Indinn J Ph'y9iol Pharmf\co] 2002; 46 (2): Ui9-166

SERUM COPPER LEVELS IN CARCINOMA OFOVARY AND CERVIX

PlKEE SAXENA*, SHANTl YADAV, SUDHA SALHANAND K. T. BHOWMICK**

Departments of "Obstetrics & Gynaecology and **Radiotherapy,Sa{darjullg Hospital,New Deilli - 110 029

(Heceived on February I, 2001)

Abstract: The rule of serum copper level (SCLl as fl di:lgnostie andprognostic tool in genital trad malignancies was evaluated. SCL wasemployed as a marker for response to trcatment (surgical/radiotherapy).129 women attending gynaecology outpatient department or admitted inlhe gynecology ward wcre studied. Of these 77 potients in the disease(study) group were proven cases of genita I tract malignancies and 52 servedas controls. Outcome meMmres studied were: SCL levels estimaled beforeinitiation of any trealnlCnt i.e. surgery/l"adiothernpy: thereafter, lit twoweeks after completiun of treatment. Follow up uf the study subjects wasdone helween 4-8 weeks and 8-10 weeks, when the patients were evaluntedfur any reC\lrrence of disease and SCL.~ were 11150 estimated. I(rusknl·Wallis Oll\~-wlly analysis of variance determined whether values variedsignillcantly among the different groups studied.

Mean SCLs were found to be significantly elevated in cascs of Ca oVllry(n:15), early CaCx (n=14) and late CaCx (n=48), as compared to the ~ontrol

group, comprising uf women with 110 signs and symptoms or malignallcy(1l=52). SCLs decreases sigllifi~antly(P<O.OOl) aner trealment ofCa ovaryand CaCx.

These results indicote a possible clinical usefulness of estimating serum~opper levels in women with genital tract cancer ll.lld suggest II role furSCL in the evnluation of lhe disease octivilY nnd as a prognusti~ lool illthe management of genital malignancies.

Key words: gynecologic malignunciesbiochemical marker disease activity

serum copper levelsresponse to thel';lpy

INTRODUCTION

A primary concern in the managementof patients with active malignant diseaseif> the problem of early diagnosis ofthe malignancy, thereby allowing therapies

-Corresponding Author

to be instituted. The awareness of thisproblem during the past two decadeshas focussed attention to the role oftrace elements in malignancies. Serumcopper level (SeL) has been shown tobe elevated in various carcinomas 0-6).

160 Saxenll et al

Elevated levels have also been describedin-patients with gynecological tumorsincluding carcinomas of cervix, ovary andendometrium (6-13).

In humans, normal SeL is about 100 J.1gldl. It has been shown that in cancer thereis an increase in amounts of copperassociated with each of the four plasmafractions, viz. transcuperein, ceruloplasmin,albumin and low molecular weightcomponents (14). Furthermore, data on bothDNA strand breaks and mutagenesis in uitroby copper bring into focus the possibilitythat excess amounts of copper might bemutagenic in uiuo and be a factOr incarcinogenesis (15)

The present study has been designedwith a twofold objective: (i) to measure SCLin proven cases of cancer of cervix andovary, and in the control group and to assesswhether changes in SCL occur with progressof disease (tj) to evaluate the role of SCLas a diagnostic and prognostic tool in genitaltract malignancies, employing SCL asa marker for response to treatment(su rgicallrad iotherapy).

METHODS

Patients

The prescnt study was carried out on129 patients attending the Gynaecology outpatient department or admitted in theGynaecology ward of Safdarjang Hospital,New Delhj. The detailed clinical history andcomplete physical examination of thepatients was recorded.

Indian J Physiol Pharmacol 2002; 46(2)

The inclusion criterion of 52 patients inthe control group was: females with no SigllSand symptoms of malignancy as suggestedby history, clinical examination, pap smear,ultrasonography (USG) of abdomen andpelvis and colposcopic examination.

The inclusion criterion of 77 patients III

the disease (study) group was: proven ca~es

of genital tract malignancies. The diagnosiswas based on the findings of pap smear,cervical biopsy, colposcopy and colpscopicdirected biopsy'. The other diagnostic testsused were histopathological examination(HPE) of endometrial curetting, fine needleaspiration cytology (FNAC) of pelvic massand usa examination of pelvis.

These patients were assigned to fourstudy groups: (i) control group with a meanage of 38.2 years (range 16-33 years); (ji)carcinoma ovary group (Cn-ovary) groupwith mean age of 37.2 years (range (13­18 yrs); (iii) early stage carcinoma of cervix(early CaCx) and (iv) late stage carcinomaof cervix (late CaCx group). Groups (iii) and(iv) collectively had a mean age of 50.7 years(range 25-80 years).

These groups were further divided intobefore surgery (Sx), after surgery; beforeradiotherapy (RT), after radiotherapy andthose lost to follow up.

Measurement or Serum Copper

Blood samples for estimation of SCLwere drawn by venipunture and collectedin clean test tubes. Serum was immediatelyseparated by centrifugation (l000 x g,

Indian J PhysioJ Pharmacol 2002; 46(2) Serum Copper Levels in Gynecologic Malignancies 161

RESULTS

Serum copper levels (SCLs) in 77 provencases of carcinoma of the cervix and ovaryand 52 age matched controls weredetermined. SCLs were found to beltign'ficantly elevated in the group ofpatients with gynaecological malignancies.These data are presented graphically inFigures 1-5.

The mean BCL in the control group was116.61 ± 25.8/pg/dl (range 80-183 p.g/dl).

The SCLs were 316.4 ± 69.7 pg/dl (range188-476 pg/dl) in the Ca ovary group244.9 ± 49.5 J.1g/dl (range 184-357 pg/dl) inthe early CaCx group and 259.9 ± 53,4 J.1gl

dl (range 173-474 p.g/dl) in the late aCxgroup of patients. These levels of serumcopper concentrations in the disea e (study)group were found to be ignificantly(P<O.OOl) increased as compared to the BCLin the control gr up (Fig. 1). However, no

CaCx LoleIn=48)

CaC~ Early(n=1.)

*

Ca Ovary(n"'5)

Control(n=621

so

'"'0

400

~ 300

~ 250

.Jo 200V)

l: 150

'"III:& 100

The follow up of the ,tudy subjectswa done between 4-8 weeks andbe ween 8-10 week, when the epati nt were evaluated clinically for !lnyrecurrence of disea e. Serum copper levelwere also estimated during the follow upschedule.

tatistical analyses

10 min) and kept at -70°C. Serum copperwa mea ured pectrophotometrically by thmethod of P rker et al (6). SCLs weree timated in th control group. SCLs wermeasured in h di eas (tudy) group withthe diagno i and suspicion of genitalmalignancy, befor initiating any treatmenti.e. urgery/radiotherapy to the patient.Thereafter, SCLs were det rmined at theend of 2 weeks after completion of treatmentto determine the change (if any) in tb SCLpost reatment.

Staging of malignancy was based uponclinical and surgical findings. All patientsgave informed consent and the study wasapproved by the Hospital EthicalCommittee.

The data were analysed u ing theKruskal Wallis one-way analysis ofvariance to determine whether values variedsignificantly among the different grouptudi d.

The re ults are given as mean andrange. Data aTe given as mean ± D. TheP values lesser than 0.05 were consideredstatistically significant.

Fig. 1: Mean serum copper levels (SCLs) in control antIdisease (study) group .

Note: In Figures 1-5, columns represent meanvalues, bars represent standard deviation ( Dl.and ·=Po::;Q.OOl

162 axella t al Indian J Physiol Pharmacal 2002; 46(2)

significant differ nce wa ob rved betwe nLs in early and late presentation of CaCx

(Fig. 1).

I wa' observed that the m an serumcopper lev Is in the Ca vary groupdecreased significantly CP<O.OOI) from316 ± 69.7 pg/dl to 201 ± 61.01 pg/dl (range119-324 pg/dl) as a . ed 2 week aftel'surgical int rvention (Fig. 2).

300

250

~ 200012;..JU 150en<:.. 100ell:E

50

CaCx early; P,e-Sx(0=14)

CaCx oarly : Posl·Sx(n=14)

Fig. 2; 11 an arum copper levels ( Ls) in patientswith carcinoma of Dval'y (CaexJ in the pre-andpost-surgery (8x) groups.

In the prasen . tudy investigation wereconcluded on th erum copper Ie el in 62

case of carcinoma of cervix in early andlate stages of progress of h di a e anddiff ren form of tr a ment. The mean SCLIn arly CaCx two w ks after surgery wa142.4 ± 58.1 p.g/dl (range 83-255 pg/dl)which wa. ignificantly <P<0.001) decreased

as compar d to the before urgery levels(Fig, 3).

("=33)

C.Cx lale : POSI-RTCaCx late: Pre-RT

("=48)

350

300

'5250

""iii.= 200....I0Ul 150I:nl..

::E 100

50

0

Fig. 3: Maan serum copper levels (8CLs) in patientswith early carcinoma of cervix' a x early) inthe pre- and post-surgery ( xl groups.

The mean SCLs in late CaCx groupdecrea ed ignificantly (P<O.OOl) after twoweeks of RT to a value of 162.2 ± 44.8 pgl

dl (range 104-335 p.g/dl) (Fig. 4).

VVhen the cases in the control group

were divided according to morphologic

differ ntiation, the mean SCLs were

Fig. 4: Mean serum copper levels ( CLs) in pati ntswith late stage carcinoma of cervix C a x lat )in the pre- and pas -radio henpy CRT) groups.

CaOv : Pre-Sx

(0:15)

400

350

300:§Cl 250-=..JU 200UlI: 1501\1OJ

~ 100

50

0

CaDY : Pre·Sx

(0=15)

Inuian .J Phy iol Ph:trma '01 2002: 4-6(2)

found to be modera ely and noo- ignificantly

I v t d in patien s with fibroid uteru(130 ± 22.5 I-Ig/dl> and In patient.wi h benign ovarian tumor (162 ± 31.8 ~lg/

dl) a compared to he SCLs in r s ofthe control group (119 ± 2 .8I-1g/dl)

(Fig. 5). • urthermor no tatis icallysignificant variation was observed in them an s of the different histological

-udy group uiz. the s uamou c 11c rcinoma group the adena-squamous cellcarcinoma group and th ad nocarcinomgroup (Table IL

erum 0Pller L "els in Gynecnlogic MnJigmmci s 163

All ca es of a ovary n=15) underw nturgical treatment. Two patient. w re los

to follow up in this group during follow upf h se patient. Of a vary 8 showed goo

clin·ieal response while 5 had re idualdiseas as diagnosed on he ba j of signsand symptom clini a1 xamination andhi topathologic I tudy of specimen resect dduring surgery of th patients. Of th 62ca. of CaCx, 1 underwent surgeryreceiv d r diother py and 17 Cll ewer lostto f( llow up after 1 w ek f compl tion oftb Ir treatment (Tabl II).

Fig. 5: Comparison of serum copper levels amongst thenon-malignan (on r Il cas . and res of thcontrols.

NOLI': In Figures 5, p valu b tw en controls andfibroid uterus is 0.313 and between controls andbenjgn ovarian tumours is 0.059.

200180

=- 180

t 140a 120

d 100I/) 80I:

:li 60:i 40

20

oControl

In=o421

Fibroid ut"rus Benign 0 ... Tumor

(n=81 In~2)

A ses ment of clinical r pon ofthe patient and carrel tiog it with hmean CL d man rat d ignificandiff r nc b tw n th pre-and pc> i

trea men alues. Furth rmore, it wasobserved hat SCL' of four p tient withpoor r pan in the a ovary groupweT 210l-lg/dl, 235 pg/dl 296 pg-/dl nd324 pg/dl' these I vels were high r hanthe m an SCL (201 pg/dl) obs rv d in hisgroup. I appears from this observationhat elevation of S L is greatest in

pati nt with active malignancies andpoorest respon e. A imilar tr nel was 'e ~n

in the S Ls of early and lat CaCx group.

TABLE 1: Correlntion or Serum Copp r I~ev Is (SCLs) With Hi topathologicalDi gnosis Of Carcinoma rviK ( a Kl.

Histopalholo/Jical dialfl1(J.~l

n:: umber f cases; I == lJercentnge

It

510506

(?'o)

(82.2)

( .11(9.1/

Mean serll1J1 copper feud ('IB I dLl

254.5253

255.1

164 Saxena el. al Indian J Physiol Pharmacol 2002; 46(2)

TABLE II: Clinical Response With Respect To treatment Modality And Follow Ull.

GrOllp Tr~(1.lmelll n (Ik)Goodn (%)

CnOv Surgery 15000%) 8 (53.33%)

(n=IS) Lost to follow up 0203.7%)

CaCx Surgery 14 (22.5%) 7 (50%)

(n=62) R:ldiothernpy 33 (53.2%) 23 (69.70%)

Lo9t to follow up 17 (27.4%)

C/inifXll Response

Modern/en (%)

2 f6.06%J

Poorn ('II)

5 (33.33%)

4 (28.5%)

8 (24.24%)

CaOv = Carcinoma of ovary; CaCx = Carcinoma of Cervix. n = number of casell; % '" percentage

In the early CaCx group 7 out of 14 patientsshowed good clinical response, while 4

patients showed poor clinical response, thiswas on account of the fact that duringsurgical treatment of these patients it wasobserved that the malignancy was morewidespread and they were probably cases oflate CaCx. However, during follow up of theearly CaCx patients showing poor responseto surgical treatment, the SCLs were 194 J.lgldl, 204 J.Ig/dl, 232 J.Ig/dl and 255 pg/dl whichwere higher than mean SCL (124.4 Ilg/dl)of the early CaCx-post surgery group. Fivepatients in the late CaCx group showed poorresponse when assessed two weeks afterradiotherapy. The SeLs of these patientswere 198 pg/dl, 205 Jlg/dl, 244 pg/dl, 267 j.lgldl and 335 J.Ig/dl; these values were higherthan the mean SCL (162.2 J.Ig/dl) observedin this group.

DISCUSSION

In the past years various biochemicalparameters have been evaluation of thetreatment responses. Serum copper levels(SCLs) have heen estimated with the samepurpose by a score of workers, and areconsidered of importance in determining

~

clinical response to therapy in a variety ofmalignant diseases.

Elevated SCLs have been described inpatients with gynaecological tumorsincluding carcinoma of ovary, cervix andendometrium.

The current study provides data onserum copper levels in 77 patients withgynaecological malignancies and 52 agematched controls. Significantly elevatedlevels of serum copper have beendemonstrated. Other studies have reportedan elevation in serum copper levels inpatients with carcinoma of female genitalorgans but in a very small series.Margalioth and coworkers reported similarfindings in 179 patients with gynaecologicmalignancies. The study further indicatesrising serum levels with increasing diseaseactivity, a decrease in response to treatmentand rising levels in case of relapse (11). Theresults of the present study are consistentwith earlier findings 00-13). Elevatedserum levels were reported (13) in womenwith cervical carcinoma. The degree ofincrease of serum copper was related to thestage of carcinoma. Furthermore, in the

Indian J Physiol Pharmacal 2002; 46(2)

present study there appeared to besignificantly progressive increase in themean serum copper values with advancingstage of CaCx evidencing a correlation ofSCC with the stage of disease. Similarlyobservation has been reported by Birdi etal and Brandes et al (6, 17). The presentstudy is noteworthy as it proves that serumcopper levels were significantly higher inovarian malignancies as compared to thosein patient in relatively healthy state withbenign tumors and fibroid uterus (Fig. 5).These findings are in accord with earlierreports (10).

However, broad overlapping values fromall the groups makes it unlikely that thefindings will be important in early diagnosisbefore there is pathological evidence ofcarcinoma. In the present study the serumcopper concentrations in the Ca ovary groupand CaCx group were significantlydecreased post operatively. This finding isconsistent with those of Gregoriadis andcowerkers (8), where they showedconsistent decrease post-operatively in theSeL of two women who underwent surgicaltreatment for carcinoma of the ovaries.

The mechanisms underlying theelevation of SCL is not clear. It is likelythat in malignant states, the intestinalbarrier to copper is covered, leading to itsrapid absorption by the liver, where moreceruloplasmin is formed and released intothe circulation (19). The normal value ofSCL for healthy women ranges from 80­100 J-lg/dl (2). In the present study SCL of180 ~g/dl separated our patients with

Serum Copper Levels in Gynecologic Malignancies 165

genital tract malignancies from those in thecontrol group; whereas, the cut off valve inn previous study was 150 ~g/dl (10).

It would be of interest to note thatan elevated SCL is not indicative of aspecific type of cancer and it may also berisen in other disease presentations.Furthermore, despite the fact that thesensitivity of serum copper level to thepresence of disease is limited, thisbiochemical marker of disease activityappears to be of significant value becauseof the case with which it can be determined,its wide availability in clinical laboratoriesand its relatively low cost.

In conclusion, the ,:urrent study provesthat SeL may be used in diagnosis ofcervix and ovarian malignancies. Weconclude that, usefulness of SCL fordiagnosis of early stage gynecologicalmalignancies is as yet difficult to advocatewith assurance, because of the relativelysmall sample of patients we have studied sofar and because most cervical and ovarianand malignancies are first seen by thephysician at a faily advanced stage.However, on the basis of the presentstudy, we believe that SCLs might havegreater applicability in the follow up andmanagement of patients during and afterthe various stages of treatment. It bas alsoevidenced that SCL may be used as checkparameter of recurrence and as a prognostictool which can be used to advantage forcontrol purpose in patients of carcinoma ofovary and cervix during and after thevarious stages of treatment.

166 Saxena el al

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