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WORLDJOURNALOFSURGICALONCOLOGYCheungetal.
WorldJournalofSurgicalOncology2010,8:38http://www.
wjso.
com/content/8/1/38OpenAccessRESEARCHBioMedCentral2010Cheungetal;licenseeBioMedCentralLtd.
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ResearchBonymetastasesfrombreastcancer-astudyoffoetalantigen2asabloodtumourmarkerKwok-LeungCheung*1,RayKIles2andJohnFRRobertson1AbstractBackground:Foetalantigen2(FA-2),firstisolatedintheamnioticfluid,wasshowntobethecirculatingformoftheaminopropeptideofthealpha1chainofprocollagentypeI.
SerumconcentrationsofFA-2appearedtobeelevatedinanumberofdisordersofbonemetabolism.
Thispaperisthefirstreportofitsroleasamarkerofbonemetabolisminmetastaticbreastcancer.
Methods:SerumFA-2concentrationsweremeasuredbyradioimmunoassayin153womenwithdifferentstagesofbreastcancerandin34normalcontrols.
Results:SerumFA-2wassignificantlyelevatedinwomenwithbonymetastases(p5cmand/orotherfeaturesoflocallyadvanceddisease(eginflammatorycancer,fixationtochestwall,ulceratingtumour)withoutanyevidenceofdistantmetastasesandattendedtheLAPCClinic.
Bloodsamplesweretakenwhenthetumourwasstillinsitu.
*Correspondence:kl.
cheung@nottingham.
ac.
uk1DivisionofBreastSurgery,UniversityofNottingham,Nottingham,UKFulllistofauthorinformationisavailableattheendofthearticleCheungetal.
WorldJournalofSurgicalOncology2010,8:38http://www.
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com/content/8/1/38Page2of44.
Womenwithadvancedbreastcancer(ABC)-ThesewerewomenattendingtheABCClinicandallhaddistantmetastases.
PreparationofSerumSamplesBloodobtainedbyvenesectionwascollectedinplaintubes,allowedtostandforatleast30minutesandthencentrifugedat2,500revolutionsperminutefor20min-utes.
Serumwaspipettedinto1-mlaliquotsandstoredinthefreezerat-20°C.
FA-2AssaysTheserumsamplesweretransportedat-20°CtotheWil-liamsonLaboratoryatStBartholomew'sHospital.
FA-2radioimmunoassayswerecarriedoutaspreviouslydescribed[3].
Theassayswereperformedinablindman-nerwithaliquotstaggedwithasamplenumberwithoutanyclinicalinformation.
StatisticalMethodsStatisticalanalysiswascarriedoutusingthestandardisedbiomedicalcomputerprogrammeSPSSforWindows(SPSSUKLtd).
TheANOVAtestwasusedformultiplegroupcomparisonofthemeanvalues.
Statisticallysignif-icantdifferencewasdefinedbyp<0.
05.
TheauthorsconfirmthatapprovalhasbeenobtainedfromLocalResearchEthicsCommitteetoconductthisstudyonbloodmarkersinbreastcancer.
ResultsThemeanvaluesofserumFA-2levelsinallfourgroupsofwomenweresummarisedinTable1.
Therewasnodif-ferenceinFA-2levelsamongnormalwomenandwomenwithbreastcancerwhichwasstillconfinedtothebreast(iePBCandLAPC)(Tables1and2).
Nevertheless,whenallstagesofcancerweretakenintoconsideration,FA-2levelsappearedtobesignificantlyelevatedincancerpatientswhencomparedtonormalwomenandthiswasduetomarkedelevationinwomenwithmetastaticbreastcancer(Table2).
WomenwithmetastaticdiseasehadamuchhighervalueofFA-2thanthosewithout(Table3)andthiswasduetothesignificantelevationofFA-2inwomenwithbonymetastases(Figure1).
Inconclusion,theresultssuggestedthatFA-2wassig-nificantlyelevatedonlyinthesubgroupofwomenwithbonymetastases.
DiscussionBloodtumourmarkersinbreastcancerhavebeenknownfordecades.
Incontrasttomarkersintheprimarytumourtissue,bloodtumourmarkersreflectadynamicsituationandtheirmeasurementscanberepeatedasrequired.
Theuseofbloodtumourmarkersismostestab-lishedinthediagnosisandmonitoringofsymptomaticmetastaticdisease.
InthediagnosisofmetastaticbreastTable1:MeanValuesofFA-2forAllWomenSamplecategoryNMean±SD(AU/ml)Normal340.
21±0.
09PBC350.
18±0.
08LAPC380.
33±0.
67ABC800.
85±1.
34All187Figure1ComparisonofFA-2levelsbetweenboneandnon-bonemetastases.
SamplecategoryNMean±SD(AU/ml)pvalueNon-bonymetastasesBonymetastases*20530.
37±0.
360.
91±0.
940.
0149*Includingpatientswithbothskeletalandextra-skeletalmetastases.
non-boneboneMetastases0.
001.
002.
003.
004.
00AUperml$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Cheungetal.
WorldJournalofSurgicalOncology2010,8:38http://www.
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3assayhasbeenshowntobesuperiorwithCEAbeingthenextmostclinicallyusefulmarker[4].
ThesensitivitycanbefurtherincreasedwhenapanelofthreemarkersieCA15.
3,CEAandESRareused[5-8].
Whiletheusefulnessofbloodtumourmarkersiswellestab-lishedinadvancedbreastcancer,activeresearch,bothclinicalandlaboratory,isongoingtorefinethemeasure-mentsofexistingmarkers,toexplorenewermarkersandtodevelopbettermarkerassays,aimingtooptimisetheiruseinadvanceddiseaseaswellastoexploittheiruseinscreeninganddiagnosisofearlyprimarybreastcancer.
Markersofbonemetabolismareamongthenewmark-erswhicharebeinginvestigated.
Traditionalmarkersofbonemetabolismincludeserumalkalinephosphatase,serumandurinarycalcium,urinaryhydroxprolineetc.
Markersofcollagensynthesishavebeenevaluatedasbonemarkersformetastaticbonediseaseduetobreastcancer.
ThemostabundantproteininboneistypeIcolla-gen.
Duringitsformationtwoextensionpeptidesfromtheprocollagenmolecule,carboxy-andaminoterminalpropeptides(PICPandPINP)arereleasedintothecircu-lationandtheyaremarkersofboneformation.
TypeIcol-lagencarboxyterminaltelopeptide(ICTP)isformedduringbonecollagenbreakdownandisagainliberatedintothecirculation.
Itslevelintheserumthereforereflectsboneresorption.
ICTPhasahighspecificitythoughrelativelylowsensitivityandisthebestbonemetabolismmarkerevaluated[9,10].
Furtherstudiestoevaluatethecost-effectivenessofmeasuringthesemark-ersandtoexplorenewermarkersofbonemetabolismarerequired[11].
Afteritsisolationfromtheamnioticfluid,FA-2wasfoundelevatedinserumofpatientswithrenalosteo-dystrophy[12]andwithprimaryhyperparathyroidism[13].
PatientswiththelatterhadFA-2levelsdroppedsig-nificantlyaftersurgicalremovaloftheparathyroidglands[13].
AllthesehavesuggestedFA-2asapossiblemarkertoevaluatebonemetabolism.
EvidenceofFA-2synthesisbyfoetalosteoblastsshownusingimmunohistochemicalstainingtechniqueshassubstantiatedthispotentialrole[14].
Thepresentstudyisthefirstreportofthemeasure-mentofserumFA-2indifferentstagesofbreastcancer.
ItshowedthatserumFA-2waselevateddistinctlyinwomenwithbonymetastases.
Itslevelsweresignificantlylowerinwomenwithoutmetastasesincludingnormalcontrols.
Thefactthatthemeanvalueinwomenwithmetastaseswassignificantlyhigherthatinwomenwith-outcouldentirelybeexplainedbytheinclusionofwomenwithbonymetastasesintheformergroup.
Themeanvalueinwomenwithnon-bonymetastaseswasvirtuallysimilartothatofthosewithoutmetastases.
InessenceserumFA-2hasbeenfoundtobesignificantlyelevatedonlyinthesubgroupofwomenwithbonymetastases.
ThesepreliminarydatapointoutthatFA-2isapotentialhelpfulbloodmarkerforbonymetastasesfrombreastcancer.
ItwouldthereforeappearthatserumFA-2mea-surementmaybeusefulinthediagnosisofbonymetasta-ses.
Whetheritwillbeshowntobesuperiortoexistingmarkersand/orradiologicalmethodsremainstobeeluci-dated.
Theotherroleoftumourmarkermeasurementisinthemonitoringoftherapy.
Inthepresenterawhentheuseofbisphosphonateshasbeenpopularisedinthemanage-mentofbonemetastasesforbreastcancer,markersofbonemetabolismmightprovideameasurementoftheeffectofsclerosisonthebonewhileconventionalbloodmarkerssuchasCA15.
3andCEAreflecttheefficacyofanti-cancertherapyontumourmass.
InthesewaysnewTable2:ComparisonofFA-2LevelsbetweenDifferentGroupsSamplecategorypvaluePBC0.
19LAPCSamplecategorypvaluePBC0.
0037ABCSamplecategorypvalueLAPC0.
0243ABCTable3:ComparisonofFA-2LevelsbetweenMetastaticandNon-MetastaticCancersSamplecategoryNMean±SD(AU/ml)pvalueNon-metastatic730.
26±0.
490.
0004Metastatic800.
85±1.
34Cheungetal.
WorldJournalofSurgicalOncology2010,8:38http://www.
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com/content/8/1/38Page4of4markershaveacomplementaryratherthananexclusiveroleinthediagnosisandmonitoringofbreastcancer[11].
Giventhepreliminaryresultsfromthisobservationalstudywhichhasitsstatisticallimitationsduetoitssmallsize,furtherstudiesarethereforerequiredtodefineindetailstheexactvalueofserumFA-2measurementinbonymetastasesfrombreastcancer.
Comparisonwithconventionalmarkersoftumourmass(egCA15.
3,CEA)andknownnovelmarkersofbonemetabolism(egPICP,PINP,ICTP)(bothinthediagnosisandinthemonitoringofresponsetosystemictherapy),andidentificationofthepatternofchangesofserumFA-2levelsinrelationtobis-phosphonatetherapyandeventssuchashypercalcaemiaareareasthatneedtobeexploredbeforetheuseofFA-2couldbeincorporatedintodailyclinicalpractice.
AbbreviationsFA-2:Foetalantigen2;CA15.
3:Cancerantigen15.
3;CEA:Carcinoembryonicantigen;PBC:Primarybreastcancer;LAPC:Locallyadvancedprimarybreastcancer;ABC:Advancedbreastcancer;PICP:CarboxyterminalpropeptideoftypeIprocollagen;PINP:AminoterminalpropeptideoftypeIprocollagen;ICTP:TypeIcollagencarboxyterminaltelopeptide.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsKLCperformedthestatisticalanalysisanddraftedthemanuscript.
AllpatientswereunderthecareofKLCandJFRRwhowereresponsibleforcollectingbloodsamplesandclinicaldata.
RKIwasresponsibleforcarryingouttheassayforFA-2.
JFRRconceivedofthestudy.
Allparticipatedinthedesign;readandapprovedthefinalmanuscript.
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doi:10.
1186/1477-7819-8-38Citethisarticleas:Cheungetal.
,Bonymetastasesfrombreastcancer-astudyoffoetalantigen2asabloodtumourmarkerWorldJournalofSurgicalOncology2010,8:38Received:16March2010Accepted:13May2010Published:13May2010Thisarticleisavailablefrom:http://www.
wjso.
com/content/8/1/382010Cheungetal;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
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WorldJournalofSurgicalOncology2010,8:38