Detection the level of YKL-40 biochemical marker and vitamin D level in sera of Iraqi Uterine cancer females' patients

: Objective: Detection the level of YKL-40 biochemical marker and vitamin D level in sera of Iraqi uterine cancer females' patients. Methodology: This study included 90 female volunteers, 30 of them were healthy volunteers who were considered as a control group, while sixty serum samples were collected from women patients suffering from uterine tumors (30 malignant and 30 fibroid benign tumors), benign cases were considered as a disease control group for malignant tumors. The average age of those females was 30-75 years, which matched the control group. All the samples were collected from Azady hospital in Kirkuk and the gynecologic department at Medical City in Baghdad during October /2012 to May /2013. All the serum samples were undergone biochemical estimation for the levels of YKL-40, and 25 (OH) vitamin D using ELISA technique, and BMI data were collected. Results: Estimation of YKL-40 levels showed that there were 28 No. (93.33%) of EC patients had high level of YKL-40, while 26 no. (86.67%) of fibroid (benign tumor) patients had low level, and 15(50.00 %) of healthy control had low. There was a significant difference found in YKL-40 level in EC patients when compared with the fibroid (benign tumor) patients and healthy control (Pvalue= 0.0001), (Pvalue= 0.0001) respectively. The highest percent of women with EC and the women with fibroid (benign tumor) had deficiency of 25 (OH) vitamin D levels (66.67%). While the highest percent of healthy control had sufficiency of 25(OH) vitamin D level (56.67%). statistically there was significant difference among study groups (p=0.0001). Were as no significant difference between EC patients and fibroid (benign tumor) patients (P-value =0.822). Recommendations: Comparing between the ykl-40 marker and other tumor marker diagnostic levels in the detection of uterine tumors. For further studies, we recommended study the diagnostic levels of ykl-40 marker and its correlation with other body tumors. It is recommended to do estimation of vitamin D levels with more advanced method and correlation of its with disease.

Cancer is caused in all or almost all instances by mutation or by some other abnormal activation of cellular secretion that control cell growth and cell mitosis. The abnormal cellular secretions called biomarker. As many as different biomarker has been discovered (3, 4) .
However, recent studies have revealed that YKL-40 has elevated serum level in several solid tumors and it is a potential biomarker in the detection and management of adenocarcinoma of several types of cancers including a diagnostic and prognostic role in the uterine cancer (6) .
It was denoted that YKL-40 is subjected to tight regulation at multiple levels. In cancer cells, its role can be compromised by various mechanisms that's include proliferation and differentiation of malignant cells, protects the cancer cells from undergoing apoptosis, stimulates angiogenesis, and stimulates fibroblasts surrounding the tumor (7) .
There is another factor which was observed to play a crucial role in cancer development, which a limited data are available that regarding the association of vitamin D with endometrial cancer risk (8) . Vitamin D deficiency is extremely common in patients with all types of cancer.
Therefore, it is important for cancer patients to be sure that do not have vitamin D deficiency. A specific type of blood test (that measures 25-hydroxyvitamin D) is the only way a person can find out if he has enough vitamin D (9) .  Table and figure shows the distribution of study groups according to age, these results showed that the majority of patients with EC is (≥60) years old with 16 patients (53.33%), while 20 patients (66.67%) for fibroid (benign tumor) in age (40-49) years old and 9 subjects (30.00%) for healthy control with age of (≥60) years old . Table data demonstrated the distribution of study groups according to BMI, that shows the majority of patients with EC had obese 24 patients (80.00%), and normal weight 1 patient (3.33%), while in patients with fibroid (benign tumor) the highest percent 15 patients (50.00%), and 14 patients (46.67%) in the healthy control were overweight. A significant difference was found between the EC patients when they were compared with that of control groups (p= 0.001).    67%), and high level 4 patients (13.33%), while limit level were 0(0%). A non significant difference was found between the patients when they were compared with that of control (P. value>0.05).  Table show that there is a no significant difference in the distribution of serum YKL-40 level between both EC patients and control group (p=0.0001). In this study the majority of patients with EC had high level 28 patients (93.33%), and low level 2 patients (6.67%), while limit level were 0(0%).  The pattern of distribution of EC patients and healthy control group according to serum 25(OH) vitamin D level is noticeable in table, which demonstrate that the majority of EC patients were had deficiency of 25(OH) vitamin D 20 patients (66.67%), while in healthy control group were had sufficiency of serum 25(OH) vitamin D 17 subjects (56%). Moreover, a significant difference was found between EC and healthy control (P value =0.0001).

Discussions:
In the current study, it was observed that the age of disease initiation was earlier among benign tumors' subjects (in the 3 rd decade) in comparison with malignant cases (at 6 th decade). In spite of that, the current findings referred to development of malignant cases as delayed as 50 years which is comparable with those estimated for American women during 2013 (10) . Results in present study are in disagreement with previous result in China by Yuan He, who observed that highest percentage (56.2%) for patients with fibroid (benign tumor) and (44.3%) for healthy controls (11) .
Considering BMI, it was referred that obesity acts as a risk factor for endometrial carcinoma in women. These results were in agreement with the observation of Charlotte Atkinson et al in USA, which showed that there was a significant difference between patients with fibroid (benign tumor) in comparison to healthy controls (P-value <0.01) (12) . The illustration for this controversy may be attributed to the fact that the age of most patients with malignant endometrial cancer was above 50 years (i.e. at age of menopause) in which most Iraqi women gain weight, perhaps due to hormonal disturbances. Regarding benign subjects and healthy women, the reason for over-weight may be related to the fact that they were not engaged in any exercise and not to mention the effects of diet.
A study of Crosbie et al. (13) , confirms that BMI is strongly associated with an increased risk of incident endometrial cancer which extends our previous meta-analysis demonstrating that the association becomes stronger above BMI 27 kg/m 2 , and that the association is particularly strong in women who have never been exposed to HRT. Finally, it shows that menopausal status and histologic subtype did not significantly impact upon these associations.
YKL-40 has been regarded as a "biomarker" or "possible cancer marker" for detecting some malignant tumors (14) . In vivo proof it has been suggested that YKL-40 may have an important effect on the proliferation and differentiation of cancer cells, and on the role in extracellular tissue remodeling, and stimulate angiogenesis and fibroblasts surrounding the tumor. Here, it was sought to determine the diagnostic value of YKL-40 in endometrial cancer using ELISA technique. The interpretations of the present results can be summarized in the following aspects; Different groups of authors indicate that the serum level of YKL-40 in healthy individuals is 42 micrograms (15) . In our control group of healthy women (without family history of endometrial or ovarian cancer, without hormonal or contraceptive therapy, without inflammatory diseases) the level slightly, but insignificantly, increased with age. Our study showed that the serum level of YKL-40 in nonproliferating benign uterine diseases was near that of healthy women. According to Johansen and co. (16) serum concentration of YKL-40 above 20% is indicative of increased serum level. In our study, pre-operative serum YKL-40 levels in EC patients were significantly higher than that in benign (fibroid) and healthy women, while there was no statistical difference between benign (fibroid) patients and healthy women, that's compatible with other studies (17) . These results show that the increasing of serum concentration of YKL-40 can be a sign of increasing risk of endometrial cancer development.
Circulating 25(OH) vitamin D level has been accepted as the best available biomarker for assessing vitamin D status, in spite of The relevant anticancer dose of vitamin D might be best quantified by average long term exposure level, in which case a single plasma 25(OH)D measurement may not adequately capture the vitamin D and cancer association (18) . Analyses of predicted and circulating 25(OH)D have already been done in separate studies for colorectal (19) . The level of 25(OH) vitamin D was analyzed in the sera of patients with endometrial cancer. Difference in the level of 25(OH) vitamin D in patients' sera of endometrial cancer and uterine fibroid in comparison with healthy control group referring to there was no association between vitamin D status and endometrial cancer incidence and development. Which compatible with the study by Liu et al. that fined no association between vitamin D status and endometrial cancer incidence in the NHS study population. However the same study thought that the protective benefits of vitamin D against endometrial cancer may not manifest unless 25(OH) D levels are significantly higher than 30 Ng/ ml and the range of exposure is much wider (20) .

Recommendations:
Comparing between the ykl-40 marker and other tumor marker diagnostic levels in the detection of uterine tumors. It is recommended to histopathologic study as soon as with the tumor marker in order to determine its prognostic role with tumors in other studies. For further studies, we recommended study the diagnostic levels of ykl-40 marker and its correlation with other body tumors. It is recommended to do estimation of vitamin D levels with more advanced method and correlation of its with disease. To conduct a large cohort study we recommended that a larger sample should be examined to confirm the work.