ORIGINAL ARTICLE

Clinical Significance of Elevated Serum Chromogranin A Levels

U. Syversen, H. Ramstad, K. Gamme, G. Qvigstad, S. Falkmer & H. L. Waldum
Institute of Cancer Research and Molecular Medicine, Norwegian University of Science and
Technology (NTNU), Trondheim, Norway; Dept. of Pathology, St. Olav’s University Hospital,
Trondheim, Norway

Syversen U, Ramstad H, Gamme K, Qvigstad G, Falkmer S, Waldum HL. Clinical significance of

elevated serum chromogranin A levels. Scand J Gastroenterol 2004;39:969–973.
Background: Chromogranin A (CgA) has been shown to be a useful marker in the diagnosis of
neuroendocrine (NE) tumours. The clinical significance of CgA has been studied mostly in patients with
known NE tumours. The diagnosis was evaluated in 153 consecutive patients in whom CgA was
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measured in a given time interval. Methods: CgA in serum was measured by radioimmunoassay.
Immunohistochemistry with an antibody against CgA was performed in tumours from patients with
adenocarcinoma and elevated CgA levels using a conventional method and the more sensitive tyramide
signal amplification (TSA) technique. Results: Elevated serum CgA levels were found in 44 patients; 19
had NE tumours and 6 had tumours classified as adenocarcinomas. With the TSA technique, a high
proportion of CgA-positive cells were disclosed in five of the adenocarcinoma patients. Patients with
atrophic gastritis (no. 2) and patients treated with inhibitors of gastric acid secretion (no. 6) also had
elevated levels of CgA. A modest increase in CgA levels was observed in 2 patients with renal
impairment, and in 9 patients without any obvious cause. Conclusion: The current study confirms that
serum CgA is a sensitive marker for the detection of NE neoplasia. Elevated levels found in patients with
adenocarcinoma may indicate NE differentiation in the tumour. CgA is a useful tool in the monitoring of
enterochromaffin-like (ECL) hyperplasia secondary to treatment with acid secretion inhibitors or atrophic
gastritis.
For personal use only.

Key words: Adenocarcinoma; atrophic gastritis; chromogranin A; neuroendocrine tumour; proton pump
inhibitor; tumour marker
Unni Syversen, M.D., Ph.D., Dept. of Endocrinology, St. Olav’s University Hospital, NO-7006
Trondheim, Norway (e-mail. unni.syversen@medisin.ntnu.no)

C
hromogranin A (CgA) in serum is a marker for
neuroendocrine (NE) tumours, and elevated levels
are found in patients with carcinoid tumour (1–5),
pheochromocytoma (6, 7), neuroblastoma (8), small cell lung
cancer (SCLC) (9) and NE prostatic carcinoma (10, 11). CgA
has been shown to reflect tumour burden (3, 8) and to be a
prognostic marker (1, 2).
CgA elevation is also described in patients with chronic
atrophic gastritis (12) and as a result of long-term use of
proton-pump inhibitors (PPIs) (13) and possibly H2-antago-
nists, due to enterochromaffin-like (ECL) cell hyperplasia
secondary to hypergastrinaemia (12, 13). In patients with
reduced renal function, there is a rise in serum CgA levels
caused by interference with the degradation in the kidneys
(14). Finally, a slight elevation of CgA has been described in
some patients with essential hypertension (15, 16).
In previous studies the role of CgA as a tumour marker has
been evaluated in patients with known NE tumour and in
control groups consisting of patients with non-NE tumour or
patients without tumour disease. In the present study we
evaluated the diagnosis in all patients in whom CgA was
measured because of suspected NE tumour. In patients with
elevated CgA and adenocarcinoma, immunohistochemistry
with antibodies against CgA was performed, using both the
conventional and the more sensitive tyramide signal ampli-
fication (TSA) technique (17) to evaluate NE differentiation
in the tumour.
Patients and Methods
The study included 153 consecutive patients (71 M (46%),
median age 53.5 (range 7–85) years, 82 F (54%), median age
58 (17–89) years) who had serum CgA levels measured at St.
Olav’s University Hospital, Trondheim. The indication for
CgA measurement was mainly suspected NE tumour.
The medical data for each patient were recorded. Renal
function was evaluated on the basis of serum creatinine values
(normally <100 mmol/L for females and <120 mmol/L for
males).
CgA immunoassay
CgA in serum was measured by radioimmunoassay as
described earlier (1, 18). The normal value for CgA is
<30 ng/mL.

 2004 Taylor & Francis DOI 10.1080/00365520410003362

 970 U. Syversen et al.
Table I. Classification of patients with elevated CgA levels (no. = 44)
Neuroendocrine tumours
Adenocarcinoma with NE differentiation
Treatment with acid secretion inhibitors or atrophic gastritis
Renal dysfunction
Other causes
NE = neuroendocrine.
CgA immunohistochemistry
Adenocarcinomas in patients with elevated serum CgA
levels were further examined using conventional immuno-
histochemistry and the more sensitive TSA technique, as
described elsewhere (17). Three parallel sections from each
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tumour specimen were stained in the same batch using the
avidin-biotin peroxidase complex (ABC) method alone or in
combination with the TSA technique. Antigen retrieval was
achieved by heating the sections in 0.01 M citrate buffer (pH
6.0) at 900 W for about 3 min (until boiling) and then for
15 min at 160 W using a commercial microwave oven
(Phillips MT 243). The ABC procedure was performed using
the Vectastain ABC kit1 (Vector Laboratories, Burlingame,
Calif., USA) according to the manufacturer’s instructions.
The primary antibody, monoclonal anti-human CgA (clone
DAK-A3, DAKO, Denmark) or an isotype-matched negative
For personal use only.
control (Code X0944, DAKO), was incubated for 20 h at 4 °C
at an IgG concentration of 0.15 mg/mL. The first section only
went through the standard ABC procedure before the
immunoreactivity was visualized with three-amino-9-ethyl-
carbazole (AEC, Vector Laboratories). The second section
was further incubated in biotinyl tyramide (TSA Indirect1,
NEN Life Science Products, USA) for 4 min at room tem-
perature. Thereafter, the section was once again incubated
with ABC for 30 min before the immunoreactivity was
visualized with AEC. The third section was treated in the
same way as section number two, but the CgA antibody was
replaced with the isotype-matched control antibody, and this
section served as a negative control. All sections were
counterstained with Mayer’s haematoxylin for 10 s.
Statistics
Results are expressed as median and range. Differences
between groups were analysed by a non-parametric test
(Mann-Whitney U test).
Results
Patients with normal serum CgA levels
Normal serum CgA levels were found in 109 patients
(71%). Eight patients had previously been radically operated
on for NE tumours (carcinoid tumour (no. 5) and pheo-
chromocytoma (no. 3)). CgA was measured only after tumour
resection in these patients, and the normal levels post-
operatively corresponded with no signs of relapse. Two
Scand J Gastroenterol 2004 (10)
No. of patients Chromogranin A in serum, ng/mL
19 152 (43–920)
6 52 (46–84)
8 67 (41–118)
2 71 and 276
9 43 (32–132)
patients operated on for adenocarcinomas also had normal
values. One patient with a paraganglioma, and one with an
inoperable islet cell carcinoma, treated with somatostatin, had
normal values. Five patients were treated with PPIs, and two
of these had values in the upper normal range. Two patients
were on H2-antagonist treatment.
Patients with elevated serum CgA levels
Forty-four patients (29%) had elevated serum CgA values
(29 M (67%), 15 F (33%), median age 62 (range 7–85) years
and 65 (range 34–89) years, respectively). The patients were
divided into five major categories as shown in Table I.
Nineteen of the patients had NE tumours (carcinoid (no. 13),
pheochromocytoma (no. 3), SCLC (no. 1), small cell carci-
noma of unknown origin (no. 1) and neuroblastoma (no. 1)); 6
patients had tumour classified as adenocarcinoma. Eight
patients received PPIs (no. 5), H2-antagonist (no. 1), or had
chronic atrophic gastritis (no. 2), and 2 patients had impaired
renal function. The median serum CgA level was significantly
higher in patients with NE tumour than in those classified as
adenocarcinoma (P < 0.01), and also significantly higher than
in those treated with PPIs (P < 0.01). Among NE tumours, the
carcinoid patients had the highest levels, 168 (43–920) ng/
mL, while the median level in the pheochromocytoma
patients was 65 (38–96) ng/ml. In nine patients, no obvious
cause could be found. These patients had hypertension (no. 2),
gastrointestinal disease of unknown aetiology (no. 2), adrenal
expansion (no. 2), unclassified hepatic disease (no. 1), von
Hippel Lindau disease (no. 1), and Crohn disease (no. 1). The
highest value was found in the patient with Crohn disease
(132 ng/mL).
Serum CgA was measured pre- and postoperatively in
seven patients with NE tumour; three of these patients had
pheochromocytoma and elevated CgA levels before tumour
resection that were normalized after surgery. Four patients
with carcinoid tumour had transient normalization post-
operatively. Three patients with NE tumours, in whom CgA
was measured only postoperatively, had elevated values and
known metastases.
Immunohistochemistry
By conventional immunohistochemistry, scattered CgA-
positive cells were found in five of the six adenocarcinomas.
A microcarcinoid was detected in addition to focally scattered
neuroendocrine cells in one of the tumours. With the addition

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Fig. 1. Photomicrographs from a colon carcinoma from a patient
with elevated serum CgA showing immunoreactivity for CgA
without (A) and with (B) tyramide signal amplification (TSA). The
more sensitive TSA technique disclosed neuroendocrine differentia-
tion in neoplastic cells not detected by conventional methods.
of the sensitive TSA technique, a higher proportion of CgA
positive cells were disclosed in these tumours (Fig. 1).
Discussion
In this study we have evaluated the clinical value of serum
CgA in 153 patients in whom it was measured because of a
suspected NE tumour. A total of 44 patients (29%) had
elevated CgA levels. Of these, 43% had NE tumours, 14% had
adenocarcinomas and 18% had atrophic gastritis or were
treated with acid secretion inhibitors. The highest serum CgA
levels were found in patients with carcinoids, which is
concordant with previous studies. CgA was found to be a
useful parameter for postoperative control and follow-up of
NE tumours.
Among the patients with normal serum CgA levels, eight
had NE tumours that had been removed by surgery. CgA
concentrations were measured only postoperatively in these
patients, and the normal values corresponded with no signs of
relapse. Normal levels were also found in a patient with
paraganglioma. These tumours are known to cause only
Serum CgA Levels 971
slight, if any, elevation in serum CgA levels (19). This could
be explained by the small size of the tumour. (20).
Furthermore, paragangliomas may fail to express CgA,
especially when they are malignant (20). A normal CgA
level was also found in a patient with a somatostatin-treated
islet cell carcinoma. The inhibitory effect of somatostatin
treatment on CgA release is the likely reason for this (21).
Thus, among non-treated patients with NE tumours, only the
one with paraganglioma had a normal CgA value.
Six patients with elevated serum CgA initially had a
diagnosis of adenocarcinoma, five of gastrointestinal and one
of prostatic origin. Immunohistochemistry showed varying
degrees of NE differentiation in the prostatic carcinoma, and
in four of the gastrointestinal carcinomas. When using the
more sensitive TSA technique, however, a significantly
higher proportion of CgA positive cells were found. The
interpretation of this finding may be that these adenocarci-
nomas in fact are NE carcinomas. This is concordant with a
previous study where gastric adenocarcinomas were reclassi-
fied to be NE carcinomas (22). Serum CgA levels were
significantly lower in these patients than in patients with
classical NE tumours. This could be due to loss of secretory
granules in the dedifferentiated neoplastic cells (22). In
previous studies, serum CgA has been found to be elevated
in a small percentage of non-NE carcinomas, and some
invstigators have interpreted this as false-positive CgA values
(23). In a study by Baudin et al., 32% of 53 patients with non-
NE tumour had CgA elevation (24). They concluded that this
could be stress-related, but no immunohistochemical data on
CgA were presented, and no information about the use of PPIs
was given (24). The significance of NE differentiation in
carcinomas is controversial. NE differentiation may indicate a
poorer prognosis and a different treatment than the conven-
tional may be required. Our observation indicates that the
presence of a NE phenotype in a traditionally non-NE
carcinoma may be detected by measurement of serum CgA.
An immunohistochemical re-evaluation should therefore be
made in tumours of patients with elevated CgA values and a
diagnosis of adenocarcinoma.
In correspondence with previous studies, CgA elevation
was found in patients with atrophic gastritis and in patients
treated with acid secretion inhibitors (12, 13). Long-term
omeprazole treatment may induce ECL cell carcinoids in rats
(25), and development of ECL carcinoids secondary to
hypergastrinaemia has also been described in humans (17).
Measurement of serum CgA may be a useful tool in
monitoring ECL cell hyperplasia in these patients. It is
important to be aware of ECL cell hyperplasia as a source of
CgA elevation, and gastrin should be measured in these
patients to assess this possibility (26).
Nine patients (5% of all patients) with elevated serum CgA
did not fit into the above-mentioned categories. One patient
had bilateral adrenal-cortical hyperplasia due to adrenogenital
syndrome. Glucocorticosteroids are known to stimulate
catecholamine synthesis and release with the possible devel-
Scand J Gastroenterol 2004 (10)
 972 U. Syversen et al.
opment of medullar hyperplasia, which may give rise to
elevated CgA levels. Nests of medullary tissue included in the
cortical adenoma could also be a source of the CgA increase
(27). In the patient with Crohn disease, an ileocecal NE
hyperplasia was described by immunohistochemistry, and this
may be the reason for the rise in CgA. Hyperplasia of the
Kultschitzky cells in the ileocecal mucosal glands has been
described in some patients with Crohn disease (28). Two
patients had hypertension and a modest rise in CgA. This is in
concordance with previous studies showing that some patients
with essential hypertension have a slight elevation in CgA
levels (15, 16). One patient had von Hippel-Lindau disease
with a known high incidence of pheochromocytoma. Finally,
two patients with gastrointestinal symptoms had slightly
elevated serum CgA levels. It hould be remembered that the
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normal range is defined as the mean  2 s (standard
deviation), and 2.5% of the normal population will necessa-
rily have values above the upper limit.
CgA is protein specific for secretory granules, and thus NE
cells. CgA in blood reflects the release from the total NE cell
mass and the renal excretion. In persons with normal renal
function, CgA will therefore be a function of the NE mass.
However, CgA elevation will be found not only in patients
with NE cell neoplasia, but also in subjects with NE cell
hyperplasia, as shown in patients with reduced gastric acidity
(12, 13). It should also be remembered that there is a gradual
For personal use only.
transition from hyperplasia to neoplasia. Therefore, the
definition of specificity of CgA elevation in patients with
NE cell neoplasia is arbitrary.
In conclusion, serum CgA is a sensitive marker for NE
tumours. We also found that CgA is an indicator of ECL cell
hyperplasia secondary to atrophic gastritis and treatment with
gastric acid inhibitors. Finally, serum CgA was elevated in
five adenocarcinomas with NE differentiation, indicating a
possible NE origin of the neoplastic cells.
Acknowledgements
This work was supported by grants from the Norwegian and
Swedish Research Councils, the Cancer Research Foundation
of St. Olav’s University Hospital, and from the Faculty of
Medicine, NTNU. We do not have financial or personal
relationships with people or organizations that could inap-
propriately influence this work.
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Received 20 February 2004

Accepted 13 May 2004
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