Tumor Markers • Levels should remain relatively constant and not uctuate in

• Tumor markers are biologic substances synthesized and patients with stable disease
released by cancer cells or substances produced by the • Should be undetectable or low in patients in complete
host in response to cancerous tissue. remission
• Tumor/neoplasm is an uncontrolled proliferation of cells in a • Should predict outcome in patients with stable disease
eukaryotic organism. Uses of Tumor Markers
• Benign neoplasm means that the tumor remains con ned to 1. screening for disease in asymptomatic population
its primary site during the life span of the organism. 2. diagnosis of disease in symptomatic patients
• Malignant neoplasm is one that is capable of invading 3. aid in clinical staging
surrounding normal tissue and metastasizing through the 4. measurement of tumor burden
circulatory and lymphatic systems to distant body sites. 5. therapeutic monitoring and selection
• Metastasis refers to the process by which the tumor cell 6. detection of recurrence of disease (relapse)
spreads to other distant body sites. 7. prognostic indicator
• Angiogenesis is development of new blood vessels to
supply oxygen and nutrients to cells
• Cell cycle refers to phases of cell activity divided into G, S,
& M( growth, DNA synthesis, & mitosis respectively)
• Oncogene encodes a protein that, when mutated, promotes
uncontrolled cell growth
• Tumor suppressor gene encodes a protein involved in
protecting cells from unregulated growth
• Cancer means a malignant neoplasm.
*Cancer remains the 2nd leading cause of mortality in developed
countries. Biologically, cancer refers to uncontrolled growth of cells
that often forms a solid mass or tumor (neoplasm) and spreads to other
*Diagnosis= high levels indicative of disease. Prognosis=high levels
parts/areas of the body. A complex combination of inherited and
associated with poor prognosis; receptor status used for indication of
acquired genetic mutations lead to tumor formation (tumorigenesis)
c h e m o t h e r a p y. M o n i t o r i n g t re a t m e n t = m o n i t o r e c a c y o f
and spreading (metastasis). During tumorigenesis, mutations activate
chemotherapy; residual disease after surgery. Detection of recurrence=
growth factors and oncogenes , in combination with inhibition of
increased associated with relapse. Screening= biopsy indication
apoptosis, tumor suppressor, and cell cycle regulation genes.
Meanwhile, as cancer progresses toward metastasis, additional genetic Laboratory considerations
changes are required, like loss of cell adhesion proteins & activation of 1. Lack of harmonization and standardization between
angionesis genes. Understanding of these genetic mechanisms lead to manufacturers
the basis for many current and future cancer treatments. Cancer is
2. Wide range of concentrations
classi ed accordingly. For example, most solid tumors (breast, lung, &
*There are 2 main lab considerations when detecting tumor markes. A.
kidney), cancer is classi ed ( using roman numerals 1 to IV) into 4
To most accurately monitor tumor marker concentrations, use the same
stages.
methodology ( or kit), apply QC during lot changes ( includes a careful
*TNM staging:
comparison of QC material and patient samples because detection of
T-tumor size and involvement/invasion of nearby tissue; scale 0-4
tumor markers can widely vary between reagent lots). B. the other main
N-regional lymph nodes involvmentl scale 0-3
consideration for tumor marker measurement is the wide range of
M-metastasis; extent of tumor spreading from one tissue to another;
concentrations encountered clinically.
scale 0-1
Example of grading of tumor: Laboratory Assays
T1 N0 M0= small tumor, no nodal involvement, and no metastasis 1. Immunoassays are most commonly used method for
Classi cation of neoplasia tumor markers. These have the ability to automate testing and
• Carcinomas – of epithelium origin (derived from the ease of use. Factors to consider in using immunoassays are
ectoderm or endoderm) assay linearity, antigen excess (hook e ect =high tumor
• Sarcomas – of mesenchymal origin marker concentration can result in falsely low concentrations
due lack of “sandwich” formation ), and the potential
Factors Associated with the Pathogenesis of tumor heterophile antibodies.
-> Chemical carcinogens 2. HPLC is commonly used to detect small molecules like
-> Radiation catecholamine metabolites in plasma and urine. This is NOT
-> Viruses subject to hook e ect, lot-to-lot antibody variation, and
-> Heredity hetorophile antibodies but is more labor intensive and
Characteristics of an ideal Tumor Marker requires more experience and skill than automated
A. analytical requirements immunoassays.
• high analytical sensitivity 3. Immunochemistry & Immuno orescence. In many
• high analytical speci city aspects, similar to immunoassay but the added value is the
• accuracy ability to determine whether the antigen in question is in a
• precision particular cell type (such as tumor) , in the subcellular
• rapid turn-around time location. One best example of the use of tumor marker that is
• easy to measure at a low cost\ detected by immunochemistry is the identi cation of estrogen
and progesterone receptors in breast cancer. When breast
B. clinical requirements tumors are positive for estrogen and progesterone receptors
• high sensitivity for disease (no false-negative results, ability at the cell surface, they tend to respond to hormonal therapy,
to detect micrometastasis) while tumors lacking these receptors are treated with other
• high speci city (no false-positive results, negative in chemotherapeutic modes.
disease-free individuals) 4. Enzyme assays =when cells die (autolysis or necrosis) or
• Levels should re ect tumor burden undergo changes in membrane permeability, enzymes are
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 released from intracellular pools into the circulation where C. Protein Tumor Marker
they can be readily detected. AFP Liver, ovary, testes
Classi cation of Tumor Markers Carcinoembryonic Colon, breast, lung
A. Endocrine Tumor markers antigen
HCG Tr o p h o b l a s t i c t u m o r, PSA Prostate
choriocarcinoma, germ cell tumor of CA 15-3 Metastatic Breast
ovary and testes CA 27-29 Metastatic Breast
calcitonin Medullary thyroid CA & CA 19-9 Gastrointestinal and adenocarcinoma
nueroendocrine tumors CA 242 Pancreas
ACTH Pituitary sdenoma, ectopic ACTH- CA 125 Ovary
producing tumor CA 72-4 Gastric, ovary, colon, breast, lung,
Chromaganin A Pheochromocytoma, neuroblastoma, pancreas
ganglioneuroma Squamous cell CA Squamous cell carcinoma, cervix, lung,
Serotonin, 5-HIAA Carcinoid tumors Ag head, neck
Cyfra 21-1 Lung
ADH Posterior pituitary tumors P-glycoprotein Drug resistance marker
Ferritin Hodgkin’s dse, acute myelocytic
gastrin neuroendocrine
leukemia, lung, liver, breast, pancreas,
glucagon Glucagonoma teratoblastoma
Beta2-microglobulin Hematologic
C-peptide Insulin secreting tumors Immunoglobulins MM, Waldenstrom’s macroglobulinemia
Thyroglobulin Thyroid
prolactin Pituitary adenoma Tissue polypeptide Breast, lung, GI, bladder, ovary, uterus,
androgen Leydig’s cell tumor of testes, adrenal Ag prostate
cortex, ovarian tumor Serum M-protein Plasma cell dyscrasias
TSH Tro p h o b l a s t i c t u m o r, p ro s t a t e ,
bronchogenic carcinoma, blood, *1. Alpha fetoprotein is abundant ( peaks at 30 weeks of gestation) in
pituitary serum in fetus. It can be elevated in pregnancy and other non-
Placental lactogen Trophoblastic tumor malignant conditions , thus can be classi ed as non speci c. It is
synthesized in fetal liver and reexpressed in patients with hepatocellular
GH Pituitary adenoma, ectopic GH- carcinoma (HCC is also known as hepatoma. This is due to chronic
secreting liver disease like hepatitis and cirrhosis) and germ cell tumors. Thus,
PTH Parathyroid AFP is used for diagnosis, staging, prognosis and treatment monitoring
of HCC
Erythropoietin Kidney 2. PSA is present in low circulating levels in men. It is produced in the
epithelial cells of the acini and ducts of prostate ducts to regulate
rennin Kidney seminal uid viscosity and is instrumental in dissolving cervical mucus
aldosterone Adrenal cortex cap, allowing sperm to enter. There are 2 forms of PSA: free and
complexed. Circulating PSA can be complexed with alpha-
cortisol Adrenal tumors antichymotrypsin or alpha macroglobulin. Although total PSA is used in
screening for and in monitoring Prostate cancer but PSA is non
Metanephrines Pheochromocytoma, paraganglioma, speci c. It can be high in benign prostatic hyperplasia (BPH) and
(fractionated) neuroblastoms prostitis. With this, additional markers like prostate cancer gene-3
*Ex. hCG=normally secreted by trophoblasts to promote implantation (PCA-3) have been used to address the lack of speci city.
of blastocyst and the placenta to maintain corpus luteum through the *Cancer antigen 125 (CA 125) can be useful for detecting ovarian
rst trimester but there are some types of tumor invasion that is similar tumors at an early stage and for monitoring treatments without surgical
to uterine implantation like trophoblastic tumors, mainly restaging. CA-125 is not usually found in serum but maybe elevated in
choriocarcinoma, and germ cell tumors of the ovary and testis. Thus patients with endometriosis, during the rst trimester of pregnancy, or
hCG is not only a pregnancy test but a prognostic indicator for ovarian during menstruation
cancer, a diagnostic indicator for testicular cancer, and most useful
marker for detection of gestational trophoblastic diseases (GTDs). D. Receptor tumor markers
GTDs include 4 distinct types of tumors ( hydatidiform mole,
p e r s i s t e n t / i n v a s i v e g e s t a t i o n a l t ro p h o b l a s t i c n e o p l a s i a , Estrogen receptor Breast
choriocarcinoma, & placental site trophoblastic tumors Progesterone Breast
receptor
Her-2/neu Breast, ovaries, gastrointestinal
B. Enzyme Tumor Markers Epidermal growth Head, neck, ovarian, cervical
ACP prostateprostate factor receptor
ALP Metastases to liver, bone, leukemia,
osteogenic sarcoma
placental ALP Ovary, lung, trophoblastic tissue, GIT, VITAMINS AND TRACE ELEMENTS
seminoma, Hodgkin’s disease Vitamins
CK-BB Prostate, breast, ovary, colon, lung, • Essential organic substances that the body does not
GIT
su ciently or cannot synthesize
LD Prognostic indicator for hematologic
malignancies • Present in almost all food groups
Neuron speci c Prognostic indicator and monitoring • Function as antioxidants, enzyme cofactors, hormones and
enolase [NSE] disease progression of important in blood cell, maturation, and bone formation and
neuroendocrine tumors.
active in energy metabolism
AMS, LPS, Trypsin, pancreas
ribonuclease Specimens
5’N, GGT liver • Serum
t e r m i n a l leukemia • Plasma
deoxynucleotidyl • Urine
Tr a n s f e r a s e , Bone
collagenase • White blood cells (ascorbic acid)
Cathepsin D Breast cancer • Method: immunoassay
Histamase Medullary thyroid CA
muramidase leukemia
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 Fat soluble vitamins Interference: hemolysis
Concentration in tissue
• <1 µg/g of wet tissue
• <0.01% of dry body weight
Essential Trace elements

Water soluble vitamins

Trace elements
• Consist of metals, EXCEPT selenium, the halogens, uoride
and iodine
• Have speci c in vivo metabolic functions that cannot be
e ectively performed by other similar elements

Samples for Trace elements measurements

• Whole blood
• Serum
• Plasma
• Urine, hair
• Nails

Mostly widely used method

• Atomic absorption spectrometry – for clinical trace element
analysis in biological samples

Other methods
• Graphite furnace AAS (GFAAS)
• Flame AAS (FAAS)
• Atomic emission spectrometry (AES)
• Neutron activation analysis (NAA)
• Inductively coupled plasma/mass spectroscopy (ICP/MS)

Reference method for zinc: ICP/MS

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