|Year : 2019 | Volume
| Issue : 7 | Page : 2414-2419
Serum fucose level in oral cancer, leukoplakia, and oral sub mucous fibrosis: A biochemical study
Satish Kumar1, Ankit Suhag2, Sumanta Kumar Kolay1, Puneet Kumar3, Anumeha Narwal4, K Srinivas5, Safiya Haideri6
1 Department of Dentistry, Darbhanga Medical College and Hospital, Darbhanga, Bihar, India
2 Department of Prosthodontics, Pacific Dental College and Hospital, PAHER University, Udaipur, Rajasthan, India
3 Department of Pedodontics, Sarjug Dental College and Hospital, Darbhanga, Bihar, India
4 Prosthodontist and Implantologist, Medi-Dent Polyclinic, Gurgaon, Haryana, India
5 Department of Oral Medicine and Radiology, CPGIDSH, Lucknow, UP, India
6 Department of Pedodontics, Govt Dental College and Hospital, Patna, Bihar, India
|Date of Submission||11-Apr-2019|
|Date of Decision||12-Apr-2019|
|Date of Acceptance||27-Apr-2019|
|Date of Web Publication||31-Jul-2019|
Dr. Satish Kumar
Department of Dentistry, Darbhanga Medical College and Hospital, Darbhanga, Bihar
Source of Support: None, Conflict of Interest: None
Aims: To estimate the serum fucose levels in clinically and histopathologically diagnosed oral cancer, oral leukoplakia, and oral submucous fibrosis cases. To compare and correlate the severity of dysplasia or histopathological grading of the premalignant and malignant lesions with serum fucose levels. Objective: To determine the role of serum fucose as a reliable biomarker for early detection of malignant transformation of potentially malignant lesions and conditions and prediction of biologic behavior of the malignant lesions. Material and Method: The intended study shall include 100 participants divided into 4 groups. Groups I, II, and III will include 25 clinically and histological diagnosed cases of oral leukoplakia, oral submucous fibrosis, and oral cancer, and 25 normal control group. Fucose was measured according to the method of Dische and Shettles as adopted by Winzler. Statistical Analysis: Statistical analysis will be done using SPSS statistical software (Version 10), and the levels of significance will be analyzed using the paired and unpaired t-tests. Result: In subjects of 4 groups were age- and gender-matched and comparable thus these may also not influence the study outcome measure (fucose levels). ANOVA revealed significantly different fucose levels among the groups (F = 17.00, P < 0.001). Mean fucose level did not differ (P > 0.05) between oral leukoplakia, oral submucous fibrosis, and oral cancer (84.5%) groups. The increase in mean fucose levels with severity was the highest in the oral cancer group followed by oral submucous fibrosis and oral leukoplakia group. The mean fucose levels did not differ between mild and moderate grades (P > 0.05) in all the 3 groups. Conclusion: The evaluation of serum l-fucose would be of good help in assessing early malignant change in increasing the accuracy of clinical diagnosis and also in assessing the spread and invasiveness of oral cancer, oral submucous fibrosis, and leukoplakia.
Keywords: Fucose, oral cancer, oral leukoplakia, premalignant
|How to cite this article:|
Kumar S, Suhag A, Kolay SK, Kumar P, Narwal A, Srinivas K, Haideri S. Serum fucose level in oral cancer, leukoplakia, and oral sub mucous fibrosis: A biochemical study. J Family Med Prim Care 2019;8:2414-9
|How to cite this URL:|
Kumar S, Suhag A, Kolay SK, Kumar P, Narwal A, Srinivas K, Haideri S. Serum fucose level in oral cancer, leukoplakia, and oral sub mucous fibrosis: A biochemical study. J Family Med Prim Care [serial online] 2019 [cited 2021 May 6];8:2414-9. Available from: https://www.jfmpc.com/text.asp?2019/8/7/2414/263757
| Introduction|| |
Oral cancer (OC) is one of the leading causes of mortality and morbidity. It is a well-known fact that early detection of cancer is essential for best chances of cure. Use of biomarker measurements for early detection is a promising research innovation being applied to various human cancers.,,,,,
It had been established that cancer cells synthesize certain glycoproteins that may be detected in body fluids. Glycoproteins contain galactose, mannose, glucosamine, galactosamine, sialic acid, or fucose as the carbohydrate residue. It has been reported that tumor cells modulate their surface by increasing fucosylation levels (addition of l-fucose at the terminal end of the oligosaccharide chain) to escape recognition, which contribute to several abnormal characteristics of tumor cells, such as decreased adhesion and uncontrolled tumor growth. Hence, monitoring serum/tissue fucose levels could be a promising approach for the early detection, diagnosis, and prognosis of various cancer types.,
OC may be preceded by precancerous lesions or conditions such as leukoplakia, oral submucous fibrosis (OSMF), etc. Oral precancer represents an increased risk of malignant transformation. Altered glycosylation of glycoconjugates, such as sialic acid, fucose, etc., are few important molecular changes that accompany malignant transformation. Alterations in serum fucose levels had been associated with certain precancerous lesions.,, Early detection of malignant transformation improves the clinical outcome of patients. The search for a biomarker that could predict the changes in the premalignant lesions would immensely help in the recognition of high-risk lesions. Therefore, if patients with clinically suspicious lesions can be analyzed with biomarkers along with routine histopathological tests for the prediction of its malignant potential, the chance of minimizing the morbidity and mortality will be high.
| Aims and Objectives|| |
- To estimate the serum fucose levels in clinically and histopathologically diagnosed OC, oral leukoplakia, and OSMF cases.
- To investigate the possible usefulness in the prediction of malignant potential of the premalignant lesions.
- To compare and correlate the severity of dysplasia or histopathological grading of the premalignant and malignant lesions with serum fucose levels.
To determine the role of serum fucose as a reliable biomarker for early detection of malignant transformation of potentially malignant lesions and conditions and prediction of biologic behavior of the malignant lesions.
| Materials and Method|| |
Source of data and sample size
The intended study included 100 subjects divided into 4 groups. Group I includes 25 age- and gender-matched healthy subjects, from patients attendants to serve as controls. Groups II, III, and IV include 25 each clinically and histological diagnosed cases of leukoplakia, OSMF, and OC patients each, respectively, between the age group 15 and 60 years, attending the Department of Oral Medicine and Radiology, Career Postgraduate Institute of Dental Sciences and Hospital. Informed consent was taken from the patients and the controls.
- Patients with clinically and histologically proven leukoplakia, OSMF, and OC.
- Patients between 15 and 60 years age group.
- Healthy subjects with no history of systemic or localized illness like allergies, renal problems, hypertension, and diabetes will be included as controls.
- Patients with known systemic conditions like diabetes, hypertension, pregnancy, allergies, infections, and liver disease will be excluded.
- Patients with >1 premalignant lesions coexisting in the oral cavity will be excluded.
- Healthy controls will be excluded on the basis of tobacco and alcohol consumption.
Fucose was measured according to the method of Dische and Shettles  as adopted by Winzler.
| Material|| |
- Ethyl alcohol (95% Ethanol)
- Sulphuric acid + H2O (6 Vol conc. H2 SO4 + H2O)
- Cysteine reagent (3%)
- Sodium hydroxide (0.2 N)
- Distilled water
- Working standard fucose solution (20 μg/mL).
Data were summarized as mean ± SE. Groups were compared using one-way analysis of variance (ANOVA) and the significance of the mean difference between the groups was done by Tukey's post hoc test. All analyses were performed on SPSS software (PSAW, windows version 18).
| Results|| |
Fucose level in age
The age of normal, oral leukoplakia, OSMF, and OC groups ranged from 20 to 55, 20 to 56, 22 to 60, and 20 to 60 years, respectively with mean (±SE) 32.60 ± 2.34, 36.68 ± 2.06, 30.72 ± 1.84, and 33.80 ± 2.56 years, respectively, as shown in [Table 1] [Figure 1]. The mean age of the oral leukoplakia group was slightly higher than the other groups. Comparing the age of 4 groups, ANOVA revealed a similar age among the groups (F = 1.27, P = 0.289). In other words, subjects of 4 groups were age- and gender-matched and comparable, thus these may also not influence the study outcome measure (fucose levels).
Fucose level between 4 groups
The fucose level of normal, oral leukoplakia, OSMF and OC groups ranged from 2.7 to 8.9, 10.0 to 73.0, 12.9 to 80.0, and 12.0 to 85.0 mg/dL, respectively with mean (±SE) 7.22 ± 0.26, 35.28 ± 4.25, 37.83 ± 4.73, and 46.63 ± 5.29 mg/dL, respectively, as shown in [Table 2]. The mean fucose level of the OC group was comparatively higher than other groups. Comparing the fucose level of 4 groups [Table 3], ANOVA revealed significantly different fucose levels among the groups (F = 17.00, P < 0.001).
Further comparing the mean fucose levels between the groups [Table 4], the Tukey test revealed significantly higher fucose levels in oral leukoplakia (79.5%), OSMF (80.9%), and OC (84.5%) groups as compared with the normal group [Figure 2]. However, the mean fucose level did not differ (P > 0.05) between oral leukoplakia, OSMF, and OC (84.5%) groups.
|Table 4: Comparison (P) of mean fucose levels between the groups by Tukey post hoc test|
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|Figure 2: Mean fucose levels of four groups. ***P<0.001- as compared to Normal|
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According to histopathological/clinical grade
When the mean fucose levels were compared with the degree of dysplasia in case of potentially malignant disorders and degree of differentiation in OC, it was observed that the mean fucose levels in all 3 groups increased with severity (mild to moderate to severe), as shown in [Table 5]. The mean serum fucose was higher in OSMF cases with mild dysplasia than well-differentiated OC and mildly dysplastic oral leukoplakia. Mean fucose levels for moderately and severely dysplastic potentially malignant disorders/moderately and poorly differentiated OC were highest for OC, followed by OSMF and oral leukoplakia. The increase in mean fucose levels with severity was the highest in the OC group followed by OSMF and oral leukoplakia groups.
Comparing the fucose levels of 3 groups and 3 grades together [Table 6], ANOVA revealed similar fucose levels among the groups (F = 2.64, P = 0.079) while significantly different among the grades (F = 148.14, P < 0.001). Further, the interaction effect of both (groups x grades) on fucose level was also found similar (F = 0.78, P = 0.541).
|Table 6: Comparison of fucose levels of three groups and three grades together by two way ANOVA|
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Further, for each group, comparing the mean fucose levels within the groups (i.e. between grades) [Table 7], Tukey test revealed significantly higher (P < 0.001) fucose levels in severe grade as compared with both mild and moderate grades in all 3 groups [Figure 3]. However, the mean fucose levels did not differ between mild and moderate grades (P > 0.05) in all the 3 groups.
|Table 7: For each group, comparison (P) of mean fucose levels between the grades (within groups) by Tukey post hoc test|
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|Figure 3: For each group, mean fucose levels between the grades (within groups). ns: P>0.05, ***P<0.001- as compared to Mild|
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When the mean fucose levels were compared for each grade between the groups, Tukey test revealed no significant difference (P > 0.05) in fucose levels among the groups in all grades, as shown in [Table 8].
|Table 8: For each grade, comparison (P) of mean fucose levels between the groups by Tukey post hoc test|
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| Discussion|| |
Oral cancer (OC) accounts for ~30%–40% of all cancers in India. During the malignant transformation of cells, there may be either an up-regulation or down-regulation of the biochemical substances. With the development of new and sensitive techniques for measuring very minute quantities of biochemical substances, now it is possible to identify early malignant transformation of the cells. Such biochemical substances are known as tumor markers.,,,
Increased level of different glycoproteins has been associated with different types of malignancies, like higher serum fucose level found in cancer of the cervix, breast, oral cavity, and lymphoma. Glycoconjugate molecules expressed in the plasma membrane of mammalian cells have also been reported to be associated with cell-to-cell adhesion, tumor progression, and metastasis.
Measurement of protein-bound carbohydrates of glycoproteins has been used as an index to glycoprotein levels now more recent trend need to be used to measure the amount of given monosaccharide as a measure of glycoproteins.,,
One of the monosaccharides is l-fucose, a hexose, which is a terminal sugar in most of the plasma glycoproteins. L-Fucose is found in many glycolipids and glycoproteins, including several families of blood group antigens., Changes have been detected in the fucosylation pattern of these molecules in the tissue of cancer patients because of fucosyltransferase activity, which is especially high in the serum of patients suffering from highly malignant or metastatic tumors.,,
In this study, the normal fucose level in the control group is 7.22 ± 0.26 mg/dL with levels ranging between 2.7 and 8.9 mg/dL. In contrast, the established normal fucose level by Parwani and Parwani  was found to be 5.32 ± 0.67 mg/dL which ranges in between 4.25 and 7.1 mg. The level obtained in this study was much similar to that obtained by Wang et al., Sharma et al., and Arya et al. Serum fucose level in this study was significantly found to be elevated among cancer patients (46.63 ± 5.29 mg/dL) when compared with leukoplakia (35.28 ± 4.25 mg/dL) and with OSMF (37.83 ± 4.73) and control group (7.22 ± 0.26 mg/dL).
Bhairavi et al. found serum l-fucosidase activity were significantly higher in OPC and OC patients compared to the controls. The OC patient showed a mean serum fucose level of 46.63 ± 5.29 mg %. Similarly, the study shows higher serum fucose levels compared with those of the control have been observed by Solanki et al., Kaswan and Kaushik et al. Agarwal et al., and Sen et al.
In this study, we observed very high serum fucose in OSMF, leukoplakia, and OC when compared with controls (P < 0.001) as like that was observed by Parwani and Parwani et al. in their study. According to Shah et al., high fucosylation is one of the characteristic features of malignancies mainly because of increased activity of fucosyltransferase activity in malignant tissue. Bose et al. also showed significantly very high levels of fucose in OC, leukoplakia, and OSMF patients (P < 0.001) when compared with control groups.
In this study, fucose level estimation is done on the basis of histopathological and clinical grade. In leukoplakia, in the mild (n = 6) histopathological condition, the fucose level is 14.82 ± 2.43, in moderate (n = 9), fucose level is 23.92 ± 0.72, and in severe (n = 10), fucose level is 57.78 ± 4.56.
In leukoplakia, in mild versus moderate condition, fucose level is not significant (P = 0.781), but in mild versus severe and moderate versus severe conditions fucose levels are significant (P < 0.001).
Estimation of fucose in oral submucosa fibrosis on the basis of histopathological/clinical grade is done in this study. In mild (grade 1, n = 6) condition, OSMF level of fucose is 15.43 ± 0.86, moderate (grade 2, n = 10) fucose level is 27.88 ± 4.75, and severe (n = 9, grade 3) fucose level is 63 ± 4.25 [Table 5].
In OSMF, comparison between mild (grade1) versus moderate (grade 2) is not significant (P = 0.367), but mild (grade 1) versus severe (grade 3) and moderate (grade 2) versus severe (grade 3) is highly significant (P < 0.001) [Table 7].
A similar study is also done in OC. In mild (n = 6) histopathological condition, fucose level is 15.11 ± 1.01, moderate (n = 7) fucose level is 31.43 ± 2.83 and in severe (n = 12) fucose level is 71.27 ± 3.41 [Table 5].
Histopathological comparison group between mild versus moderate is not significant (P = 0.141), but mild versus severe and moderate versus severe is significant (P < 0.001) [Table 7].
Bose et al. (2013) studied on patients with metastases had higher levels of the biomarkers than the patients with primary OC. However, elevations only in LSA levels were statistically significant and also a significant change present is severe in comparison with moderate.
Similarly, the current study also shows the level of serum fucose is significant in severe in comparison of mild and severe to moderate.
Seibert et al. suggested that the elevation of serum fucose merely reflects the occurrence of tissue destruction and release of preformed fucose at the site. However, Shetlar et al. suggested that tissue proliferation rather than repair is a more probable cause for the increase in serum fucose.,, Estimation of such fucose conjugated proteins is suggestive to be good biomarkers in the diagnosis of OC cases as well as in assessing the prognosis of such cases. The estimation of serum fucose levels may be used as a biomarker in the diagnosis as well as prognosis of different histopathological grades of OC.
Rai et al. in 2015 discuss the high significance of serum fucose in oral squamous cell carcinoma and leukoplakia subjects compared with normal controls. There was a gradual increase in the values noted from control to leukoplakia and to squamous cell carcinoma that is the same in our study.
| Conclusion|| |
This study is aimed at evaluation of serum fucose in oral submucosa fibrosis, leukoplakia, and OC and the results obtained showed the very high significance for serum fucose levels in oral submucosa fibrosis, leukoplakia, OC group as compared with healthy individuals. Analysis of the markers can be an additional tool for diagnosis, prognosis, and treatment monitoring of cancer patients.
Therefore, the evaluation of serum l-fucose would be of good help in assessing early malignant change in increasing the accuracy of clinical diagnosis and also in assessing the spread and invasiveness of OC, OSMF, and leukoplakia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brian MN, Christopher JL, Sunguk C, Aleksey L, Adele M, William LB, et al
. Serum biomarker profiles as diagnostic tools in lung cancer. Cancer Biomark 2011-2012;10:3-12.
Sen U, Guha S, Chowdhury JR. Serum fucosyl transferase activity and serum fucose levels as diagnostic tools in malignancy. Acta Medica Okayama 1983;37:457-62.
Dnistrian AM, Smith C, Schwartz D. Lipid Bound sialic acid as a marker in lung cancer. Clin Chem 1985;31:982.
Dang HS, Pamnani S, Thapar A, Gupta MM. Serum protein bound fucose level in hepatic malignancy. Indian J Cancer 1985;22:211-6.
Thompson S, Turner GA. Elevated levels of abnormally-fucosylated haptoglobins in cancer sera. Br J Cancer 1987;56:605-10
Shin Yazawa, R Agupathy Madiyalakan, Hldeakl Izawa, Takayuki Asao, Ken Furukawa, cancer-Associated Elevation Of α (I+3)-LFucosyltransferase Activity In Human Serum Cancer 1988;62:516-20.
Parwani RN, Parwani SR. Quantitative evaluation of serum fucose in oral squamous cell carcinoma patients. J Can Res Ther 2011;7:143-7. [Full text]
Sawke NG, Sawke GK. Serum fucose level in malignant diseases. Indian J Cancer 2010;47:452-7.
] [Full text]
Thompson S, Cantwell BMJ, Cornell C, Turner GA. Abnormally-fucosylated haptoglobin: A cancer marker for tumour burden but not gross liver metastasis. Br J Cancer 1991;64:386-90.
Shah M, Telang S, Raval G, Shah P, Patel PS. Serum fucosylation changes in oral cancer and oral precancerous conditions. Cancer 2008;113:336-46.
Rao VR, Krishnamoorthy L, Kumaraswamy SV, Ramaswamy G. Circulating levels in serum of total sialic acid, lipid-associated sialic acid, and fucose in precancerous lesion and cancer of the oral cavity. Cancer Detect Prev 1998;22:237-40.
Shashikant M, Rao BB. Study of serum fucose and serum sialic acid levels in oral squamous cell carcinoma. Indian J Dent Res 1994;5:119-24.
Dische Z, Shettles LB. A specific color reaction of methyl pentoses and a spectrophotometric micromethod for their determination. J Biol Chem 1948;175:595-604.
Winzler RJ. Determination of serum glycoproteins. Methods Biochem Anal 1955;2:279-311.
Manjula S, Monteiro F, Rao Aroor A, Rao S, Annaswamy R, Rao A. Assessment of serum L-fucose in brain tumor cases. Ann Indian Acad Neurol 2010;13:33-6.
] [Full text]
Vajaria BN, Patel KR, Begum R, Shah FD, Patel JB, Shukla SN, et al
. Evaluation of serum and salivary total sialic acid and α-l-fucosidase in patients with oral precancerous conditions and oral cancer. Oral Sur, Oral Med, Oral Pathol Oral Radiol 2013;115:764-71.
Wang JW, Ambros RA, Weber PB, Rusano TG. Fucosyltransferase and alpha- L fucosidase activities and fucose levels in normal and malignant endometrial Tissue. Cancer Res 1995;55:3654-8.
Abdel-Alee H, Ahmed A, Sabra AM, Zakhari M, Soliman M, Hamed H. Serum alpha L-fucosidase enzyme activity in ovarian and other female genital tract tumors. Int J Gynecol Obstet 1996;55:273-9.
Fernández-Rodríguez J, Páez de la Cadena M, Martínez-Zorzano VS, Rodríguez-Berrocal FJ. Fucose levels in sera and in tumours of colorectal adenocarcinoma patients. Cancer Lett 1997;121:147-53.
Bathi RJ, Nandimath K, Kannan N, Shetty P. Evaluation of glycoproteins as prognosticators in head and neck malignancy. Cancer 1991;67:135-40.
Sharma NC, Sur BK. Serum fucose and sialic acid levels in Indian children and adults under normal and pathological conditions. Indian J Med Res 1967;55:380-4.
Arya DB, Bhatnagar KK. Evaluation of serum fucose level. Indian J Surg 1974;36:224-8.
Solanki RL, Ramdev IN, Sachdev KN. Serum protein bound fucose in the diagnosis of breast malignancy. Indian J Med Res 1978;67:786-91.
Kaswan HS, Kaushik SK. Serum fucose levels in the diagnosis of carcinoma breast. Indian J Surg 1982;44:741-3.
Agarwal DP, Punia DP, Nawalkha PL, Khuteta KP. Effect of therapeutic irradiation on serum fucose levels in patients of oral cancer. Indian J Radiol 1980;34:255-9.
Sen R, Sur R, Dasgupta R, Muzumdar GC. Serum pseudocholinesterase activity and protein bound fucose level in oral malignancy. Indian J Cancer 1987;24:242-9.
Bose KS, Gokhale PV. Quantitative evaluation and correlation of serum glycoconjugates: Protein bound hexoses, sialic acid and fucose in leukoplakia, oral sub mucous fibrosis and oral cancer. J Nat Sci Biol Med 2013;4:122-5.
Baxi BR, Patel PS, Adhvaryu SG, Dayal PK. Usefulness of serum glycoconjugates in precancerous and cancerous diseases of the oral cavity. Cancer 1991;67:135-140.
Seibert FB, Seibert MV, Atno AJ, Campbell HW. Variation in protein and polysaccharide content of sera in the chronic diseases, tuberculosis, sarcoidosis and carcinoma. J Clin Invest 1947;26:90-102.
Shetlar MR, Foster JV, Keithh K, Shetlar CL, Bryan RS, Everett D. The serum polysaccharide level in malignancy and in other pathological conditions. Cancer Res 1949;9:515-9.
Macbeth RA, McBride G. Serum protein-bound fucose in patients with breast masses. Cancer Res 1965;25:1779-80.
Kumar S, Saxena M, Srinivas K, Singh VK. Fucose: A biomarker in grading of oral cancer. Natl J Maxillofac Surg 2015;6:176-9.
] [Full text]
Rai NP, Anekar J, Shivaraja Shankara YM, Divakar DD, Al Kheraif AA, Ramakrishnaiah R, et al.
Comparison of serum fucose levels in leukoplakia and oral cancer patients. Asian Pac J Cancer Prev 2015;16:7497-500.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]