الفهرس 
Introduction
Aim of the workOnly 14 pages are availabe for public view
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Abstract
This study was conducted on thirty two female patients with breast cancer (group 1) and twenty female patients with benign breast lesions (group 2). They were selected among cases referred to surgical department of Assiut University hospital and South Egypt Cancer Institute before any treatment or surgical intervention. Serum glucose, Kidney function tests, Liver function tests, Peripheral haemogram, abdominal ultrasound, Chest X-ray, MRI and bone scan were done for all patients. Also, thirty apparently healthy female individuals were included in this study (from healthy volunteers after informed consent) as a control group for comparison (group 3). All these apparently healthy individuals had normal clinical examination, normal bilateral breast mammography, normal chest x-ray and normal abdominal ultrasound.
The following specific investigations were done for all the studied persons:
1. Serum CA 15-3 by chemiluminescent immunometric assay.
2. Serum CEA by chemiluminescent immunometric assay.
3. Plasma cfDNA (GAPDH) by Real-time PCR (RT-PCR).
4. Serum telomerase mRNA (hTERT) by Real-time PCR (RT-PCR).
Findings of this study:
1) Cancer Antigen 15-3 (CA15-3) level:
The level of serum CA15-3 (meanSE) in group 1, 2 and 3 was (53.54±8.22 IU /ml) , (28.75 ± 3.45 IU/ml) and (25.23 ± 2.14 IU/ml), respectively. A statistical significant elevation was observed in breast cancer group when compared with benign lesion and control groups. But, no significant difference between patients with benign breast lesions and control group could be detected as regard serum CA15-3 level (mean ± SE).
In group 1: 40.6% of the patients had elevated levels of serum CA15-3 above the cut off value which was 47.1 IU/ml.
In group 2: 25% of the patients had elevated serum CA15-3 level.
None of the healthy females in control group (group 3) had elevated CA15-3 level above the cut-off value.
2) Carcinoembryonic Antigen (CEA) level:
The level of serum CEA (meanSE) in group 1, 2 and 3 was (7.49±1.91 ng/ml), (2.08 ± 0.25 ng/ml) and (2.67 ± 0.18 ng/ml), respectively. There was a statistical significant elevation in breast cancer group when compared to benign lesion and control groups. But, there was insignificant difference in patients with benign breast lesions when compared to control groups as regard serum CEA level (mean ± SE).
In group 1: 28.1% of the patients had elevated levels of serum CEA above the cut off value which was 4.0 ng/mL.
In group 2: none of the patients had elevated serum CEA level.
None of the healthy females in control group (group 3) had elevated serum CEA level above the cut-off value.
3) Plasma cfDNA (GAPDH) level:
The level of plasma GAPDH (meanSE) in group 1, 2 and 3 was (3646.9 721.35 GE/ml), (230.44 21.72 GE/ml) and (191.46 ± 14.95 GE/ml), respectively.There was a highly statistical significant elevation in breast cancer group when compared to benign lesion and control groups, but there was no significant difference between benign lesion group and control group as regard plasma GAPDH level (mean ± SE).
In group 1: 87.1% of the patients had elevated levels of plasma GAPDH above the cut off value which was 343.5 GE/ml.
In group 2: 15% of the patients had elevated plasma GAPDH level.
In group 3: none of the healthy females in control group had elevated plasma GAPDH level above the cut-off value.
4) Telomerase mRNA (hTERT) level:
The expression level of serum hTERT (meanSE) in group 1, 2 and 3 was (126.01±38.94), (0.928 ± 0.28) and (0.216 ± 0.06), respectively. A highly statistical significant elevation was observed in breast cancer group when compared to patients with benign lesions and control group. Also, there was a statistical significant elevation in benign lesion group when compared to control group as regard serum telomerase mRNA level (mean ± SE).
In group 1: 78.1% of the patients had elevated levels of serum hTERT above the cut off value which was 1.0 .
In group 2: 15% of the patients had elevated serum hTERT level.
None of the healthy females in control group (group 3) had elevated hTERT level above the cut-off value.
Relation between the tumor markers and tumor staging:
There was no relation between the serum level of CA15-3 or CEA and the advancement of the breast cancer represented by the increase in the clinical staging of the disease. There was statistically significant increase in serum CA15-3 and CEA levels in early stage (Stage I and II) of breast cancer group compared to benign lesion group. Also, there was statistically significant increase in serum CA15-3 but not CEA levels in early stage (Stage I and II) of breast cancer group compared to control group. Moreover, there was statistically significant increase in serum CEA but not CA15-3 levels in late stage (Stage III and IV) of breast cancer group compared to early stage (Stage I and II) of breast cancer.
Also, there was no significant relation between serum CA15-3 or CEA and tumor size. Moreover, there was no significant relation between serum CA15-3 and lymph node involvement. But, there was a statistical significant relation between serum CEA level and lymph node involvement.
By comparing patients with distant metastasis (stage IV breast cancer) versus patients free of distant metastasis (stages I, II and III), we found no statistical significant difference as regard serum CA 15-3 and CEA level (mean ± SE).
There was a statistical significant elevation in the level of plasma GAPDH and serum hTERT with the advancement of the breast cancer represented by the increase in the clinical staging of the disease. There was highly statistically significant increase in plasma GAPDH and serum hTERT level in early stage (Stage I and II) of breast cancer group compared to benign lesion and control groups. Moreover, there was statistically significant increase in plasma GAPDH and serum hTERT level in late stage (Stage III and IV) of breast cancer group compared to early stage (Stage I and II) of breast cancer.
Also, there was a significant relation between plasma GAPDH, but not hTERT, level and tumor size. But, there was no significant relation between plasma GAPDH or serum hTERT level and lymph node involvement according to TNM staging inspite that plasma GAPDH and serum hTERT level (mean ± SE) in patients with lymph node involvement (N1, N2 and N3) was higher than that of patients without lymph node involvement (N0).
Patients having distant metastasis (stage IV breast cancer) had statisticaly significant higher plasma GAPDH and serum hTERT level (mean ± SE) than those free of distant metastasis (stages I, II and III).
Diagnostic value of CA15-3, CEA, cfDNA and telomerase mRNA:
The ROC curves of serum CA15-3, serum CEA, plasma GAPDH and serum hTERT were constructed to compare their diagnostic value, in such a way that the higher area under the curve (AUC) corresponds to a better diagnostic test. Circulating free DNA and serum telomerase had the highest AUC when discriminating breast cancer group from benign lesion or control group, suggesting a strong discrimination power and nominates plasma GAPDH and serum hTERT as diagnostic tests with an excellent accuracy. On the other hand, hTERT had the highest AUC when discriminating benign lesion group from control group, suggesting a strong discrimination power and nominates serum telomerase as the only diagnostic test of them that can discriminate benign lesion group from control group.
Differentiating breast cancer group from benign lesion group and control group revealed that cfDNA had the highest sensitivity (87.1%). It also had highest positive predictive value (90%) and highest negative predictive value (82%). hTER had a sensitivity of 80.6%, PPV of 89.3%, NPV of 80%. Moreover, measurement of the two new markers (cfDNA and telomerase mRNA) in combination increases the sensitivity of the test (87.4%). The diagnostic accuracy of cfDNA was 90% and that of telomerase mRNA was 89.3% and both were higher than that of the conventional markers (CA15-3 and CEA).
Differentiating breast cancer group from benign lesion group revealed that the specificity of CA 15-3, CEA, cfDNA and telomerase mRNA was 73.7%, 95%, 84.2% and 84.2%, respectively. Differentiating breast cancer group from control group revealed that the specificity of CA 15-3, CEA, cfDNA and telomerase mRNA was 97%, 86.2%, 100% and 97%, respectively.
When discriminating early stage of breast cancer from late stage of breast cancer or control group, the AUC for plasma GAPDH and serum hTERT were higher than that of CA 15-3 and CEA, this indicates a strong discrimination power of plasma GAPDH and serum hTERT and nominates them as diagnostic tests with an excellent diagnostic accuracy while nominates serum CA 15-3 and CEA as diagnostic tests with poor diagnostic accuracy. Also, when discriminating early stage of breast cancer group from benign lesion group, the AUC for plasma GAPDH was higher than that of serum CEA and hTERT while the AUC of CA 15-3 was the lowest one, this suggest a strong discrimination power of GAPDH and nominates it as a diagnostic tests with an excellent accuracy while CA 15-3 is considered a diagnostic test with poor diagnostic accuracy.
Plasma GAPDH and serum hTERT had the highest sensitivity when discriminating early stage of breast cancer from the late stage (94.7% for both markers), highest sensitivity when discriminating early stage of breast cancer from the benign lesion group (75% and 58.3%, respectively) and highest sensitivity (75% and 58.3%, respectively) and specificity (100%) when discriminating early stage of breast cancer from the control group.
Correlation of CA15-3, CEA, cfDNA and Telomerase mRNA with each other:
There was a significant positive correlation between serum telomerase mRNA expressions and plasma GAPDH concentrations.