflammatory biomarkers CRP, ESR WBC and of tumor markers CA125, CA19-9, CEA, NSE and CYFRA21-1 in venous blood collected prior to the administration of antibiotics or any other medication. Blood for the evaluation of tumor markers was collected in plastic tubes without anticoagulant and was left at room temperature for 30 min, until coagulated. The samples were then centrifuged at 3,000 rpm for 15 min (Hettich zentrifugen D-78532 Tuttlingen, Germany) and the serum was kept at 80°C until processed (within a week of collection). C-reactive protein was measured on a Turbi-Quick analyzer, Vital Diagnostics (Italy), and ESR on a Vesmatic 20 analyzer, Menarini Diagnostics (Italy). WBCs count was calculated by a Sysmex Corporation XE-5000 analyzer (Japan). CA19-9, CA 125 and CEA were measured on an Architect i2000SR Abbott analyzer (USA). NSE was measured on a Liaison, Diasorin analyzer (Italy) and CYFRA21-1 on a Cobas 6000, Roche analyzer (Switzerland). Serum CA19-9, CA125 and NSE concentrations were measured by the chemiluminescence method, CEA by the Immunochemiluminescent Metric Assay (ICMA), while serum CYFRA21-1 by the electrochemiluminescence method. The serum reference range of CA125 and CA19-9 was 35 and 37 KU/L, respectively. For CEA, the reference range for smokers and non-smokers was 3 and 10 μg/L, respectively. The serum reference range of NSE and CYFRA21-1 was 20 and 3.3 μg/L, respectively. On admission day chest radiograms were taken (X-ray Generator Philips Optimus 5-Germany), electrocardiogram was recorded (CardiMax FX-7202 Fukuda Denshi, Japan) and echocardiography was performed by portable echocardiograph (CX50 xMATRIX Philips, The Netherlands).
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Tumor markers in COPD exacerbations The patients answered the mMRC questionnaire one day prior to their discharge home, in order to assess their symptoms, particularly dyspnea. On the day of discharge, pulmonary function was evaluated by a spirometer after bronchodilatation, (400 mcg inhaled salbutamol), in order to record Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC) and the ratio of FEV1/ FVC. According to these measurements, patients were classified in COPD spirometric stage of severity by GOLD. The spirometer used was Pulmonary Function Testing FRC & DLCO modules-Quark PFT4 (Cosmed, Italy). Predicted volumes were yielded from standard nomograms for comparison. Statistical analysis All collected data were coded and typed to be statistically processed. The SPSS 19.0 (SPSS Inc, Chicago, IL, USA) statistical program was used. All variables were tested for normal distribution using the Kolmogorov-Smirnov assay. Logarithmic transformation was done for all variables which were not normally distributed, in order to be used in the analysis. For normally distributed data, t-test for independent pairs of observations was used for the comparison of normally distributed quantitative characteristics between the different groups while χ2 test was used for the comparison of qualitative characteristics. The Pearson’s correlation coefficient r was used to control the associations between the quantitative parameters. The multivariate regression analysis was used in order to find independent associations between WBC, CRP and ESR levels and the studied tumor markers. For each study group three models were created with dependent variables WBC, CRP and ESR and independent variables the five examined tumor markers. All independent variables in the multivariate analysis models were tested for multi-linearity; p-values 0.05 were considered statistically significant.
Results Twenty-seven patients (51.9%) were classified as group C and 25 (48.1%) as group D according to the COPD severity. Demographic and clinical characteristics of study patients are shown in Table I. Some 36.5% of study patients were current smokers, 59.6% ex-smokers, while only 3.8% never smoked. Hypoxia (paO2 60 mmHg) was present at the 59.6% of the study patients and hypercapnia (paCO2 45 mmHg) at the 19.2%. Regarding the received medication for COPD; all subjects received inhaled anticholinergics, 65.4% inhaled short acting β2 agonists, 38.5% inhaled long acting β2 agonists and 61.5% combination of inhaled corticosteroids
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Table I. Demographic and clinical characteristics of the study patients. Number of patients (%) Gender Male Female COPD severity Group C Group D Smoking status Current Former Never Hypoxia (yes) Hypercapnia (yes) Received therapy Anticholinergic (inhaler) (yes) Short acting β2-agonist (inhaler) (yes) Long acting β2-agonist (inhaler) (yes) Theophylline (oral) (yes) Steroid long acting β2-agonist (inhaler) (yes) Steroid (inhaler) (no) Steroid (oral) (no) Inhibitors Phosphodiesterase-4 (oral) (yes)
35 (67.3%) 17 (32.7%) 27 (51.9%) 25 (48.1%) 19 31 2 31 10
(36.5%) (59.6%) (3.8%) (59.6%) (19.2%)
52 34 20 25 32 52 52 16
(100%) (65.4%) (38.5%) (48.1%) (61.5%) (100%) (100%) (30.8%)
and long acting β2 agonists. Theophylline orally received the 48.1%, and orally inhibitors of fosfodiesterasis-4 (PDE4) the 30.8% of the patients. However, corticosteroids either orally or inhaled as a single therapy were not given to any of the patients. Patients in group D had higher levels of CA125 compared to group C (53.8 4.6 versus 14.1 5.4 KU/L, respectively, p 0.01) and higher levels of CA19-9 (21.8 5.4 versus 11.5 2.5 KU/L, respectively, p 0.01). In contrast, there was no significant difference in two study groups regarding the levels of NSE, CEA and CYFRA21-1. Levels of CRP were higher in group D compared to group C (61.8 8.9 versus 15.1 3.9 mg/L, respectively p 0.01).There was no significant difference between study groups regarding the number of WBCs and ESR (Table II). Then we investigated possible associations between inflammatory biomarkers and the tumor markers under study (three models for each inflammatory biomarker were used in the multivariate analysis). In group C multivariate regression analysis showed a positive relation between CRP and CA125 (p 0.05). However, no such relation between WBCs and ESR and the studied tumor markers was observed. In group D multivariate regression analysis showed a positive relation between WBCs and NSE (p 0.02), between CRP and CA19-9 (p 0.02) and NSE (p 0.001) as well as between ESR and NSE (p 0.03). Discussion The results of the present study showed that levels of CA125 and CA19-9 increased in patients with
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N. Barouchos et al. Table II. Demographic and laboratory parameters of study patients according to chronic obstructive pulmonary disease (COPD) severity.
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COPD severity
Age (years) WBC (x10E9/L) CRP (mg/L) ESR (mm/h) CEA (μg/L) CA19-9 (KU/L) CA125 (KU/L) NSE (μg/L) CYFRA21-1 (μg/L) paO2 (mmHg) paCO2 (mmHg) pH HCO3- (mEq/L) SpO2 (%) Duration of COPD (years) Smoking (pack-years)
Group C
Group D
p-value
67.3 7.4 10.878 4.843 15.1 ⴞ 3.9 33.5 2.9 3.2 0.2 11.5 ⴞ 2.5 14.1 ⴞ 5.4 7.2 1.8 1.8 0.5 61.4 ⴞ 9.2 42.3 9.3 7.4 0.04 26.8 4.6 88.1 ⴞ 7.1 5.1 ⴞ 0.5 60.6 3.3
69.5 8.5 12.524 5.287 61.8 ⴞ 8.9 40.3 4.9 9.6 2.3 21.8 ⴞ 5.4 53.8 ⴞ 4.6 12.7 3.6 2.8 0.7 53.7 ⴞ 9.7 47.5 15.2 7.4 0.05 29.5 5.8 83.2 ⴞ 9.5 8.9 ⴞ 0.7 65.9 4.7
0.32 0.25 0.01 0.40 0.11 0.01 0.01 0.07 0.07 0.005 0.14 0.73 0.07 0.04 0.001 0.46
WBC, white blood cells; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; CEA, Carcinoembryonic antigen; CA19-9, cancer antigen 19-9; CA125, cancer antigen 125; NSE, neuron specific enolase; CYFRA21-1, cytokeratin fragments 19; paO2, arterial oxygen tension; paCO2, arterial carbon dioxide tension; HCO-3, bicarbonate; SpO2, arterial oxyhemoglobin saturation. Figures in bold referred to the statistically significant results, p-values0.05.
COPD exacerbation according to the disease severity. However, levels of CEA, NSE and CYFRA21-1 were not influenced. In group C, a relation between CRP and CA125 was observed. In group D, a relation between WBCs and NSE, CRP and CA19-9 and NSE, as well as between ESR and NSE was observed. Even though serum tumor markers were introduced for monitoring the response to therapy in patients suffering from cancer and for detecting early relapse in malignancy, it has been reported that elevated levels of several tumor markers can also be detected in benign diseases and that their levels can be increased in non-neoplastic lung diseases [17,20,27]. COPD is defined as an incompletely reversible airflow limitation associated with inflammation, in which monocytes and macrophages are the predominant inflammatory cells. Various inflammatory mediators derived from these inflammatory cells are suggested to contribute to the chronic inflammation and cause lung tissue damage [15]. Cancer antigen 125 Cancer antigen 125 is a glycoprotein that is synthesized and secreted by normal epithelial cells of central airways and/or respiratory glands and that this substance is not a specific indicator of abnormal cellular activity [28]. It is most often associated with epithelial ovarian cancer [15]. Elevated CA-125 levels are seen in various other malignant conditions such as lung and breast cancer [29] and also in
benign pulmonary diseases. The CA125 can be used to identify COPD patients with right ventricle failure [30]. Serum CA125 levels were higher in idiopathic pulmonary fibrosis (IPF) patients than normal values and higher than those of the COPD patients [31]. Serum CA125 was related to the activity and severity of pulmonary tuberculosis (TB) [32]. Furthermore, increased serum levels of CA125 in cystic fibrosis (CF) patients were associated with severe CF transmembrane conductance regulator mutations and a severe phenotype [32], while an impressive increase of CA125 has been also observed in acute bronchopneumonia [20]. In this study mean value of CA125 was increased in group D, but not in group C. In accordance with our results, Bulut and co-workers reported that CA125 levels were significantly higher in patients with very severe COPD than in patients with moderate and severe COPD [15], since mean value of CA125 was significantly higher in group D than in group C. Chronic bronchitis patients, regardless of smoking status, presented on bronchial biopsies with focal squamous metaplastic change, goblet cell hyperplasia and enlargement of the bronchial gland mass because of the inflammatory process [34], and the elevation of serum CA125 might be attributed to this process. An important finding of our study that has not been described previously in the literature, to the best of our knowledge, is that in group C, a statistically significant correlation was observed between CRP and CA125 emphasizing the potential role of inflammation.
Tumor markers in COPD exacerbations
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Cancer antigen 19-9 Cancer antigen 19-9 is an intercellular adhesion molecule that is synthesized and secreted by normal epithelial cells of central airways and/or respiratory glands such as CA125 [28]. Primarily increased in patients with pancreatic and biliary tract cancer [15], but also in lung tumors, especially in adenocarcinomas, are a known fact, although uncommon [35]. A few investigators have reported elevated serum CA19-9 levels in patients with non-malignant respiratory diseases, such as idiopathic interstitial pneumonia and diffuse panbronchiolitis, bronchiectasis, collagen disease-associated pulmonary fibrosis and tuberculosis. In previous studies that used immunohistochemical staining, CA19-9 was reported to be selectively expressed in regenerating epithelial cells associated with inflammatory changes in the peripheral lungs, in patients with idiopathic interstitial pneumonia and diffuse panbronchiolitis, regardless of the etiology. The mechanisms increasing serum CA19-9 levels in non-malignant disease are not clear [36]. In this study mean value of CA19-9 was not elevated, neither in group C, nor in group D in our patient population. This finding was not expected. As we mentioned above, the CA19-9 serum levels was elevated in benign pulmonary diseases that are associated with lung inflammatory changes. In contrast, we expected some elevation of the CA19-9 levels in patients with COPD exacerbation due to the inflammatory process. Also mean value of CA19-9 was significantly higher in group D compared to group C. In agreement with our results, a previous study has shown that CA19-9 levels were significantly elevated in patients with very severe COPD compared to patients with moderate and severe COPD [15]. In addition, a result of this study that has not been described previously in the literature to the best of our knowledge, is the significant correlation between the levels of CRP and CA19-9 that we observed in group D. Probably this finding can be attributed, to the presence of chronic inflammatory lung changes. Carcinoembryonic antigen Carcinoembryonic antigen is an oncofetal glycoprotein that is involved in cell adhesion; its production normally starts during fetal development but ceases shortly after birth, and only a very small amount can be detected in the serum of healthy persons CEA can be produced in the epithelium of mouth, stomach, intestines, bile ducts, and respiratory tract ranging from the trachea to the alveoli [37]. The CEA serum levels is a marker of malignant diseases such as lung cancer [24] and can also be elevated in benign respiratory diseases, such as idiopathic lung fibrosis, bronchial asthma with mucoid impaction, in allergic bronchopulmonary aspergillosis (ABPA). In ABPA
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elevation of serum CEA levels might be associated with consolidation in the lung and might be attributed to the presence of local inflammation. This finding suggests that CEA is correlated with the inflammatory activity of ABPA [37]. Furthermore, higher concentrations of CEA are detected in men vs. women [38], elderly vs. younger [39] and smokers vs. non-smokers [40]. In the present study, mean value of CEA was elevated in group D, but not in group C. However, there was not a statistically significant difference between them. In a previous study Bullut and coworkers, showed that patients with very severe COPD and Cor Pulmonale had a significantly higher mean value of CEA serum levels [15]. The elevation of CEA might be attributed to the presence of local lung inflammation. The role of CEA elevation remains unclear. Larger numbers of cases should be collected and evaluated. Furthermore, no association was observed between CEA and the inflammatory biomarkers under investigation in both groups.
Enolase Enolase molecules in mammalian tissues are dimers composed of three immunologically distinct subunits (α, β and γ). The γ subunit, which has been designated as NSE, is highly concentrated in neurons, neuroendocrine cells, and neurogenic tumors [41]. NSE is used in the diagnosis and monitoring of patients with small cell lung cancer (SCLC) and can be taken as a distinguishing marker between SCLC and non-small cell lung cancer (NSCLC), given that SCLC is a neurosecretion tumor, that results in NSE expressing highly in SCLC patients [42]. Significant levels of γ-enolase have also been found in bronchial epithelial cells, and type II pneumocytes [41]. However, NSE was elevated in patients with benign pulmonary diseases. The highest levels were observed in patients with diseases associated with lung infiltrates (tuberculosis, embolism, pneumonia) as opposed to those not so associated (COPD, asthma). These data suggest that alveolar, interstitial, or distal airway damage or perhaps local hypoxia could contribute to the release of NSE. In fact, NSE has been found immunohistochemically in ganglion cells and nerve fibers throughout the respiratory tract. On the other hand, hypoxia appears to have a role in the immunoreactive expression of enolase in lung cancer cells [43]. In the present study, as we expected, the mean value of NSE was not increased neither in group C, nor in group D. Furthermore, the mean value of NSE was not significantly different between groups C and D. This finding is in agreement with the above observations. In group D, a significant correlation existed between mean values of NSE and CRP, ESR and WBCs. We therefore observed that NSE was the
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unique tumor marker, which is correlated with all three inflammatory biomarkers under investigation. Perhaps expression of NSE is associated with chronic inflammation that occurs in COPD patients, a finding that requires further investigation.
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Cytokeratin 19 (CK-19) Cytokeratin 19 (CK-19) is a protein component of the intermediate filament protein in epithelial cells. When epithelial cells transform into malignant cells, the keratin content is increased. Due to necrosis of tumor cells, the soluble fragment CYFRA21-1 of CK-19 is released into the blood. However, CYFRA21-1 in serum will increase when epithelial cells transform into cancerous tumor cells, especially squamous epithelial cells of the lung and bladder transitional cells. CYFRA21-1 is a sensitive tumor marker for diagnosis and monitoring of NSCLC, particularly in squamous cell tumors [42]. Elevated serum CYFRA21-1 levels were observed in some non-malignant respiratory diseases, especially in IPF and collagen disease associated pulmonary fibrosis (CDPF). The value of serum CYFRA21-1 would reflect the severity of lung injury in non-malignant respiratory diseases and might be related to the prognosis in patients with IPF and CDPF [44]. Serum CYFRA21-1 is a sensitive and useful marker for diagnosis and evaluation of disease severity of autoimmune pulmonary alveolar proteinosis (APAP), and may predict the response to granulocytemacrophage colony-stimulating factor (GM-CSF) inhalation. Immunohistochemistry showed that CYFRA21-1 was localized on hyperplastic alveolar type II cells and lipoproteinaceous substances in alveoli [45]. In this study the mean value of CYFRA21-1 was not increased neither in group C nor in group D, as expected. In COPD patients epithelial cells did not transform into cancerous tumor cells. Also, no statistically significant difference existed between the two groups. However, the present study failed to show any relation between CYFRA21-1 levels and the severity of COPD. This finding is in agreement with a previous one that indicated that the mean value of CYFRA21-1 in serum was not increased and did not differ significantly between patients with COPD and those with lung cancer [16]. Finally, there was not a correlation between CYFRA21-1 and any of the inflammatory biomarkers under investigation. Our study has some limitations. First of all, the number of patients enrolled in the study was small and therefore our results cannot be extrapolated to the general population. A second, major limitation is that we did not perform any computer tomography scan, nor cytological examination of biological fluids in order to exclude coexisting malignancy in study patients. Thus the exclusion of any malignancy was based on medical history. Furthermore the data
presented were based on one serum sample, and although serial blood tests for tumor marker levels could reinforce our findings, the trend seen in our results was clear, even from one measure. In conclusion, levels of CA 125 and CA 19-9 increased in patients with COPD exacerbation according to the disease severity. Inflammation might have a key pathogenetic role linking the above tumor markers with the COPD severity. However, our results remain to be confirmed by other studies in order to introduce the tumor markers in clinical practice for the diagnosis and monitoring of nonneoplastic diseases, including COPD. A biomarker or a panel of biomarkers that allows a more precise etiologic diagnosis might be desirable. The clinical utility of these results at this point of time is unknown and deserves future research.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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measurements in exacerbations of chronic obstructive pulmonary disease. Respir Med 1998;92:664–7. Buess T, Ludwig C. Diagnostic value of C-reactive protein in comparison with erythrocyte sedimentation as routine admission diagnostic test. Schweiz Med Wochenschr 1995; 125:120–4. Saldías PF, Díaz PO, Dreyse DJ, Gaggero BA, Sandoval AC, Lisboa BC. Etiology and biomarkers of systemic inflammation in mild to moderate COPD exacerbations. Rev Med Chil 2012;140:10–8. Bulut I, Arbak P, Coskun A, Balbay O, Annakkaya AN, Yavuz O, Gülcan E. Comparison of serum CA 19.9, CA 125 and CEA levels with severity of chronic obstructive pulmonary disease. Med Princ Pract 2009;18:289–93. Hillas G, Moschos C, Dimakou K, Vlastos F, Avgeropoulou S, Christakopoulou I, Rasidakis A, Bakakos P. Carcinoembryonic antigen, neuron-specific enolase and cytokeratin fragment 19 (CYFRA 21-1) levels in induced sputum of lung cancer patients. Scand J Clin Lab Invest 2008;68:542–7. Sanguinetti CM, Riccioni G, Marchesani F, Pela R, Cecarini L. Bronchoalveolar lavage fluid level of carcinoembryonic antigen in the diagnosis of peripheral lung cancer. Monaldi Arch Chest Dis 1995;50:177–82. Karnak D, Beder S, Kayacan O, Ibi E, Oflaz G. Neuron-specific enolase and lung cancer. Am J ClinOncol 2005;28:586–90. Lai RS, Hsu HK, Lu JY, Ger LP, Lai NS. CYFRA 21-1 enzyme-linked immunosorbent assay. Evaluation as a tumor marker in non-small cell lung cancer. Chest 1996;109: 995–1000. Marechal F, Berthiot G, Deltour G. Serum levels of CA-50, CA-19.9, CA-125, CA-15.3, enolase and carcinoembryonic antigen in non-neoplastic diseases of the lung. Anticancer Res 1988;8:677–80. Hata S, Sakamoto Y, Yamamoto Y, Nara S, Esaki M, Shimada K, Kosuge T. Prognostic impact of postoperative serum CA 19-9 levels in patients with resectable pancreatic cancer. Ann Surg Oncol 2012;19:636–41 Sorensen SS, Mosgaard BJ. Combination of cancer antigen 125 and carcinoembryonic antigen can improve ovarian cancer diagnosis. Dan Med Bull 2011;58:A4331. Vignot S, Brochet C, Debord C, Lauratet B, Bernard M. Potential value of CA125 kinetic monitoring in the initial management of advanced epithelial ovarian cancer. Ann BiolClin 2011;69:597–604. Fletcher RH. Carcinoembryonic antigen. Ann Intern Med 1996;104:66–73. Perkins GL, Slater ED, Sanders GK, Prichard JG. Serum tumor markers. Am Fam Physician 2003;68:1075–82. Varol E, Ozaydin M, Dogan A, Kosar F. Tumour marker levels in patients with chronic heart failure. Eur J Heart Fail 2005;7:840–3. Shitrit D, Zingerman B, Shitrit AB, Shiomi D, Kramer MR. Diagnostic value of CYFRA21-1, CEA, CA19-9, CA15-3, and CA125 assays in pleural effusions: analysis of 116 cases and review of the literature. Oncologist 2005;10:501–7. Matsuoka Y, Endo K, Kawamura Y, Yoshida T, Saga T, Watanabe Y, Koizumi M, Nakashima T, Konishi J, Yamaguchi N, Yatani R. Normal bronchial mucus contains high levels of cancer-associated antigens, CA125, CA19-9, and carcinoembryonic antigen. Cancer 1990;653:506–10.
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[29] Sjovall K, Nilsson B, Einhorn N. The significance of serum CA 125 elevation malignant and nonmalignant diseases. Gynecol Oncol 2002;85:175–8. [30] Yilmaz MB, Zorlu A, Dogan OT, Karahan O, Tandogan I, Akkurt I. Role of CA-125 in identification of right ventricular failure in chronic obstructive pulmonary disease. Clin Cardiol 2011;34:244–8. [31] Rusanov V, Kramer MR, Raviv Y, Medalion B, Guber A, Shitrit D. The significance of elevated tumor markers among patients with idiopathic pulmonary fibrosis before and after lung transplantation. Chest 2012;141:1047–54. [32] Kim ES, Park KU, Song J, Lim HJ, Cho YJ, Yoon H, Lee J, Lee CT, Park JS. The clinical significance of CA-125 in pulmonary tuberculosis. Tuberculosis 2013;93:222–6. [33] Gronowitz E, Pitkänen S, Kjellmer I, Heikinheimo M, Strandvik B. Association between serum oncofetal antigens CA19-9 and CA125 and clinical status in patients with cystic fibrosis. Acta Paediatr 2003;92:1267–71. [34] Marina AE, Ciurea P, Pirici D, Ciurea R. Chronic bronchitis: a retrospective clinicopathologic study of 25 cases. Rom J Morphol Embryol 2012;53:503–13. [35] Rottenberg Y, Nisman B, Peretz T. Extreme high levels of CA19.9 associated with adenocarcinoma of the lung. Israel Med Assoc J. 2009;11:116–7. [36] Shin JY, Yoo SJ, Park BM, Jung SS, Kim JO, Lee JE. Extremely increased serum carbohydrate antigen 19-9 levels caused by new or resistant infections to previous antibiotics in chronic lung diseases. Tuberc Respir Dis 2013;75: 125–7. [37] Noguchi T, Yamamoto K, Moriyama G, Saito Y, Kyoyama H, Mikami S, Ono R, Kobayashi T, Yamana K, Evaluation of serum levels of carcinoembryonic antigen in allergic bronchopulmonary aspergillosis. Nippon Med Sch 2013;80: 404–9. [38] Beaudonnet A, Gounon G, Pichot J, Revenant MC. Sex- and age-related influences on carcinoembryonic antigen in blood. ClinChem 1981;27:771. [39] Touitou Y, Proust J, Klinger E, Nakache JP, Huard D, Sachet A. Cumulative effects of age and pathology on plasma carcinoembryonic antigen in an unselected elderly population. Eur J Cancer ClinOncol 1984;20:369–74. [40] Stevens DP, Mackay IR. Increased carcinoembryonic antigens in heavy smokers. Lancet 1973;ii:1238–9. [41] Ferrigno D1, Buccheri G, Biggi A. Serum tumour markers in lung cancer: history, biology and clinical applications. Eur Respir J 1994;7:186–97. [42] Wang R, Wang G, Zhang N, Li X, Liu Y. Clinical evaluation and cost-effectiveness analysis of serum tumor markers in lung cancer. Biomed Res Int 2013;2013:195692. [43] Collazos J, Esteban C, Fernández A, Genollá J. Measurement of the serum tumor marker neuron specific enolase in patients with benign pulmonary diseases. Am J Respir Crit Care Med 1994;150:143–5. [44] Nakayama M, Satoh H, Ishikawa H, Fujiwara M, Kamma H, Ohtsuka M, Sekizawa K. Cytokeratin 19 fragment in patients with nonmalignant respiratory diseases. Chest 2003;123:2001–6. [45] Arai T, Inoue Y, Sugimoto C, Inoue Y, Nakao K, Takeuchi N, Matsumuro A, Hirose M, Nakata K, Hayashi S. CYFRA21-1 as a disease severity marker for autoimmune pulmonary alveolar proteinosis. Respirology 2014:19:246–52.
ORIGINAL ARTICLE
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Comparison of tumor markers and inflammatory biomarkers in chronic obstructive pulmonary disease (COPD) exacerbations
NIKOLAOS BAROUCHOS1,2,3, ATHANASIA PAPAZAFIROPOULOU4, NICOLETTA IACOVIDOU5, NIKOLAOS VRACHNIS6, NEKTARIOS BAROUCHOS1, ELENI ARMENIAKOU1,2, VASILIKI DIONYSSOPOULOU2, ALEXANDROS G. MATHIOUDAKIS1,3, ELENI CHRISTOPOULOU1,3, SPIRIDOULA KOLTSIDA1 & ELENI BASSIAKOU1 1National
and Kapodistrian University of Athens, Medical School, Athens, 2Intensive Care Unit, 3Pulmonary Department, and 43rd Pathology Department – Diabetes Center, General Hospital of Nikaia “St. Panteleimon”, Piraeus, 52nd Department of Obstetrics and Gynecology, Neonatal Division, National and Kapodistrian University of Athens, Medical School, Athens, Greece, and 62nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Medical School, Athens, Greece
Abstract Objective. The aim of the present study was: (a) to measure levels of the tumor markers, Carcinoembryonic antigen (CEA), Cancer antigen 19-9 (CA19-9), Cancer antigen 125 (CA125), Neuron specific enolase (NSE) and Cytokeratin fragments 19 (CYFRA21-1); (b) to investigate any correlation between them and the inflammatory biomarkers C-reactive protein (CRP), Erythrocyte sedimentation rate (ESR) and white blood cells count (WBC), in patients with chronic obstructive pulmonary disease (COPD) exacerbation, who belong in groups of severity C and D, as classified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD); (c) and finally, to compare these results in these two groups. Material and methods. Fifty-two patients with COPD exacerbation [35 male/17 female, mean age ( SD) 68.3 6.4 years] were the study subjects, and were classified in severity groups C (n 27) and D (n 25), based on the spirometric classification, the number of exacerbations in the preceding year and the assessment of their symptoms by GOLD. Results. CEA and CA125 were increased in group D. In group C, there was a significant correlation between CRP and CA125 (p 0.05). In group D, there was a significant correlation between WBC and NSE (p 0.02), between CRP and CA19-9 (p 0.02) and NSE (p 0.001), and between the ESR and NSE (p 0.03). CA125 (p 0.01) and CA19-9 (p 0.01) were significantly higher in group D compared to group C. In contrast, there was no significant difference in two groups for NSE, CEA and CYFRA21-1. Conclusion. Certain tumor markers were increased and were associated with increased levels of inflammatory biomarkers and with the disease severity. Inflammation might have a key pathogenetic role linking the above tumor markers with the severity of COPD. Key Words: Blood sedimentation, chronic obstructive pulmonary disease, C-reactive protein, disease exacerbation, leukocytes, tumor markers
Introduction Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide with a great impact on health economics and the society as its prevalence increases progressively over the last years [1–3]. COPD exacerbations are one of the most common causes of hospitalization among these patients
[4–6]. Based on the spirometric classification, on the number of exacerbations in the preceding year and on the assessment of symptoms, patients with COPD are classified in four groups of severity (A, B, C, D) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) [7–10]. Several studies so far have shown that in COPD exacerbation, inflammatory biomarkers such as
Correspondence: Nikolaos Barouchos, MD, MSc, Medical School of National and Kapodistrian University of Athens, 75 Mikras Asias Street, 115 27 Athens, Greece. Tel: 30 21057 49479. E-mail: [email protected] (Received 8 July 2014 ; accepted 25 November 2014 ) ISSN 0036-5513 print/ISSN 1502-7686 online © 2015 Informa Healthcare DOI: 10.3109/00365513.2014.992944
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C-reactive protein (CRP), White blood cells count (WBCs) and Erythrocyte sedimentation rate (ESR) are increased [11–14]. Additionally, it has been observed that tumor markers, Cancer antigen 19-9 (CA19-9) and Cancer antigen 125 (CA125) are increased in relation to the severity of COPD [15]. However, the existing literature data regarding the prognostic value of several tumor markers on lung diseases are conflicted. It has been shown that serum levels of other tumor markers, such as Carcinoembryonic antigen (CEA), Neuron specific enolase (NSE) and Cytokeratin fragments 19 (CYFRA21-1), did not differ between patients with lung cancer compared to patients with non-neoplastic lung diseases, such as acute pneumonia, COPD and interstitial lung diseases [16,17]. However, the existing literature data regarding the pathogenetic role of tumor markers in COPD exacerbations are limited. Therefore, the aim of the present study was to evaluate the serum levels of aforementioned tumor markers (CA125, CA19-9, CEA, NSE and CYFRA21-1) in patients with COPD exacerbation, who belong in severity groups C and D by GOLD and to investigate whether a correlation, between them and the inflammatory biomarkers (CRP, ESR and WBCs) exists. We also aimed at comparing these results in the two groups under investigation.
Materials and methods Ninety-nine patients with COPD exacerbation were enrolled in the study. Exclusion criteria were: lung [18–20], pancreatic [21], ovarian [22,23] and colorectal cancer [24,25], or any other kind of known neoplasia, using data obtained from their medical history. Patients with heart failure were excluded as well as existing studies suggest that tumor markers CA19-9 and CA125 are increased in patients suffering from this condition [26]. Patients with pneumonia, cystic fibrosis or with a known collagen disease [17,20], and with any other inflammatory or infectious diseases which increase inflammatory biomarkers CRP, ESR and WBC were also excluded. Finally, we did not include patients of severity groups A and B, because they are at low risk and have a lower risk for exacerbation [7] and only a small percentage of them may present in the emergency department with COPD exacerbation. On final evaluation (clinical and laboratory) 47 of them were excluded; 12 had various kinds of malignancy, seven had acute pneumonia, three had collagen disease with pulmonary involvement, 16 had heart failure and nine after classification of COPD severity by GOLD belonged in groups A and B. Finally, 52 patients with acute exacerbation of COPD fulfilled the inclusion criteria [35 males/17 females, mean age ( standard deviation) 68.3 6.4 years] and were included. They were hospitalized (from October 2012 to April 2013) in the Pulmonary
Department of the General Hospital of Nikaia “St. Panteleimon”, Piraeus, until the remission of exacerbation and discharge from the hospital. General Hospital of Nikaia is a tertiary hospital with 40,000 admissions approximately annually and covering about one million people in the greater area of Piraeus. All patients gave informed consent prior to their participation in the study. The study was approved by the Hospital’s Ethics Committee. Patients were classified in severity groups C and D by GOLD based on spirometric classification, on the number of exacerbations in the preceding year, using data obtained from medical history and on the assessment of symptoms especially of dyspnea using the modified British Medical Research Council (mMRC) questionnaire [7–10]. On the admission day the following investigations were performed: arterial blood gases determination and blood pH (arterial blood gas analyzer Nova-Biomedical, Start Profile, Critical Care Xpress-UK). Arterial oxyhemoglobin saturation (SpO2) was measured non-invasively by pulse oximetry (Nonin GO2 LCD-USA). Measurement of inflammatory biomarkers CRP, ESR WBC and of tumor markers CA125, CA19-9, CEA, NSE and CYFRA21-1 in venous blood collected prior to the administration of antibiotics or any other medication. Blood for the evaluation of tumor markers was collected in plastic tubes without anticoagulant and was left at room temperature for 30 min, until coagulated. The samples were then centrifuged at 3,000 rpm for 15 min (Hettich zentrifugen D-78532 Tuttlingen, Germany) and the serum was kept at 80°C until processed (within a week of collection). C-reactive protein was measured on a Turbi-Quick analyzer, Vital Diagnostics (Italy), and ESR on a Vesmatic 20 analyzer, Menarini Diagnostics (Italy). WBCs count was calculated by a Sysmex Corporation XE-5000 analyzer (Japan). CA19-9, CA 125 and CEA were measured on an Architect i2000SR Abbott analyzer (USA). NSE was measured on a Liaison, Diasorin analyzer (Italy) and CYFRA21-1 on a Cobas 6000, Roche analyzer (Switzerland). Serum CA19-9, CA125 and NSE concentrations were measured by the chemiluminescence method, CEA by the Immunochemiluminescent Metric Assay (ICMA), while serum CYFRA21-1 by the electrochemiluminescence method. The serum reference range of CA125 and CA19-9 was 35 and 37 KU/L, respectively. For CEA, the reference range for smokers and non-smokers was 3 and 10 μg/L, respectively. The serum reference range of NSE and CYFRA21-1 was 20 and 3.3 μg/L, respectively. On admission day chest radiograms were taken (X-ray Generator Philips Optimus 5-Germany), electrocardiogram was recorded (CardiMax FX-7202 Fukuda Denshi, Japan) and echocardiography was performed by portable echocardiograph (CX50 xMATRIX Philips, The Netherlands).
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Tumor markers in COPD exacerbations The patients answered the mMRC questionnaire one day prior to their discharge home, in order to assess their symptoms, particularly dyspnea. On the day of discharge, pulmonary function was evaluated by a spirometer after bronchodilatation, (400 mcg inhaled salbutamol), in order to record Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC) and the ratio of FEV1/ FVC. According to these measurements, patients were classified in COPD spirometric stage of severity by GOLD. The spirometer used was Pulmonary Function Testing FRC & DLCO modules-Quark PFT4 (Cosmed, Italy). Predicted volumes were yielded from standard nomograms for comparison. Statistical analysis All collected data were coded and typed to be statistically processed. The SPSS 19.0 (SPSS Inc, Chicago, IL, USA) statistical program was used. All variables were tested for normal distribution using the Kolmogorov-Smirnov assay. Logarithmic transformation was done for all variables which were not normally distributed, in order to be used in the analysis. For normally distributed data, t-test for independent pairs of observations was used for the comparison of normally distributed quantitative characteristics between the different groups while χ2 test was used for the comparison of qualitative characteristics. The Pearson’s correlation coefficient r was used to control the associations between the quantitative parameters. The multivariate regression analysis was used in order to find independent associations between WBC, CRP and ESR levels and the studied tumor markers. For each study group three models were created with dependent variables WBC, CRP and ESR and independent variables the five examined tumor markers. All independent variables in the multivariate analysis models were tested for multi-linearity; p-values 0.05 were considered statistically significant.
Results Twenty-seven patients (51.9%) were classified as group C and 25 (48.1%) as group D according to the COPD severity. Demographic and clinical characteristics of study patients are shown in Table I. Some 36.5% of study patients were current smokers, 59.6% ex-smokers, while only 3.8% never smoked. Hypoxia (paO2 60 mmHg) was present at the 59.6% of the study patients and hypercapnia (paCO2 45 mmHg) at the 19.2%. Regarding the received medication for COPD; all subjects received inhaled anticholinergics, 65.4% inhaled short acting β2 agonists, 38.5% inhaled long acting β2 agonists and 61.5% combination of inhaled corticosteroids
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Table I. Demographic and clinical characteristics of the study patients. Number of patients (%) Gender Male Female COPD severity Group C Group D Smoking status Current Former Never Hypoxia (yes) Hypercapnia (yes) Received therapy Anticholinergic (inhaler) (yes) Short acting β2-agonist (inhaler) (yes) Long acting β2-agonist (inhaler) (yes) Theophylline (oral) (yes) Steroid long acting β2-agonist (inhaler) (yes) Steroid (inhaler) (no) Steroid (oral) (no) Inhibitors Phosphodiesterase-4 (oral) (yes)
35 (67.3%) 17 (32.7%) 27 (51.9%) 25 (48.1%) 19 31 2 31 10
(36.5%) (59.6%) (3.8%) (59.6%) (19.2%)
52 34 20 25 32 52 52 16
(100%) (65.4%) (38.5%) (48.1%) (61.5%) (100%) (100%) (30.8%)
and long acting β2 agonists. Theophylline orally received the 48.1%, and orally inhibitors of fosfodiesterasis-4 (PDE4) the 30.8% of the patients. However, corticosteroids either orally or inhaled as a single therapy were not given to any of the patients. Patients in group D had higher levels of CA125 compared to group C (53.8 4.6 versus 14.1 5.4 KU/L, respectively, p 0.01) and higher levels of CA19-9 (21.8 5.4 versus 11.5 2.5 KU/L, respectively, p 0.01). In contrast, there was no significant difference in two study groups regarding the levels of NSE, CEA and CYFRA21-1. Levels of CRP were higher in group D compared to group C (61.8 8.9 versus 15.1 3.9 mg/L, respectively p 0.01).There was no significant difference between study groups regarding the number of WBCs and ESR (Table II). Then we investigated possible associations between inflammatory biomarkers and the tumor markers under study (three models for each inflammatory biomarker were used in the multivariate analysis). In group C multivariate regression analysis showed a positive relation between CRP and CA125 (p 0.05). However, no such relation between WBCs and ESR and the studied tumor markers was observed. In group D multivariate regression analysis showed a positive relation between WBCs and NSE (p 0.02), between CRP and CA19-9 (p 0.02) and NSE (p 0.001) as well as between ESR and NSE (p 0.03). Discussion The results of the present study showed that levels of CA125 and CA19-9 increased in patients with
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N. Barouchos et al. Table II. Demographic and laboratory parameters of study patients according to chronic obstructive pulmonary disease (COPD) severity.
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COPD severity
Age (years) WBC (x10E9/L) CRP (mg/L) ESR (mm/h) CEA (μg/L) CA19-9 (KU/L) CA125 (KU/L) NSE (μg/L) CYFRA21-1 (μg/L) paO2 (mmHg) paCO2 (mmHg) pH HCO3- (mEq/L) SpO2 (%) Duration of COPD (years) Smoking (pack-years)
Group C
Group D
p-value
67.3 7.4 10.878 4.843 15.1 ⴞ 3.9 33.5 2.9 3.2 0.2 11.5 ⴞ 2.5 14.1 ⴞ 5.4 7.2 1.8 1.8 0.5 61.4 ⴞ 9.2 42.3 9.3 7.4 0.04 26.8 4.6 88.1 ⴞ 7.1 5.1 ⴞ 0.5 60.6 3.3
69.5 8.5 12.524 5.287 61.8 ⴞ 8.9 40.3 4.9 9.6 2.3 21.8 ⴞ 5.4 53.8 ⴞ 4.6 12.7 3.6 2.8 0.7 53.7 ⴞ 9.7 47.5 15.2 7.4 0.05 29.5 5.8 83.2 ⴞ 9.5 8.9 ⴞ 0.7 65.9 4.7
0.32 0.25 0.01 0.40 0.11 0.01 0.01 0.07 0.07 0.005 0.14 0.73 0.07 0.04 0.001 0.46
WBC, white blood cells; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; CEA, Carcinoembryonic antigen; CA19-9, cancer antigen 19-9; CA125, cancer antigen 125; NSE, neuron specific enolase; CYFRA21-1, cytokeratin fragments 19; paO2, arterial oxygen tension; paCO2, arterial carbon dioxide tension; HCO-3, bicarbonate; SpO2, arterial oxyhemoglobin saturation. Figures in bold referred to the statistically significant results, p-values0.05.
COPD exacerbation according to the disease severity. However, levels of CEA, NSE and CYFRA21-1 were not influenced. In group C, a relation between CRP and CA125 was observed. In group D, a relation between WBCs and NSE, CRP and CA19-9 and NSE, as well as between ESR and NSE was observed. Even though serum tumor markers were introduced for monitoring the response to therapy in patients suffering from cancer and for detecting early relapse in malignancy, it has been reported that elevated levels of several tumor markers can also be detected in benign diseases and that their levels can be increased in non-neoplastic lung diseases [17,20,27]. COPD is defined as an incompletely reversible airflow limitation associated with inflammation, in which monocytes and macrophages are the predominant inflammatory cells. Various inflammatory mediators derived from these inflammatory cells are suggested to contribute to the chronic inflammation and cause lung tissue damage [15]. Cancer antigen 125 Cancer antigen 125 is a glycoprotein that is synthesized and secreted by normal epithelial cells of central airways and/or respiratory glands and that this substance is not a specific indicator of abnormal cellular activity [28]. It is most often associated with epithelial ovarian cancer [15]. Elevated CA-125 levels are seen in various other malignant conditions such as lung and breast cancer [29] and also in
benign pulmonary diseases. The CA125 can be used to identify COPD patients with right ventricle failure [30]. Serum CA125 levels were higher in idiopathic pulmonary fibrosis (IPF) patients than normal values and higher than those of the COPD patients [31]. Serum CA125 was related to the activity and severity of pulmonary tuberculosis (TB) [32]. Furthermore, increased serum levels of CA125 in cystic fibrosis (CF) patients were associated with severe CF transmembrane conductance regulator mutations and a severe phenotype [32], while an impressive increase of CA125 has been also observed in acute bronchopneumonia [20]. In this study mean value of CA125 was increased in group D, but not in group C. In accordance with our results, Bulut and co-workers reported that CA125 levels were significantly higher in patients with very severe COPD than in patients with moderate and severe COPD [15], since mean value of CA125 was significantly higher in group D than in group C. Chronic bronchitis patients, regardless of smoking status, presented on bronchial biopsies with focal squamous metaplastic change, goblet cell hyperplasia and enlargement of the bronchial gland mass because of the inflammatory process [34], and the elevation of serum CA125 might be attributed to this process. An important finding of our study that has not been described previously in the literature, to the best of our knowledge, is that in group C, a statistically significant correlation was observed between CRP and CA125 emphasizing the potential role of inflammation.
Tumor markers in COPD exacerbations
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Cancer antigen 19-9 Cancer antigen 19-9 is an intercellular adhesion molecule that is synthesized and secreted by normal epithelial cells of central airways and/or respiratory glands such as CA125 [28]. Primarily increased in patients with pancreatic and biliary tract cancer [15], but also in lung tumors, especially in adenocarcinomas, are a known fact, although uncommon [35]. A few investigators have reported elevated serum CA19-9 levels in patients with non-malignant respiratory diseases, such as idiopathic interstitial pneumonia and diffuse panbronchiolitis, bronchiectasis, collagen disease-associated pulmonary fibrosis and tuberculosis. In previous studies that used immunohistochemical staining, CA19-9 was reported to be selectively expressed in regenerating epithelial cells associated with inflammatory changes in the peripheral lungs, in patients with idiopathic interstitial pneumonia and diffuse panbronchiolitis, regardless of the etiology. The mechanisms increasing serum CA19-9 levels in non-malignant disease are not clear [36]. In this study mean value of CA19-9 was not elevated, neither in group C, nor in group D in our patient population. This finding was not expected. As we mentioned above, the CA19-9 serum levels was elevated in benign pulmonary diseases that are associated with lung inflammatory changes. In contrast, we expected some elevation of the CA19-9 levels in patients with COPD exacerbation due to the inflammatory process. Also mean value of CA19-9 was significantly higher in group D compared to group C. In agreement with our results, a previous study has shown that CA19-9 levels were significantly elevated in patients with very severe COPD compared to patients with moderate and severe COPD [15]. In addition, a result of this study that has not been described previously in the literature to the best of our knowledge, is the significant correlation between the levels of CRP and CA19-9 that we observed in group D. Probably this finding can be attributed, to the presence of chronic inflammatory lung changes. Carcinoembryonic antigen Carcinoembryonic antigen is an oncofetal glycoprotein that is involved in cell adhesion; its production normally starts during fetal development but ceases shortly after birth, and only a very small amount can be detected in the serum of healthy persons CEA can be produced in the epithelium of mouth, stomach, intestines, bile ducts, and respiratory tract ranging from the trachea to the alveoli [37]. The CEA serum levels is a marker of malignant diseases such as lung cancer [24] and can also be elevated in benign respiratory diseases, such as idiopathic lung fibrosis, bronchial asthma with mucoid impaction, in allergic bronchopulmonary aspergillosis (ABPA). In ABPA
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elevation of serum CEA levels might be associated with consolidation in the lung and might be attributed to the presence of local inflammation. This finding suggests that CEA is correlated with the inflammatory activity of ABPA [37]. Furthermore, higher concentrations of CEA are detected in men vs. women [38], elderly vs. younger [39] and smokers vs. non-smokers [40]. In the present study, mean value of CEA was elevated in group D, but not in group C. However, there was not a statistically significant difference between them. In a previous study Bullut and coworkers, showed that patients with very severe COPD and Cor Pulmonale had a significantly higher mean value of CEA serum levels [15]. The elevation of CEA might be attributed to the presence of local lung inflammation. The role of CEA elevation remains unclear. Larger numbers of cases should be collected and evaluated. Furthermore, no association was observed between CEA and the inflammatory biomarkers under investigation in both groups.
Enolase Enolase molecules in mammalian tissues are dimers composed of three immunologically distinct subunits (α, β and γ). The γ subunit, which has been designated as NSE, is highly concentrated in neurons, neuroendocrine cells, and neurogenic tumors [41]. NSE is used in the diagnosis and monitoring of patients with small cell lung cancer (SCLC) and can be taken as a distinguishing marker between SCLC and non-small cell lung cancer (NSCLC), given that SCLC is a neurosecretion tumor, that results in NSE expressing highly in SCLC patients [42]. Significant levels of γ-enolase have also been found in bronchial epithelial cells, and type II pneumocytes [41]. However, NSE was elevated in patients with benign pulmonary diseases. The highest levels were observed in patients with diseases associated with lung infiltrates (tuberculosis, embolism, pneumonia) as opposed to those not so associated (COPD, asthma). These data suggest that alveolar, interstitial, or distal airway damage or perhaps local hypoxia could contribute to the release of NSE. In fact, NSE has been found immunohistochemically in ganglion cells and nerve fibers throughout the respiratory tract. On the other hand, hypoxia appears to have a role in the immunoreactive expression of enolase in lung cancer cells [43]. In the present study, as we expected, the mean value of NSE was not increased neither in group C, nor in group D. Furthermore, the mean value of NSE was not significantly different between groups C and D. This finding is in agreement with the above observations. In group D, a significant correlation existed between mean values of NSE and CRP, ESR and WBCs. We therefore observed that NSE was the
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unique tumor marker, which is correlated with all three inflammatory biomarkers under investigation. Perhaps expression of NSE is associated with chronic inflammation that occurs in COPD patients, a finding that requires further investigation.
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Cytokeratin 19 (CK-19) Cytokeratin 19 (CK-19) is a protein component of the intermediate filament protein in epithelial cells. When epithelial cells transform into malignant cells, the keratin content is increased. Due to necrosis of tumor cells, the soluble fragment CYFRA21-1 of CK-19 is released into the blood. However, CYFRA21-1 in serum will increase when epithelial cells transform into cancerous tumor cells, especially squamous epithelial cells of the lung and bladder transitional cells. CYFRA21-1 is a sensitive tumor marker for diagnosis and monitoring of NSCLC, particularly in squamous cell tumors [42]. Elevated serum CYFRA21-1 levels were observed in some non-malignant respiratory diseases, especially in IPF and collagen disease associated pulmonary fibrosis (CDPF). The value of serum CYFRA21-1 would reflect the severity of lung injury in non-malignant respiratory diseases and might be related to the prognosis in patients with IPF and CDPF [44]. Serum CYFRA21-1 is a sensitive and useful marker for diagnosis and evaluation of disease severity of autoimmune pulmonary alveolar proteinosis (APAP), and may predict the response to granulocytemacrophage colony-stimulating factor (GM-CSF) inhalation. Immunohistochemistry showed that CYFRA21-1 was localized on hyperplastic alveolar type II cells and lipoproteinaceous substances in alveoli [45]. In this study the mean value of CYFRA21-1 was not increased neither in group C nor in group D, as expected. In COPD patients epithelial cells did not transform into cancerous tumor cells. Also, no statistically significant difference existed between the two groups. However, the present study failed to show any relation between CYFRA21-1 levels and the severity of COPD. This finding is in agreement with a previous one that indicated that the mean value of CYFRA21-1 in serum was not increased and did not differ significantly between patients with COPD and those with lung cancer [16]. Finally, there was not a correlation between CYFRA21-1 and any of the inflammatory biomarkers under investigation. Our study has some limitations. First of all, the number of patients enrolled in the study was small and therefore our results cannot be extrapolated to the general population. A second, major limitation is that we did not perform any computer tomography scan, nor cytological examination of biological fluids in order to exclude coexisting malignancy in study patients. Thus the exclusion of any malignancy was based on medical history. Furthermore the data
presented were based on one serum sample, and although serial blood tests for tumor marker levels could reinforce our findings, the trend seen in our results was clear, even from one measure. In conclusion, levels of CA 125 and CA 19-9 increased in patients with COPD exacerbation according to the disease severity. Inflammation might have a key pathogenetic role linking the above tumor markers with the COPD severity. However, our results remain to be confirmed by other studies in order to introduce the tumor markers in clinical practice for the diagnosis and monitoring of nonneoplastic diseases, including COPD. A biomarker or a panel of biomarkers that allows a more precise etiologic diagnosis might be desirable. The clinical utility of these results at this point of time is unknown and deserves future research.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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