Journal of Surgical Oncology 2003;83:248252

Elevation of Preoperative Serum C-Reactive Protein

Level Is Related to Poor Prognosis in Esophageal
Squamous Cell Carcinoma
HIDEAKI SHIMADA, MD,* YOSHIHIRO NABEYA, MD, SHIN-ICHI OKAZUMI, MD, HISAHIRO MATSUBARA, MD,
TOORU SHIRATORI, MD, TAITO AOKI, MD, MAKOTO SUGAYA, MD, YUKIMASA MIYAZAWA, MD,
HIDEKI HAYASHI, MD, SHIN-ICHI MIYAZAKI, MD, AND TAKENORI OCHIAI, MD
Department of Academic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan

Background and Objectives: An increased serum C-reactive protein (CRP) level was
found in patients with various malignant tumors and was associated with poor
prognosis. The aim of this study was to analyze the clinicopathological significance
and the prognostic value of preoperative CRP levels in patients with esophageal
squamous cell carcinomas.
Patients and Methods: The preoperative CRP level was measured by enzyme-linked
immunosorbent assay (ELISA) in 150 patients with primary esophageal squamous cell
carcinomas. All patients underwent radical surgery without any preoperative therapy.
The patients were divided into two groups using a cut-off value of 1.0 mg/dl. The
pathological classifications of the tumor were examined according to the TNM/UICC
classification. The associations between the clinicopathological factors and CRP level
were determined. The prognostic value of CRP was determined using Coxs proportional hazards model.
Results: Thirty-five patients (23%) showed high CRP levels (more than 1.0 mg/dl).
Statistically significant differences in CRP levels were observed depending on tumor
depth (P 0.022) and TNM/UICC stage (P 0.001). A high CRP level was associated
with poor survival (P 0.005) and was confirmed by multivariate analysis.
Conclusions: A high CRP level is associated with tumor progression and poor survival
in patients with esophageal squamous cell carcinoma.
J. Surg. Oncol. 2003;83:248252.

2003 Wiley-Liss, Inc.

KEY WORDS: CRP; esophageal cancer; prognosis

INTRODUCTION
Esophageal carcinoma is one of the most lethal
malignant tumors [1]. The aggressive behavior of this
tumor is often associated with systemic spread of the
disease at the time of diagnosis [24]. The malignant
potential of esophageal carcinoma has been evaluated by
several serum markers [58]. Increased C-reactive protein (CRP) levels also have been found as a paraneoplastic syndrome for several malignant tumors [915].
Although several reports suggested that a high CRP level
is associated with poor prognosis in a number of cancer
types [8,9,12,13], the clinical significance of CRP levels
in patients with esophageal cancer has been examined in
a limited study. Nozoe et al. reported that the elevation of
2003 Wiley-Liss, Inc.

serum CRP was an independent prognostic factor for

esophageal carcinoma patients [10]. However, they
included patients who underwent preoperative therapy
and patients who underwent non-curative surgery in their
study. Because preoperative therapy and surgical curability have significantly impact on prognosis, we focused
Grant sponsor: Ministry of Education, Science, and Culture of Japan
(Advanced Medicine Development Project and #12671200).
*Correspondence to: Hideaki Shimada, MD, Department of Academic
Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana,
Chuou-ku, Chiba, Japan, 260-8677, Fax: 81-43-226-2113.
E-mail: hshimada@med.m.chiba-u.ac.jp
Accepted 23 April 2002
DOI 10.1002/jso.10275
Published online in Wiley InterScience (www.interscience.wiley.com).

CRP Level in Esophageal Cancer

on patients who underwent curative surgery without any

preoperative therapy in the present study. We excluded
the patients who had received any treatments before
surgery, because precise pathological staging in the
resected specimens was vital to evaluate prognostic value
of preoperative CRP level with multivariate analysis.
In this study, we measured the CRP levels in 150
patients with primary esophageal squamous cell carcinoma to determine both the clinicopathological and
prognostic significance of CRP levels in these patients.
We found that a high CRP level was associated with
tumor progression and poor prognosis.
PATIENTS AND METHODS
Patients and Tumor Evaluation

Between 1991 and 2000, 150 patients with histologically confirmed primary esophageal squamous cell carcinomas who were treated at Chiba University Hospital
were studied. Patients were recruited and serum samples
were collected according to the protocol guidelines
approved by the institutional review board. Informed
consent was obtained from all of the subjects. Patients
consisted of 128 males (85%) and 22 females (15%) with
a mean age of 65 years (range: 3587 years). Each
patient underwent an en bloc esophagectomy with
locoregional lymphadenectomy through a right thoracotomy and laparotomy with reconstruction using the
stomach or colon. The locoregional lymphadenectomy
included a two-field lymph node dissection (mediastinal
and abdominal regions) for carcinomas of the lower third
of the esophagus and a three-field lymph node dissection
(cervical, mediastinal, and abdominal regions) for carcinomas of the upper two-thirds of the esophagus [3,4]. All
of the patients were classified according to the TNM/
UICC classification system in conjunction with pathological examination of the resected specimens [16]. The
patients included 22 with stage I cancer; 45 with stage II;
71 with stage III; and 12 with stage IV. None of the
patients had received blood transfusions, radiotherapy, or
chemotherapy within the 6 months of the study.

249

Statistical Analyses

Comparisons between unpaired groups were made

using the MannWhitney U test. Survival probabilities
were calculated using the product limit method of Kaplan
and Meier, with while considering treatment-related
deaths and deaths caused by esophageal cancer. Differences between groups were determined using the logrank test. Fishers exact probability test was used to
determine the significance of differences between the two
groups. The influence of each significant predictor
identified by univariate analysis was assessed by multivariate analysis using Coxs proportional hazards model.
All statistical analyses were carried out using the Stat
View program (SAS Institute Inc., Cary, North Carolina),
and all P values were considered statistically significant
if <0.05.
RESULTS
CRP Level and Clinicopathological Variables
of Esophageal Squamous Cell Carcinoma

The serum CRP levels for 115 patients (77%) were less
than 1.0 mg/dl (low CRP group, 0.23  0.22 mg/dl) and
the CRP levels for 35 patients (23%) were higher than
1.0 mg/dl (high CRP group, 3.47  3.10 mg/dl) (Fig. 1).
Such a high degree of serum increases (of more than
10 mg/dl) was recognized in four patients. While no
correlation was found between the CRP level and either
gender (P 0.377) or distant metastasis (P 0.563),
CRP levels were increased in elderly patients (P 0.094)
and patients with nodal metastasis (P 0.092). CRP
levels significantly increased in patients with deep tumors

Serum Sampling and Enzyme Immunoassay

for Serum CRP Level

Blood samples were obtained by venous punctuation

before initiating treatment. Each sample was centrifuged
at 3,000g for 5 min and then frozen at
808C until the
time of the assay. The repeated thawing and freezing of
samples was avoided. The serum CRP levels were measured with a Latex CRP immunodetection kit (CRPLATEXSEIKEN, Tokyo, Japan). The cut-off values
were 1.0 mg/dl with a specificity of 99% (624 out of 632
healthy persons had levels less than 1.0 mg/dl).

Fig. 1. The scatter and mean value in the high C-reactive protein
(CRP) group and low CRP group.

250

Shimada et al.

(P 0.023) and those with advanced tumor stage

(P < 0.001) (Table I). Within the high CRP group, 86%
of patients had T2T4 tumors and 80% of patients had
stage III or IV.
Prognostic Significance of CRP level

In order to investigate whether high CRP levels can

help predict the prognosis of patients with esophageal
squamous cell carcinomas, we performed a Kaplan
Meier analysis and the log-rank test. Among the clinicopathological factors considered, the 5-year survival was
significantly better in patients with T1 tumors, no lymph
node metastasis, and no distant metastasis (Table II). The
low CRP group showed a significantly better 5-year
survival than the high CRP group (Fig. 2A). After
adjusting TNM stages, although the low CRP group
showed significantly better survival than high CRP group
in stage I & II (Fig. 2B), no significant difference was
observed in stage III & IV (Fig. 2C). All clinicopathological factors listed in Table II were tested by multivariate analysis and independent prognostic factors were
identified using Coxs proportional hazards model. The
results showed that CRP level was an independent
prognostic factor for esophageal squamous cell carcinoma (Table III Model A). Because high CRP is
significantly associated with advanced stage, CRP level
was not an independent prognostic factor in Model B.

TABLE II. Univariate KaplanMeier Analysis in Patients With

Esophageal Squamous Cell Carcinoma
Variables
Gender
Male
Female
Age
<65
65
Tumor depth
T1
T2T4
N factor
N0
N1
M factor
M0
M1
CRP < 1.0 mg/dl
CRP  1.0 mg/dl

5-year survival rate

43.3
24.0

0.248

43.2
37.2

0.583

67.6
17.3

<0.001

73.7
21.8

<0.001

44.1
14.3
44.1
27.5

0.070

0.005

DISCUSSION
In the present study, we found that preoperative serum
CRP levels were elevated in patients with advanced
TABLE I. Relationship Between the CRP Concentration and the
Clinicopathological Variables in 150 Patients With Esophageal
Squamous Cell Carcinoma
Variables
Gender
Male
Female
Age
<65
65
Tumor depth
T1
T2T4
N factor
N0
N1
M factor
M0
M1
Stage
III
Stage
IIIIV

Number of patients

CRP  1.0 mg/dl

128
22

31
4

0.377

81
69

15
20

0.094

43
107

5
30

0.022

36
114

5
30

0.092

138
12

32
3

0.563

67

<0.001

83

28

Fig. 2. Overall survival curves for patients with esophageal carcinoma after curative resection. High CRP group vs. low CRP group.
The P values were determined using the Log-rank test. A: All patients,
(B) stage I & II, and (C) stage III & IV.

CRP Level in Esophageal Cancer

251

TABLE III. Risk Factors Affecting Survival Rate by Multivariate KaplanMeier Analysis in 150
Patients With Esophageal Squamous Cell Carcinoma
Variables
Model A
T1 vs. T2T4
N0 vs. N1
M0 vs. M1
Low CRP vs. ccchigh CRP
Model B
Stage I & II vs. III & IV
Low CRP vs. high CRP

Multivariate P

Hazards ratio

95.0% CI

0.029
0.005
0.827
0.049

2.22
3.10
1.08
1.68

1.094.54
1.406.84
0.532.24
1.012.82

<0.001
0.198

2.95
1.42

1.665.24
0.832.41

esophageal squamous cell carcinomas. In addition, CRP

levels increased with tumor progression resulting in poor
prognosis. CRP has been reported to be produced by
hepatocytes [17,18] and to be intimately associated with
inflammatory cytokines produced by tumor cells [19,20].
As a result, the gradual increase in CRP levels that was
observed with increasing tumor size and progression may
be caused by excess inflammatory cytokines produced by
the large number of cancer cells in patients with advanced
disease. This relationship was confirmed in the present
study, in which the CRP level correlated with the depth of
invasion, the degree of lymph node metastasis, and the
presence of distant metastasis. Based upon these results,
we speculated that tumor volume and advanced stage
might contribute to CRP levels.
A number of studies have shown that increased CRP
levels in various solid tumors are associated with poor
prognosis [915]. In our study, the survival of patients in
the high CRP group was significantly worse than that of
the low CRP group. Although the difference in survival
rates was mainly attributable to differences in TNM
staging between the low and high CRP groups, CRP was
an independent prognostic factor according to multivariate analysis. Serum CRP was found to identify a
subgroup of curatively resected patients at risk for short
survival.
According to the manufacturers instructions, we used
the cut-off value of 1.0 mg/dl as an upper limit of the
normal range. Because Nozoe et al. used a different assay
system; their cut-off value was 0.5 mg/dl. When we used
0.5 mg/dl as a cut-off value, the high CRP group showed
significantly worse survival than that of the low CRP
group. However, the CRP level was not an independent
prognostic factor according to multivariate analysis (data
not shown).
Possible explanations for the malignant potential of the
tumors with high serum CRP levels are as follows: (i)
tumors with high CRP levels showed resistance to
chemotherapy [21,22], (ii) over-expression of IL-6
increases the anti-apoptotic activity and tumorigenic
potency [23], (iii) high serum levels of CRP correlate

with T cell impairment [24], (iv) increased levels of

serum angiogenic factors correlate with increased serum
CRP levels (our unpublished data). Although a previous
study included the patients who underwent preoperative
treatment and the patients who received non-curative
resection [10], we evaluated the impact of the CRP levels
only in patients who underwent curative surgeries alone
without any preoperative treatments. The differences may
contribute to the borderline significance of the CRP level
in multivariate analysis. Even for patients who underwent
curative surgery, about half of the patients developed
tumor recurrence. Because high CRP levels after surgery
were reported to be useful in predicting tumor recurrence
in colon carcinoma [25], further prospective studies will
be required to address the clinical utility of CRP levels in
monitoring esophageal carcinomas after surgery. Because
several reports suggested that aspirin might reduce the
risk of development and growth of esophageal cancers
[2629], aspirin may attenuate the CRP response resulting in better treatment responses and better survival in
patients with high CRP levels.
In summary, we have shown that CRP may be used to
predict patient survival after surgery and that CRP may
complement the prognostic value of TNM staging.
Because ELISA is a quick and easy to perform assay,
the measurement of CRP may prove to be a useful clinical
method in esophageal carcinomas.
REFERENCES
1. Daly JM, Karnell LH, Menck HR: National cancer database
report on esophageal carcinoma. Cancer 1996;78:18201828.
2. Tachimori Y, Kato H: Diagnosis and surgery of esophageal
cancer. Crit Rev Oncol Hematol 1998;28:5771.
3. Isono K, Ochiai T, Okuyama K, et al.: The treatment of lymph
node metastasis from esophageal cancer by extensive lymphadenectomy. Jpn J Surg 1990;20:151157.
4. Isono K, Sato H, Nakayama K: Results of a nationwide study on
the three-field lymph node dissection of esophageal cancer.
Oncology 1991;48:411420.
5. Shimada H, Takeda A, Nabeya Y, et al.: Clinical significance of
serum vascular endothelial growth factor in esophageal cancer
patients. Cancer 2000;92:663669.
6. Nabeya Y, Shimada H, Okazumi S, et al.: Serum cross-linked
carboxyterminal telopeptide of type I collagen (ICTP) as a useful

252

7.
8.
9.
10.
11.

12.

13.
14.
15.

16.
17.

Shimada et al.
prognostic tumor marker in patients with esophageal squamous
cell carcinoma. Cancer 2000;94:940949.
Shimada H, Takeda A, Nabeya Y, et al.: Prognostic significance of
serum thymidine phosphrylase in the patients with esophageal
squamous cell carcinoma. Cancer 2002;94:19471954.
Shimada H, Okazumi S, Matsubara H, et al.: Prognostic signifcance of serum p53 antibodies in the patients with esophageal
squamous cell carcinoma. Surgery 2002;132:4147.
Nakanishi H, Araki N, Kudawara I, et al.: Clinical implications of
serum C-reactive protein levels in malignant fibrous histiocytoma.
Int J Cancer 2002;99:167170.
Nozoe T, Saeki H, Sugimachi K: Significance of preoperative
elevation of serum C-reactive protein as an indicator of prognosis
in esophageal carcinoma. Am J Surg 2001;182:197201.
Miyata Y, Koga S, Nishikido M, et al.: Predictive values of acute
phase reactants, basic fetoprotein, and immunosuppressive acidic
protein for staging and survival in renal cell carcinoma. Urology
2001;58:161164.
Deichmann M, Benner A, Waldmann V, et al.: Interleukin-6 and
its surrogate C-reactive protein are useful serum markers for
monitoring metastasized malignant melanoma. J Exp Clin Cancer
Res 2000;19:301307.
Kodama J, Miyagi Y, Seki N, et al.: Serum C-reactive protein as a
prognostic factor in patients with epithelial ovarian cancer. Eur J
Obstet Gynecol Reprod Biol 1999;82:107110.
Falconer JS, Fearon KC, Ross JA, et al.: Acute-phase protein
response and survival duration of patients with pancreatic cancer.
Cancer 1995;75:20772082.
Nielsen HJ, Christensen IJ, Sorensen S, et al.: Preoperative
plasma plasminogen activator inhibitor type-1 and serum Creactive protein levels in patients with colorectal cancer. The
RANX05 Colorectal Cancer Study Group. Ann Surg Oncol 2000;
7:617623.
Sobin LH, Wittekind C: International union against cancer:
TNM classification of malignant tumors. 5th edition. New York:
Wiley-Liss; 1997.
Ritchite DG, Fuller GM: Hepatocyte-stimulating factor: A
monocyte-derived acute-phase reguratory protein. Ann NY Acad
Sci 1983;408:490502.

18. Castell JV, Gomez-Lechon MJ, et al.: Interleukin6 is the major

regulator of acute phase protein synthesis in adult human
hepatocytes. FEBS Lett 1989;242:237239.
19. Ljungberg B, Grankvist K, Rasmuson T: Serum interleukin-6 in
relation to acute-phase reactants and survival in patients with
renal cell carcinoma. Eur J Cancer 1997;33:17941798.
20. Yoshida N, Ikemoto S, Narita K, et al.: Interleukin-6, tumor
necrosis factor alpha, and interleukin-1beta in patients with renal
cell carcinoma. Br J Cancer 2002;86:13961400.
21. Ueno H, Okada S, Okusaka T, et al.: Prognostic factors in patients
with metastatic pancreatic adenocarcinoma receiving systemic
chemotherapy. Oncology 2000;59:296301.
22. Heys SD, Ogston KN, Simpson WG, et al.: Acute phase proteins
in patients with large and locally advanced breast cancer treated
with neo-adjuvant chemotherapy: Response and survival. Int J
Oncol 1998;13:589594.
23. Jee SH, Shen SC, Chiu HC, et al.: Overexpression of interleukin-6
in human basal cell carcinoma cell lines increases anti-apoptotic
activity and tumorigenic potency. Oncogene 2001;20:198208.
24. Maccio A, Lai P, Santona MC, et al.: High serum levels of soluble
IL-2 receptor, cytokines, and C reactive protein correlate with
impairment of T cell response in patients with advanced epithelial
ovarian cancer. Gynecol Oncol 1998;69:248252.
25. McMillan DC, Wotherspoon HA, Fearon KC, et al.: A prospective
study of tumor recurrence and the acute-phase response after
apparently curative colorectal cancer surgery. Am J Surg 1995;
170:319322.
26. Li M, Lotan R, Levin B, et al.: Aspirin induction of apoptosis in
esophageal cancer: A potential for chemoprevention. Cancer
Epidemiol Biomarkers Prev 2000;9:545549.
27. Husain SS, Szabo IL, Tamawski AS: NSAID inhibition of GI
cancer growth: Clinical implications and molecular mechanisms
of action. Am J Gastroenterol 2002;97:542553.
28. Farrow DC, Vaughan TL, Hansten PD, et al.: Use of aspirin and
other non-steroidal anti-inflammatory drugs and risk of esophageal and gastric cancer. Cancer Epidemiol Biomarkers Prev 1998;
7:97102.
29. Funkhouser EM, Sharp GB: Aspirin and reduced risk of esophageal carcinoma. Cancer 1995;76:11161119.