Determining the relationship between serum acute phase reactants and cervical premalignant lesions: a cohort study

Abstract BACKGROUND: Acute phase reactants play a role in the progression and prognosis of many malignant and premalignant tumors. This study investigated the diagnostic value of certain reactants as markers for cervical premalignant lesions. OBJECTIVES: Despite advanced screening and vaccination programs, cervical cancer remains a serious health problem worldwide. We aimed to determine the possible relationship between premalignant cervical disease and serum acute phase reactant levels. DESIGN AND SETTING: This study included 124 volunteers who underwent cervical cancer screening. We divided the patients into three groups according to cervical cytology and histopathological findings as follows: no cervical lesion, low-grade neoplasia, or high-grade neoplasia. METHODS: We included women aged 25–65 years with benign smear or colposcopy results, low- and high-grade squamous intraepithelial lesions. The benign group was based only on cytology findings, whereas the other groups were based on histopathology findings. Demographic data and serum albumin, fibrinogen, ferritin, and procalcitonin levels were evaluated in the three groups. RESULTS: We found significant differences among the three groups in terms of age, albumin level, albumin/fibrinogen ratio, and procalcitonin level. The regression analysis revealed lower serum albumin levels in the low- and high-grade squamous intraepithelial lesion groups compared with the benign group. CONCLUSION: This is the first study to evaluate the importance of serum inflammatory markers in cervical intraepithelial lesions. Our results indicate that serum albumin level, albumin/fibrinogen ratio, procalcitonin level, and neutrophil values differ among cervical intraepithelial lesions.


INTRODUCTION
Cervical cancer is the third most diagnosed gynecological cancer and cause of death in the United States. 1 Owing to advanced screening programs, cervical cancer currently has lower incidence and mortality rates compared with endometrial and ovarian cancer. However, cervical cancer remains a significant cause of cancer morbidity and mortality in countries with limited access to screening programs. Cervical cancer screening facilitates the detection and treatment of premalignant cervical lesions before cancer develops. Current screening methods include human papillomavirus (HPV) testing, cervical cytology (also known as the Pap test or Pap smear), or both. 2 HPV is positively detected in 99.7% of patients diagnosed with cervical cancer. 2 The infection of the cervical transformation zone with oncogenic HPV subtypes results in the initiation of carcinogenesis. The development of high-grade cervical intraepithelial neoplasia and invasive cancer from the first infection takes an average of 15 years, although rapid progression has also been reported. 3 Inflammation reportedly plays an essential role in the formation, progression, and even invasion and metastasis of tumor cells. In reviewing the literature, we noted that numerous inflammatory complete blood parameters and acute phase reactants have been used in tumor diagnosis and prognosis. [4][5][6][7][8]

OBJECTIVE
We aimed to evaluate the relationship between cervical premalignant lesions and serum albumin, fibrinogen, ferritin, and procalcitonin levels. These molecules play essential roles in systemic inflammation, as well as the detection of cervical premalignant lesions to a certain degree, considering the carcinogenesis process begins in the presence of HPV infection. to determine whether the data showed a normal distribution.

RESULTS
The descriptive analysis results of the demographic and laboratory characteristics of the cases screened for cervical intraepithelial lesions are shown in Table 1. This study included 124 participants. The mean age of all participants was 40.1 ± 9.7 years.
We conducted a further evaluation by biopsy in 18 patients with smear results indicating LSIL, 11 patients with HSIL, and 21 patients with atypical squamous cells of undetermined significance. The number of patients with benign cervical cytology findings was 68 (56.2%); 53 patients whose final pathology results were benign were included in the three-group analysis (42.7%).
Despite benign smear findings, 15 patients underwent histopathological examinations because they were HPV-positive. Invasive cancer was detected in three patients, although these patients were not included in further analyses ( Table 1).
We divided the included patients into benign, LSIL, and HSIL groups according to cervical cytology and final histopathology results. There was a statistically significant difference between the groups in terms of age, albumin level, procalcitonin level, and albumin/fibrinogen ratio (P < 0.01, P = 0.006, P = 0.006, and P = 0.067, respectively). When we evaluated the groups using binary post hoc, a statistically significant difference was observed between the benign and LSIL groups in terms of age, albumin, and procalcitonin values (P = 0.043, P = 0.05, P = 0.017, respectively). Binary post hoc analysis between the benign and HSIL groups showed statistical significance in terms of age, albumin level, and albumin/fibrinogen ratio. Meanwhile, procalcitonin levels did not differ between the two groups. No significant differences were observed in the laboratory parameters between the LSIL and HSIL groups ( Table 1).
To determine the most compatible independent predictive variable for cervical intraepithelial lesions, multiple regression analysis was performed among the three groups, and the results are presented in Table 2. Although the benign cervical lesion group was the reference category, according to the multinomial logistic regression analysis, albumin values were significantly lower in the LSIL and HSIL groups than those in the reference group (P = 0.042 and P = 0.027, respectively). Each one-unit decrease in albumin level caused a 0.8-fold increase in the development of LSIL and HSIL ( Table 2).
Receiver operating characteristic curves were created for the albumin parameter, and its predictive effect on the development of LSIL and HSIL was determined. The areas under the curve (AUCs), sensitivity, and specificity were calculated. The cutoff value for albumin was based on the values in the benign group. Descriptive analyses were performed using the mean and standard deviation (X ± standard deviation) for normally distributed data and median and minimummaximum values for nonnormally distributed data. Statistical significance was set at P < 0.05. For two-group analyses of the results that were significant in the multiple regression analysis, Gabriel tests were used when variances from post hoc tests were homogeneously distributed, and Games-Howell tests when they were not. Homogeneity of variances was evaluated using the Levene's test. * One-way analysis of variance; # Kruskal Wallis test. HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion; min-max = minimum-maximum; SD = standard deviation. g/dl: gram/deciliter, mcl: microliter, fl: femtoliter, g/l: gram/liter, mg/dl: milligram/deciliter, ng/ml: nanogram/milliliter. P values < 0.05 were considered significant.  Figure 1).
In this study, 32 patients underwent conization for the final diagnosis. We divided these patients into LSIL (n = 13) and HSIL (n = 19) groups after pathological examinations. Comparison tests were performed in terms of laboratory parameters in these two groups. Accordingly, plasma leukocyte and neutrophil levels were statistically significantly higher in the HSIL group than those in the LSIL group (P < 0.05) ( Table 5).

DISCUSSION
This case-control study aimed to compare inflammatory markers between women with and without cervical intraepithelial lesions. Serum albumin levels were significantly lower in women with premalignant lesions compared with women with benign lesions.
Cervical intraepithelial neoplasms are premalignant squamous lesions of the cervix that are diagnosed by cervical biopsy and histological examination. These premalignant lesions of the cervix have undergone terminological changes over time and have since been revised. In the last classification system, the histological   findings of the cervix are presented using the same terminology as the cytological findings. 10 In women in developing countries, cervical cancer is the second most common type of cancer and the third most common cause of cancer-related death. 11  We found some differences in laboratory values for whole blood markers and biochemical acute phase reactants in patients with cervical LSIL and HSIL compared with those of benign patient groups.
Several factors are involved in the pathogenesis of cancer and precancerous lesions. The relationship between cancer and inflammatory processes and the role of inflammation-related parameters in this pathogenesis have been demonstrated in many studies. [13][14][15] A study by Sattar et al. determined that serum albumin levels in nonsmall cell lung cancer were lower than those in a healthy population. 16 Moreover, Erlinger et al. reported that serum C-reactive protein levels were higher in patients with colorectal cancer compared with a healthy group. 17 Although studies show that plasma fibrinogen elevation is significantly increased in many malignancies, previous studies and meta-analyses that evaluated the albumin and fibrinogen parameters together revealed that the proportional values of these two molecules differ significantly among cancer patients. [18][19][20][21][22][23] In a 2016 study, plasma ferritin levels had a significant relationship with prostate cancer. 7 A review published in 2016 that analyzed 15 articles found that serum procalcitonin levels are significantly valuable for the early diagnosis of infection-related complications and exacerbations in cancer patients. 24 This finding indicates that although the procalcitonin molecule is not a direct cancer marker, it may differ significantly in malignancies compared with healthy populations and may be a topic of further study. However, previous studies have shown that serum procalcitonin levels increase significantly in lung, medullary thyroid, and metastatic liver cancer. [25][26][27] Complete blood parameters have been extensively studied in many malignancies because they are easy to obtain, readily available, economical, and have pioneered many studies in the literature. Hemoglobin level, white blood cell count, and thrombocyte count and their relative values, which were among the complete blood parameters, also differed significantly in cancer patients compared with a healthy population. 6,[28][29][30] An article published in 2019 showed that serum neutrophil/lymphocyte and platelet/ lymphocyte ratios were significantly associated with cervical cancer and cancer stage. 31 Although studies and reviews have been conducted on the relationship between cancer, inflammation, and inflammatory molecules, the mechanisms that can assist in monitoring and screening cancer and precancerous lesions are unclear. We analyzed inflammation-associated whole blood parameters and other markers to observe cervical intraepithelial lesions exposed to HPV-related infection and inflammation processes. We divided the patients into two groups according to histopathological examination results: LSIL and HSIL groups according to the histopathological examination results of participants who were HPV-DNA positive. We observed that the neutrophil count was higher in the HSIL group. In addition, when we evaluated the conization patients in the LSIL and HSIL groups, we found that the serum neutrophil count was higher in the HSIL group. This increase in cervical lesions and serum neutrophil values indicates that this parameter may be a supportive method for screening or observations. Previous studies have reported a relationship between serum neutrophil and neutrophil/lymphocyte ratio and inflammation. Increased neutrophil concentration is considered to promote neoplastic progression. [31][32][33] This study investigated the relationship between inflammatory blood markers and precursor lesions in women screened for cervical cancer. Among these parameters, albumin/fibrinogen ratio and albumin, neutrophil, and procalcitonin levels were significantly associated with cervical intraepithelial lesions. However, these results may not directly indicate the role these molecules play in cervical cancer screening and may not indicate a direct relationship between the disease and its severity. This study was based on the observation of these laboratory parameters in a healthy population and a population with cervical lesions. Our findings may gain further significance by observing a larger group of patients, conducting additional multicenter studies, and incorporating different molecules into the analysis. To the best of our knowledge, this is the first such study in the literature.

CONCLUSION
In conclusion, there is no low-cost, highly-specific diagnostic laboratory marker that can assist the smear and HPV tests used in screening for cervical cancer and intraepithelial lesion precursors to cervical cancer. Low serum albumin levels may be predictive of cervical lesion development. Future studies with more patients and different study designs may provide new data for the prediagnosis and follow-up of premalignant cervical diseases. This study is the first to evaluate the importance of serum inflammatory markers in cervical intraepithelial lesions. According to our results, serum albumin, albumin/fibrinogen ratio, procalcitonin, and neutrophil values were significantly correlated in cervical intraepithelial lesions.