and The Hidden TumorOrly & Mira Barak

Tumor Markers DiaSorin 9.11.2010

CASE A

Female,74 years oldClinical findings:

Acute symptoms:Stomach ache,

Increased liver size and tenderness

Laboratory findings:,

Fullness

Weight loss-7kg in 2 months

Laboratory findings:

Cholestatic tests impairment and

Additional health status:

increased LDH

Imaging findings:Additional health status:asthma

diabetes

Imaging findings

Infiltrated liver with metastatic patterndiabetes

hypertension

hypothyroidismyp y

Is there any need for tumor markers?

Case ACase A TUMOR MARKERS

CASE Bmale 87 years oldmale,87 years old

Acute symptoms:W k

TUMOR MARKERS

Weakness

Burning on urination

Weight loss 15kg in last Weight loss-15kg in last year

Additional health Additional health status:dyslipidemia y p m

hypothyroidism

Is there any need for tumor markers?

CASE CMale 73years old TUMOR MARKERSMale,73years old

Acute symptoms:Shortness of breath after a long flight with diagnosis of PE and DVT

Additional health status:Hypertension

Hyperparathyroidism

BPH with PSA 10ng/ml

Colon polypectomy

Is there any need for tumor markers?

and The Hidden Tumor

T k t d t t d ?Tumor markers- to do or not to do?

Intermediate summaryIntermediate summary k f l lCase A: tumor markers for tumor localization?

Case B: tumor markers as screen method to ruleout malignancy?out malignancy?

Case C: tumor markers as a diagnosis mean in a Case C: tumor markers as a diagnosis mean in a monitored patient with additional suspicion of paraneoplastic involvement (hypercoagulation)?paraneoplastic involvement (hypercoagulation)?

History…..

1846-Bence Jonce

1940 id h h t1940-acid phosphatase

1963 AFP1963-AFP

1965-CEA1965-CEA

1980-CA125 PSA1980 CA125, PSA

1980-oncogenes and tumor suppressor genesn g n n um r uppr r g n

2001-microarray,mass spectrophotometry, bioinformaticsy p p y

• Hormones (hCG; calcitonin; gastrin; prolactin)

• Enzymes (acid phosphatase; alkaline phosphatase; PSA)

• Proteins & Glycoproteins (CA 125; CA 15.3; CA 19.9)

• Oncofetal antigens (CEA, AFP)

• Receptors (ER, PR, EGFR)

O (R M bl b )• Oncogenes (Ras; Myc; abl-bcr)

• Tumor suppressor genes (BRCA1; p53; Rb)

TM are usually glycoproteins found in blood or excretions,

indicating the presence, course and prognosis of a neoplastic

process

TM are not tissue or tumor specificTM are not tissue or tumor specific

TM are produced by benign and malignant tissue: the

difference is only quantitative

TM levels are dependent on synthesis secretion release TM levels are dependent on synthesis, secretion, release,

clearance of the molecule as well as are dependent on tumor

size metastases and angiogenesissize, metastases and angiogenesis

TM are not tissue or tumor specific

TM are produced by benign and malignant tissue:

the difference is only quantitativeTumor Markers Cancers What else?

y q

AFP (Alpha-fetoprotein)

Liver, germ cell cancers of ovaries or testes

Also elevated during pregnancy, cirrhosis

CA 15-3 Breast and others including Also elevated in benign CA 15 3 Breast and others including lung and ovaries

Also elevated in benign breast conditions;

CA 19-9 Pancreatic, sometimes l t l d bil d t

Also elevated in pancreatitis d i fl t b l colorectal and bile ducts and inflammatory bowel

diseaseCA 125 ovarian Also elevated with

endometriosis, some other diseases and benign conditions; pregnancy,

iascites

CEA (Carcino- Colorectal, lung, breast, Elevated in other conditions (embryonic antigen)

gthyroid, pancreatic, liver, cervix, and bladder

such as hepatitis, COPD, colitis, pancreatitis and in cigarette smokers

There are no TM “normal levels”-the cut-off value is determined in 95% of

הערות לסמני סרטן כפי שמופיעות באוטולאב cut off value is determined in 95% of

blood donors and patients with benign diseases of similar origin.

CEA ) ng/ml (:

5.5 מהבריאים פחות מ- 95ב- %

CA 15 3)U/ml(:

The cut-off values are irrelevant in cancer patients: the single relevant value is the level of TM obtained

CA 15-3)U/ml(: 30 מהנבדקים פחות מ- 95%ב-

CA 125 ) U/ml (:

35value is the level of TM obtained מהבריאים פחות מ-95%ב- during monitoring of the patient in the same lab with the same kit, since the TM kinetics is more important than its

CA19-9 ) U/ml (:

39 מהנבדקים פחות מ- 99ב- %

E E ( )/ lTM kinetics is more important than its absolute value. The kinetics of the TM can differentiate between a benign and malignant process.

ALPHA FETO PROTEIN (AFP)) ng/ml(: 7 מהבריאים פחות מ- 95%ב-

PSA :

מ95%ב קטן 4nמהנבדקים m gn n p .

An increase in the TM level within the reference range may be very

4 מהנבדקים קטן מ-95%ב- הערכת סיכון אישי 2.5מעל

:FPSA

reference rangeלשקול עם מדדים נוספים may be very significant.

ק

הערות כלליות לכל אחד מהסמנים

אינו שולל או מאמת ממאירותללבמעקב השווה לערך קודם

T k ili di (TMUGS)Tumor marker utility grading system (TMUGS)

explanationLevel of pfuse

no clinical use- do not use routinely0 y

There is a clinical correlation- in research- do not use routinely -+/

There is clinical correlation-unknown if the TM use has any additional value or can influence mode of therapy- do not use

ti l

+

routinelyThere is additional specific information, but it should be used only together with other diagnostic means for getting clinical

+2y g g f g g

significance-use routinely only in specific casesIndependent diagnostic tool for routine clinical use+3

Retrospective study on 8253 patientsRetrospective study on 8253 patientsWhen TM are used?Which TM are used?Wh t th t ?What was the outcome?

Follow-up

Clinical suspicion

Appropriate TM? Guidelines?Guidelines?

NACB: Tumor Markers 2009The National Academy of Clinical BiochemistryThe National Academy of Clinical Biochemistry

Laboratory Medicine Practice Guidelines

Practice Guidelines And Recommendations For Use Of Tumor Markers In The Clinic

Draft Guidelines - Second Posting

“Although in certain circumstances tumor markers may aid in diagnosis, speculative measurement of panel of tumor markers

(“fishing”) should be discouraged”( f g ) g

• TM usually have a “mean lead time” of 3-12 months in i t th di ti comparison to other diagnostic means

E h TM h ifi i i t• Each TM has a specific in-vivo t1/2

Th l l f h TM i i fl d b i d i i • The level of the TM is influenced by its production in benign diseases and by adjacent tissues.

• The TM level is influenced also by individual factors, circadian rhythm hormones hemodynamic and circadian rhythm, hormones, hemodynamic and iatrogenic factors.

• TM levels are influenced by the sample preparationand the kits used. and the kits used.

M l d iMean lead timetreatmenttreatment

(TM)

CT- CT- CT- CT+

1 2 3 4 5 6 7months

TT1/2TREATMENT

1000 <T1/2 <1/2

(TM)

100

( )

10

TIME

TM ki iTM kineticsTREATMENT INCREASE

DECRESEDECREASE +/-INCREASE

(TM)

NO CHANGE

(TM)

NO CHANGE

TIME

Follow-up by TMTM courseClinical course

between two t sts f d

Increase by >25%Malignancytests performed within 1 month

progression

Decrease not Decrease by >50%Partial remission Decrease not caused by production

Decrease by >50%Partial remission

production cessation or necrosis

Not defined by TM

Complete remission

Biological variation and total errorg

Total error%Precision%Intraindividual marker Total error%P<0.05

Precision%Intraindividual cv%

marker

21 84 79 3CEA 21.84.79.3CEA

23.36.813.6CA 125

17.52.95.7CA 15-3

18.55.110.1MCA

44.312.324.5CA 19-9 44.312.324.5CA 19 9

9.03.05.9β2MG

30.07.014.0PSA

TM standardizationl sourceyearInternational

standardTM

Cord blood1972IS 72/225AFP Cord blood1972IS 72/225AFP

Liver metastases

1973IRP 73/601CEAmetastasesPurified β hCG

& nicked HCG1975IS75/537HCG

1975IRP75/551bHCG

90:102000IS/670PSA 90 10C :F

2000IS/670PSA

Free purified2000IS96/668F-PSA

--noneCA125CA15-3CA19-9CA72-4

Intermediate summaryIntermediate summary

Case A: tumor markers for tumor Case A tumor markers for tumor localization?

CASE AClinical findings:

Female,74 years oldClinical findings

Increased liver size and tenderness

Acute symptoms:Stomach ache,

Laboratory findings:

Fullness

Weight loss-7kg in 2 months

Cholestatic tests impairment and increased LDH

Imaging findings:

Additional health status:

Imaging findings

Infiltrated liver with metastatic pattern

asthma

diabetes

hypertension

hypothyroidism

A huge tumor in colonoscopy

CEACEAIgG supergene family

ImmunoglobulinsT cell receptor

CEACA 125CA15-3 p

Growth factor receptorN-CAM

CA602

Biliary glycoprotein Non specific cross reacting agent

Coreprotein

Core chain Peripheral chainCore chain Peripheral chain

CA 72-4CA 546

CA 19-9CA 50

Lewis antigen and CA 19-9

Colorectal Cancer

10%

5% 3%

15% CE15% CEA

CA 19 938% 29%

CA 19-9

CA 242 CA 242 …

NACB: Practice Guidelines And Recommendations For Use Of Tumor Markers In The Clinic Colorectal Cancer (Section 3C)

2003

Guideline recommendations for tumor markers use 2007

Colorectal Cancer:

CEA

Screening and diagnosing noScreening and diagnosing – no

staging / prognosis, detecting recurrence monitoring therapy yesrecurrence, monitoring therapy – yes

Use immediate postoperative-no

Intermediate summaryIntermediate summary

k f l l Case A: tumor markers for tumor localization -no-nofollow-up- yesfollow up yes

Case B: tumor markers as screen method to l t li ? rule out malignancy?

CASE Bmale 87 years oldmale,87 years old

Acute symptoms:W kWeakness

Burning on urination

Weight loss 15kg in last Weight loss-15kg in last year

Additional health Additional health status:dyslipidemia y p m

hypothyroidism

do you know?...

"Elementary, my dear Watson” has not d i f Si C D l b ks b t appeared in any of Sir Conan Doyle books, but

in the first Sherlock Holmes film…..

Intermediate summaryIntermediate summaryC A k f l li i Case A: tumor markers for tumor localization -

no

Case B: tumor markers as screen method to ruleCase B: tumor markers as screen method to ruleout malignancy- only PSA: yes

Case C: tumor markers as a diagnosis mean in a Case C tumor markers as a diagnosis mean in a monitored patient with additional suspicion of paraneoplastic involvement (hypercoagulation)?p p yp g

CASE CMale 73 years oldMale, 73 years old

Acute symptoms:Shortness of breath after a long flight with diagnosis of PE and DVT

Additional health status:Hypertension

Hyperparathyroidism

BPH with PSA 10ng/ml

Colon polypectomy

Prostate cancer

Prostate CancerThe most wide spread tumor in menThe most wide spread tumor in men

Histological found in 42% of men over 50y (NO tests >75y- task force)

Low mortality rate, but in advanced disease-no cure

Th m t f l TM f d lm t l i l i th t tThe most useful TM, found almost exclusively in the prostate,but in all prostate diseases

NCCN 2004-cut off 2.5 ng/ml

Stamey 2004: the PSA era in USA isover- the test is all but useless

NCCN 2004 cut off 2.5 ng/ml

Catalona 2005: PSA saves lives(17% diagnosed with PC- 84% will survive( gdue to PSA early detection and treatment)# deaths(USA) 1997-42000

2007-27000

Thompson 2005: no cut-off level effectively identifiesmen with the disease

Prostate Cancer• Free PSA (uncomplexed form)

– 5-40% of PSA

%f PSA ↑ more benign

• PSA Complexes (cPSA) S omp exes (c S )

– PSA--1-antichymotrypsin (ACT)

– (60-95% of PSA)(60 95% of PSA)

– PSA--1-protease inhibitor (API)

(1 2 5% of PSA)– (1-2.5% of PSA)

– …etc.

No previous prostate manipulations

Significant change-above the test total error

PSA parametersPSA parametersT-PSA age dependent

/ yearsng/ml<49<2.5<59<3 5 <59<3.5<69<4.5<79<6.5

low specificity in olderF-PSA above 13%

796.5

Variability of kitsPSA velocity <0.75 ng/ml/year3 f ll-3 years follow-up

PSA density <0.15 ng/ml per gr tissueinaccuracy of TRUSinaccuracy of TRUS

PSA biological rolesgPro-PSA

PSA Physiological substrate(s)

Activation (hk2)

y g ( )Inhibitors (Zn, Serpins) Other competing proteases

Effect

beneficialCell differentiation

harmfulResistance to tamoxifen

Reduced cell growth rate

d f

Releases mitogens

Stimulates cell growthInduction of apoptosis

Antiangiogenic stimulus

g

Activates cytokines

Promotes invasionstimulusReduced migration

Promotes invasion

Promotes metastasisSemen liquefaction

Guideline recommendations for tumor markers use 2009

Prostate Cancer: PSA

Screening (with DRE), diagnosis, prognosis,

monitoring – yesg y

% free PSA – (PSA 4-10 ng/ml and DRE negative)

diagnosis – yes

h l l d Trousseau’s syndrome: multiple definitions and multiple mechanisms

-hypercoagulability syndrome associated with cancer-By its original definition, the di i f T ’ diagnosis of Trousseau’s

, retrospectsyndrome is made in when the occult malignancy is foundfound

Intermediate summaryIntermediate summaryC s A: t m m k s f t m l li ti n Case A: tumor markers for tumor localization -

noCase B: tumor markers as screen method to rule

l nl PSA: sout malignancy- only PSA: yes

Case C: tumor markers as a diagnosis mean in a monitored patient with additional suspicion of p pparaneoplastic involvement (hypercoagulation)?- yesyp y

Other frequent questions:CA -125 in males and PSA in females:

Use of TM for follow-up of rare malignancies: mesotheliomathat developscanceris a rare form ofmalignant mesotheliomamore preciselyMesothelioma(

CA 125 in males and PSA in females:Possible, but not recommended

that developscanceris a rare form of , malignant mesotheliomamore precisely , Mesothelioma(.mesotheliumfrom the protective lining that covers many of the body's internal organs, the

.asbestosIt is usually caused by exposure to

Use of TM in samples other than serum (sputum, peritoneal wash,

Possible, but not recommended

pleural effusion, cyst fluid etc.):

No relative valuesUsually no possibility of follow-up

When to perform TM?p-Before any treatment: surgery, chemotherapy,

radiotherapy, hormonal therapypy, py

-After therapy:-2-10 days according to t1/2 of the TMh 3 h d i h fi -each 3 months during the first two years

after treatment and each half year for the next 3 years

-before each treatment change

-With each suspicion of recurrence

When restaging-When restaging

-2-4 weeks after a clinical unexpected significant increase in 4 weeks after a cl n cal unexpected s gn f cant ncrease n the marker level during monitoring

WhatWhat will bewill bein thein the

future?future?

MALDI, matrix-assisted laser desorption/ionization; TOF,

time of flightt me of fl ght

During cancer development, cancer cells and/or the surrounding microenvironment and/or the surrounding microenvironment generate proteins and peptides of different type and in different concentrations than normal cells concentrations than normal cells. Can be analyzed by imaging-based mass spectrometry and the patterns compared with controls to identify cancer-specific with controls to identify cancer specific changes that may prove to be clinically useful.