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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 376-381

Role of sialic acid as biochemical marker in oral leukoplakia and oral squamous cell carcinoma


Department of Oral Pathology, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India

Date of Submission28-Apr-2020
Date of Decision25-May-2020
Date of Acceptance10-Jun-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Archana Sonone
Department of Oral Pathology, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_162_20

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  Abstract 


Introduction: Tumor markers are biochemical substances released by tumor cells either due to the reason or consequence of carcinogenesis process. Neoplasms often have an increased concentration of sialic acid on the tumor cell surface and are shed or secreted by some of these cells which increase the concentration in blood. Aim and Objectives: We aimed to determine the serum levels of total sialic acid (TSA), lipid-bound sialic acid (LBSA), and ratio of TSA to total protein (TP) in patients with oral leukoplakia (LP) and oral squamous cell carcinoma (OSCC) patients. Materials and Methods: The study comprises 75 participants which include 25 cases of LP, 25 cases of OSCC, and 25 cases of healthy cases as control. Ten-milliliter intravenous blood was collected under aseptic condition, and biochemical analysis of TSA, LBSA, and TP was done by spectrophotometer. Results: We observed that the levels of TSA, LBSA, and TSA/TP were significantly increased in Oral Leukoplakia (OLP) and OSCC as compared to the healthy control group. Conclusion: The increased level of TSA, LBSA, and TSA/TP in LP helps to determine the early stage of the disease. Further differentiation in grades of OSCC is also possible by these biochemical markers. Thus, serum levels of total antioxidant status, LBSA, and TSA/TP can be used as diagnostic and prognostic markers.

Keywords: Oral leukoplakia, oral squamous cell carcinoma, sialic acid


How to cite this article:
Sonone A, Hande A, Gawande M, Patil S, Sharma P. Role of sialic acid as biochemical marker in oral leukoplakia and oral squamous cell carcinoma. J Datta Meghe Inst Med Sci Univ 2020;15:376-81

How to cite this URL:
Sonone A, Hande A, Gawande M, Patil S, Sharma P. Role of sialic acid as biochemical marker in oral leukoplakia and oral squamous cell carcinoma. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 7];15:376-81. Available from: http://www.journaldmims.com/text.asp?2020/15/3/376/308549




  Introduction Top


Oral squamous cell carcinoma (OSCC) is one of the life-threatening and mutilating diseases affecting the humanity. It is a major health problem in the Indian subcontinent where it ranks among the top three types of cancer in the country.[1] Most of the OSCCs are preceded by asymptomatic clinical lesions together called oral potentially malignant disorders (OPMDs) or a precancerous lesion. The prevalence of precancerous lesions in the oral cavity is about 2.5% in the general population.[2] About 15%–48% of the OSCCs are developed from innocent-appearing precancerous lesions,[3],[4] and approximately 60% of them are clinically present as white keratotic lesions.[5] Oral leukoplakia (LP) is the most common white keratotic lesion among OPMD. It is defined as “a predominantly white lesion or plaque of questionable behavior having excluded clinically and histopathologically, any other definable white disease or disorder as stated by van der Waal.”[6] The overall frequency of malignant transformation rate of LP varies between 15.6% and 39.2%,[7],[8] which is highest of other OPMDs.

In spite of the vast majority of the researches and advances in the field of surgical oncology, the mortality rate remains unchanged.[9] The 5-year survival rate is estimated to be about 50%.[1] OSCC is usually detected at later stages which results in unfortunate treatment outcomes and causes considerable financial constraint to the patients. Early detection of OSCC offers long-term survival and has the potential to improve treatment outcomes and make health care affordable. Thus, inexpensive and accessible diagnostic tools could be the game-changer to reduce the mortality and morbidity of cancer.

This motivates the search of markers with diagnostic and prognostic relevance in OSCC.[9] There are various biological markers which can be used to monitor the progression of OSCC and predict the therapeutic response and prognostic outcome of cancer. They may also aid in the diagnosis of the disease. These markers, referred to as tumor markers, are naturally occurring or modified molecules that can be measured in serum, plasma, or other body fluids and their concentration alters in the presence of cancer.[10]

Glycoconjugates are the general classification for carbohydrates covalently linked with other chemical species such as proteins, peptides, lipids, and saccharides.[11] These glycoconjugates act as a marker, which play a significant role in cancer.[12],[13] Terminal epitopes of carbohydrates have been proposed to play a significant role in cell–cell interactions, in the development of cell adhesion, and in malignant transformation. Sialic acids are nonreducing, negatively charged, terminal carbohydrate residues of oligosaccharide chain of many glycoproteins and glycolipids. Due to their exposed position, they play an important role in cell-to-cell adhesion, recognition, invasiveness, and immunogenicity. In neoplastic transformation, these glycoconjugates get altered and released into circulation through increased turn over by secretions and shedding from malignant cells. This leads to increased levels of sialic acid in blood due to its nonreducing termini. Thus, estimation of sialic acids may act as an effective diagnostic and prognostic marker and may be useful in mass screening of LP and OSCC cases.[14],[15],[16] In the present study, efforts were made to determine the efficacy of not only total sialic acid (TSA) and lipid-bound sialic acid (LBSA) but also total proteins (TPs) as tumor markers in patients suffering from LP as well as OSCC.


  Materials and Methods Top


The present observational cross-sectional study was conducted on individuals reporting to the Outpatient Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, Wardha, Maharashtra, India, for the duration of 1 year and 6 months. The study comprised 75 participants which included 25 patients diagnosed clinically and confirmed histopathologically with LP (Group I), 25 patients diagnosed clinically and confirmed histopathologically with OSCC (Group II), and 25 healthy controls (Group III). Informed consent was obtained from all the participants. Ethical clearance was obtained from the Ethical Committee of the institute. Detailed case history was recorded along with thorough examination of the soft and hard tissues of the oral cavity. In Groups I and II, patients with a history of any systemic diseases such as diabetes mellitus, hypertension, endocrine disorders, and cardiovascular disorders, pregnant and lactating women, and patients diagnosed with malignancies in sites other than the oral cavity were excluded. Patients who were on any medications and diagnosed with any other oral mucosal lesions were also excluded. Participants in Group III were healthy without any oral or systemic diseases, who were not under any medications and did not have any oral adverse habits.

The histopathological grading of OSCC was done according to the malignancy grading system proposed by Broders et al.[17] LP was graded according to the status of the presence or absence of dysplasia as per Smith–Pindborg criteria.[18] Under all aseptic precautions, venous blood was drawn from the mid-cubital/antecubital vein with the help of disposable 5-mL sterile syringe and 22G needle. The blood was transferred to sterile glass bulb and allowed to clot for an hour. Serum was separated and centrifuged at 4000 RPM. Serum samples were stored at -20°C in a deep freezer until tested. Protocol for estimation of serum TSA was followed as per Plucinsky et al.[19] and LBSA by Katopodis et al.[20] Resorcinol reagent method was used for the evaluation of TSA and LBSA and biuret for TP.[21]

Statistical analysis

Data were analyzed using software SPSS 24.0 version (SPSS Statistics for Windows, version x.0, SPSS Inc., Chicago, Ill., USA), and P < 0.05 is considered as level of significance. Statistical analysis was done using descriptive and inferential statistics. One-way ANOVA and multiple comparison: Tukey's test were used to see the difference among the means of three groups and t-test was used to compare the means between the groups.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Sharad Pawar Dental College, Sawangi(M), Wardha. Date: 20th March 2018 with Reference no DMIMS(DU)/IEC/2018/277.


  Results Top


In the present study on clinicopathological analysis in LP, the patients' ages were in the range of 31–80 years, with an average of 45.8 years. Among 25 patients of LP, 13 (37.3%) patients showed the presence of dysplasia. Estimation of serum TSA, LBSA, and ratio of TSA/TP was carried out in LP. The mean value of TSA, LBSA, and ratio of TSA/TP in LP patients was 65.24 mg/dl, 22.29 mg/dl, and 10.76 mg/dl, respectively. On comparison of these values with the control group, it was found statistically significant (P = 0.001) [Table 1].
Table 1: Comparison of total sialic acid, lipid-bound sialic acid, total protein, and ratio of total sialic acid/total protein in Group I in Group II and Group III

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Further, on comparison of serum TSA among dysplastic and nondysplastic cases of LP, TSA was increased significantly from normal (53.89 ± 5.98 mg/dl) to no dysplasia (61.91 ± 5.23 mg/dl) to (67.897 ± 5.56 mg/dl) dysplasia (P = 0.001). On evaluation of LBSA and TSA/TP ratio levels and their comparison from normal to no dysplasia to dysplasia, we observed no significant difference (P > 0.001) [Table 2].
Table 2: Comparison of total sialic acid, lipid-bound sialic acid, and ratio of total sialic acid/total protein in nondysplastic to dysplastic cases of leukoplakia

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On evaluation of clinicopathological analysis of OSCC cases, the patients' ages were in the range of 39–86 years, with an average of 54.36 years. In general, OSCC was observed mostly in males (56%) as compared to females (44%), with a ratio of 1.5:1. Further, on evaluation of histopathological grading of OSCC, 80% of the cases were in “well-differentiated oral squamous cell carcinoma (WDOSCC)” grade, whereas 20% were in “moderately differentiated oral squamous cell carcinoma (MDOSCC)” grade. No case was there in “poorly differentiated OSCC” grade.

On evaluation of TSA, LBSA, and ratio of TSA/TP in OSCC, TSA and LBSA were found to increase significantly from normal (53.897 ± 5.9861 mg/dl and 18.1740 ± 3.36466 mg/dl) to OSCC (85.938 ± 13.1784 mg/dl and 33.2016 ± 6.20393 mg/dl). Similarly, the ratio of TSA/TP was also increased significantly from normal (8.924 ± 1.8264 mg/gm) to OSCC (15.420 ± 4.5771 mg/gm) [Table 1].

There were twenty cases in WDOSCC grade of OSCC, whereas five were in MDOSCC grade. On comparison of TSA in WDOSCC and MDOSCC cases, it was increased significantly from WDOSCC (84.506 ± 12.2444 mg/dl) to MDOSCC (97.734 ± 3.98977 mg/dl). Similarly, LBSA and TSA/TP ratio were also found to increase significantly from WDOSCC (32.4567 ± 5.98368 mg/dl and 14.692 ± 3.8887 mg/g) to MDOSCC (38.6280 ± 3.98977 mg/dl and 20.652 ± 1.5701 mg/g) [Table 3].
Table 3: Comparison of total sialic acid, lipid-bound sialic acid, and ratio of total sialic acid/total protein in different histological grades of oral squamous cell carcinoma cases

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It is observed that on comparison of TSA, LBSA, and ratio of TSA/TP in nondysplastic to dysplastic cases LP to OSCC, TSA was found to increase from nondysplastic (61.91 ± 5.23 mg/dl) to dysplastic cases (67.897 ± 5.56 mg/dl) of LP to OSCC (85.938 ± 13.1784 mg/dl) [Graph 1]. On evaluation of LBSA and TSA/TP, it was found to increase from nondysplastic (22.1675 ± 3.91172 mg/dl and 10.223 ± 1.7752 mg/g) to dysplastic (22.4950 ± 3.69350 mg/dl and 11.083 ± 1.6897 mg/g) cases of LP and further cases of OSCC (33.2016 ± 6.20393 mg/dl and 15.420 ± 4.5771 mg/g). However, the difference between nondysplastic and dysplastic cases of OLP was not significant [Graph 2] and [Graph 3].




  Discussion Top


Diagnosing oral cancers at an early stage is significant in improving the survival rate and reducing the morbidity associated with the disease. Although a visible lesion precedes the development of majority of the oral cancers, sometimes it may disguise itself and precancerous or cancerous changes are not always be discernible clinically or histologically. Estimation of various biomarkers in serum may act as an adjunct to conventional biopsy procedure, and inference of these biomarkers may provide a noninvasive and cost-effective method for screening the oral cancer patients.

Tumor markers are biochemical substances released by tumor cells either due to the reason or consequence of carcinogenesis process. Thus, these biomarkers could be of substantial diagnostic and prognostic importance in cancer patients. Cell membrane becomes altered during the process of carcinogenesis and is vital for uncontrolled growth and malignant behavior of the neoplastic cells. Certain glycoproteins and glycolipids may prove to be specific tumor markers as these are the major constituents of the cell membrane. Increased levels of glycopeptides containing mannose, galactose, sialic acid, and fructose are reported in altered cells of several types of solid tumors, suggesting a relationship among malignant transformation and alterations in cell-surface glycoconjugates.[10]

Literature search has revealed the estimation of serum sialic acid in various types of malignancies such as carcinoma of the breast,[22] colorectal carcinoma,[19],[23] lung carcinoma,[24] malignant melanoma,[25],[26] and OSCC.[27],[28],[29],[30],[31],[32],[33],[34],[35],[36] However, very few studies have been reported in the literature regarding the correlation of serum TSA and TP in OLP and OSCC.

The present study included 25 clinically and histologically diagnosed cases of LP. The mean of TSA, LBSA, and ratio of TSA/TP in LP cases was 65.24 mg/dl, 22.29 mg/dl, and 10.76 mg/dl, respectively, and was statistically significant as compared to control group patients [Table 1].

With regard to TSA, we observed significantly increased levels in LP as compared to control group patients (P = 0.001). Our findings were consistent with Raval et al.,[36] Rajpura et al.,[16] Vajaria et al.,[37] Joshi and Patil,[38] and Taqi.[39] We also observed a significantly increased level of LBSA in OLP (P = 0.001). Our results are in accordance with Baxi et al.[29] and Taqi.[39] We further evaluated the ratio of TSA/TP in LP and observed significantly increased levels as compared to the control group. As per our knowledge, this is the first attempt of estimation of TSA/TP ratio in PL. Further, on comparison of TSA, LBSA, and ratio of TSA/TP among dysplastic and nondysplastic cases of LP, we observed significantly increased levels from normal to nondysplastic to dysplastic cases of LP [Table 2]. Although morphological and cellular alterations in dysplastic cells are discernible in histological examination of tissue, molecular modifications cannot be perceived as a much earlier phase of cellular transformation. Alteration of sialic acids and the terminal carbohydrate residues of oligosaccharide chain of many glycoproteins is observed during neoplastic transformation. Further, these get released into circulation through shedding of dysplastic cells. Thus, significantly increased levels of TSA and LBSA suggest the alterations in glycoproteins during the process of cellular and molecular changes of transformation of normal into dysplastic cells and their release into serum.

With reference to OSCC, we observed significantly increased levels of TSA as compared to normal [Table 1]. Our results are in accordance with Shashikanth and Rao,[32] Rao et al.,[14] and Joshi and Patil.[38] Similarly, LBSA was also found to increase which is in agreement with Rajpura et al.[16] and Taqi.[39] The ratio of TSA/TP was also higher as compared to normal which is in contrast to observations by Raval et al.[36] The variations among the levels might be attributed to different techniques applied. It is observed that all three parameters, i.e., TSA, LBSA, and TP/TSA, were increased significantly from normal to nondysplastic to dysplastic cases of OLP to OSCC [Graphs 1-3]. Sialic acid is nonreducing, negatively charged, terminal carbohydrate residues of oligosaccharide chain of many glycoproteins and glycolipids. Due to their exposed position, they play an important role in cell-to-cell adhesion recognition, invasiveness, and immunogenicity. In neoplastic transformation, these glycoconjugates get altered and released into circulation through increased turnover by secretions and shedding from malignant cells. This leads to increased levels of sialic acid in blood due to its nonreducing termini.

In the present study, we also attempt to compare all three parameters according to the histopathological grading of OSCC. Rajpura et al.[16] and Taqi[39] compared the levels of TSA and LBSA in OSCC according to histopathological grading. With reference to histological grading of OSCC, the levels of TSA, LBSA, and TSA/TP increased in MDOSCC as compared to WDOSCC [Table 3]. In MDOSCC, cellular activity is more as compared to WDOSCC which further results in increased turnover of tumor cells and ultimately due to increased sialic acid concentration in blood.[40],[41],[42],[43],[44],[45],[46],[47],[48],[49]


  Conclusion Top


We observed an increase in TSA, LBSA, and total antioxidant status/TP in LP which helps in determining the early stage of the disease. The level of serum TSA increased from normal to nondysplastic to dysplastic cases in LP, suggesting its association with malignant transformation. There is a progressive elevation in serum levels of TSA, LBSA, and TSA/TP in grades of OSCC that is from WDOSCC to MDOSCC. Thus, serum levels of TSA, LBSA, and TSA/TP can be used as diagnostic and prognostic markers in LP and OSCC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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