CLINICAL CHEMISTRY 2 – LECTURE
important in order to maintain the pH within the normal
Lesson 1: BLOODED GASES
COURSE OUTCOMES:
At the end of this session, the student is expected to:
1. Describe the principles involved in the measurement of pH,
pCO2,PO2, and the various hemoglobin species.
2. Outline the interrelationship of the buffering mechanisms
of bicarbonate, carbonic acid, and hemoglobin.
3. Explain the clinical significance of the pH and blood gas
parameters.
4. Identify some common causes of nonrespiratory acidosis
and alkalosis, and mixed abnormalities. State how the body
attempts to compensate (kidneys and lungs) for the various
conditions
KEY TERMS:
Acid
 substance that can yield a hydrogen ion or hydronium
ion when dissolved in water
* strong acid- pKa less than 3.0
* Strong bases- pKa greater than 9.0
Base
 a substance that can yield hydroxyl ion when
dissolved in water.
Buffer
 the combination of a weak acid or weak base and its
salt, is a system that resist changes in pH.
Respiration
 process to supply cells with oxygen for metabolic
processes and remove the carbon dioxide produced
during metabolism.
Partial pressure
 is the amount of pressure contributed by each gas to
the total pressure exerted by the mixture.
Acidemia
 occurs when arterial blood pH <7.35.
Alkalemia
 occurs when arterial blood pH >7.45.
Hypercapnia
 is increased blood PCO2.
Hypocapnia
 is decreased blood PCO2.
Partial pressure of carbon dioxide (PCO2)
 measured in blood as mmHg
Concentration of dissolved carbon dioxide (cdCO2)
 includes undissociated carbonic acid (H2CO3) and
carbon dioxide dissolved in blood (represented by
PCO2).
Concentration of total carbon dioxide(ctCO2)-
 includes bicarbonate (primary component), carbamino-
bound CO2, carbonic acid, and dissolved carbon
dioxide
Acid-Base Balance
range (7.35-7.45), increase in H+ decreases the pH, decrease
in H+ increases the pH
REGULATION OF ACID-BASE BALANCE
1. Lungs- help maintain acid-base balance through gas
exchange or respiration, rapid and short term
compensation, analytes controlled are oxygen and carbon
dioxide, responsible for the removal of excess
Carbon dioxide (CO2) (partial pressure), responsible for the
regulation of the CO2 in the blood
2. Kidneys- help maintain acid-base balance through
reabsorption or excretion of bicarbonate, slow but long
term compensation, analyte controlled is bicarbonate
BUFFER SYSTEMS: REGULATION OF H+
Bicarbonate-carbonic acid buffer system:
 all buffers consist of a weak acid (carbonic acid which is
regulated by lungs), and its salt or conjugate base
(bicarbonate that is regulated by kidneys),
 ratio must be 20:1 in order to maintain normal pH, major
buffer system, most important buffer system that is
present in all body fluids, first line of defense against
extreme changes in pH, amount of carbon dioxide is
stimulus whether to increase or decrease the rate of
respiration
* H2CO3 dissociates into CO2 and H2O allowing CO2
to be eliminated by the lungs and H+ as water
* changes in CO2 modify the ventilation (respiratory)
rate
* HCO3 concentration can be altered by the kidneys.
Henderson-Hasselbalch Equation
 states the relationship between lungs, kidneys and pH,
pK is 6.1
Bicarbonate- total carbon dioxide minus carbonic acid,
regulated by kidneys
Carbonic acid- partial pressure of carbon dioxide x 0.0307,
regulated by lungs
0.0307- combination of the solubility constant for pCO2 and
the factor to convert mm Hg to millimoles
FORMULA:
 pH is directly proportional to bicarbonate- an increase
in bicarbonate causes an increase the pH and vice
versa
 pH is indirectly proportional to partial pressure of
carbon dioxide- an increase in pCO2 causes a decrease
in pH and vice versa
 ACID-BASE DISORDERS
ACIDOSIS AND ALKALOSIS
 changes in pH can be caused by either defect in the lungs
(respiratory) or defect in the kidneys (metabolic).
 Because the body’s cellular and metabolic activities are
pH dependent, the body tries to restore acid-base
homeostasis whenever imbalance occurs
 This action by the body is termed compensation, the
body accomplishes this by altering the factor not
primarily affected by the pathologic process. When the
lungs have problem, the kidneys will compensate.
When the kidneys have problem, the lungs will
compensate.
 Fully compensated- implies that the pH has
returned to the normal range (20:1).
 • Partially compensated- implies that the pH is
approaching normal.
dioxide which forms less carbonic acid in the blood
(i.e., less hydrogen ions), this increases the 20:1
ratio between cHCO3 and cdCO2 which increases
the blood pH, may be caused by hypoxia, anxiety,
nervousness, excessive crying, pulmonary embolism,
pneumonia, congestive heart failure, salicylate
overdose, seen in hypokalemia
RESPIRATORY ACIDOSIS
 primary cdCO2 excess expressed as increase in PCO2
(hypercapnia), inability of a person to exhale CO2
through the lungs (hypoventilation) causes an
increase of PCO2, the increased PCO2 causes an
increase in the concentration of dissolved carbon
dioxide which forms carbonic acid in the blood, this
decreases the 20:1 ratio between cHCO2 and cdCO2
which decreases the blood pH, may be caused by
chronic obstructive pulmonary disease such as
chronic bronchitis and emphysema ingestion of
narcotic and barbiturates, and severe infections of
the central nervous system such as meningitis.

pH pCO2 HCO3
7.35-7.45 35-45 22-26
mmHg mEq/L
Respiratory ⇩ ⇧ N
acidosis
Respiratory ⇧ ⇩ N
alkalosis
Metabolic ⇩ N ⇩
acidosis
CLASSIFICATION OF ACID-BASE IMBALANCE Metabolic ⇧ N ⇧
METABOLIC ALKALOSIS alkalosis
 primary bicarbonate excess, the bicarbonate
concentration increases causing the increase in the Common cause Common
20:1 ratio between cHCO3 and cdCO2which results mechanisms
in the increase in the blood pH, may be caused by Inability to exhale Renal
ingestion of excess base, decreased elimination of CO2: compensation:
base, or loss of acidic fluids, seen in hypokalemia Respiratory Emphysema, Excretion of H+ in
and hypochloremia acidosis pulmonary edema, urine
Airway *ventilation
METABOLIC ACIDOSIS obstruction,
COPD, pneumonia
 primary bicarbonate deficit, the bicarbonate
Low CO2: Renal
concentration decreases causing a decrease in the Hyperventilation, compensation:
20:1 ratio between cHCO3 and cdCO2which results Pulmonary Excretion of OH- in
in a decrease in the blood pH, may be caused by disease, urine
Respiratory
organic acid production or when ingestion exceeds Psychogenic,
alkalosis
the excretion rate, disorders include diabetic Sever anxiety, *breathe into a
ketoacidosis, alcoholism, renal failure diarrhea, Panic attack, paper bag
defect in the kidney, non-respiratory origin, seen in Pain, Aspirin
hyperkalemia and hyperchloremia (Salicylate)
overdose
Loss HCO3:Severe Respiratory
RESPIRATORY ALKALOSIS
diarrhea, failure to compensation:
 primary cdCO2 deficit expressed as decrease in excrete H+, renal Hyperventilation
Metabolic
PCO2 (hypocapnia), decreased PCO2 results from an failure
acidosis
accelerated rate or depth of respiration or a
combination of both, excessive exhalation of carbon Excess acid:
dioxide (hyperventilation) reduces the PCO2 causing Diabetic
a decrease in the concentration of dissolved carbon ketoacidosis,
 Lactic
acidosis and renal
failure
Loss of stomach Respiratory
acid (vomiting), compensation:
Metabolic Bicarbonate Hypoventilation
alkalosis excess: excessive
intake of
antacid, diuretics,
severe hydration
OXYGEN
Oxygen- is transported bound to hemoglobin present
in red blood cells and in a physically dissolved
state.
FACTORS CONTROL OXYGEN TRANSPORT :
1. PO2
2. free diffusion of oxygen across the alveolar membrane
3. affinity of hemoglobin for oxygen.
OXYGEN METABOLISM
 release of oxygen to the tissues facilitated by an
increase in H+ concentration and PCO2 levels at the
tissue level.
 Under normal circumstances, the saturation of
hemoglobin with oxygen is 95%. When the PO 2 is >110
mm Hg, greater than 98% of hemoglobin binds to
oxygen.
 When a person's oxygen saturation falls below 95%,
either the individual is not getting enough oxygen or
does not have enough functional hemoglobin available
to transport the oxygen.
 The amount of functional hemoglobin available in the
blood can be altered due to decreased red blood cells
or presence of nonfunctional hemoglobin
BLOOD COLLECTION FOR BLOOD GAS AND pH
ANALYSIS
1.Arterial whole blood using heparin as the anticoagulant
2.Venous blood usually 0.03 pH units lower than arterial
blood, venous and capillary blood can also be used for
analysis provided that they undergo arterialization
 Arterialization- immerse the puncture site in an 45 ̊C
water bath, wrap the puncture site with a prewarmed
towel wetted with water of 45 ̊C
3. Syringe with rubber stopper- specimen should be sealed.
 Heparinized plastic syringe- leaking gases through
plastic
 Glass syringe pretreated with heparin - reusable,
most accurate results obtainable, lesser tendency
for bubble formation
4. anaerobic collection- do not use vacutainer tube,
oxygen contamination increases pO2 by the residual O2
present in the nitrogen-filled vacutainer tube
• Place specimen on ice water or ice bath
• 3 hours- this prevents O2 consumption by the RBC
and release of acidic metabolites, this will also
stabilize the pH and pCO2 up to 3 hours
• No to clot, hemolysis or bubbles
5. Specimen was exposed to room air- increase in oxygen,
decrease in carbon dioxide, decrease in pH
6. Sealed specimen was left at room temperature -
decrease in oxygen, increase in carbon dioxide,
decrease in pH
7. Excess heparin- heparin is an acid mucopolysaccharide,
it is often used at a concentration of 0.2 mg/mL of
blood, excess heparin leads to acidic pH of blood
specimen
METHODOLOGY
 Ph - glass electrode connected to a reference
electrode (calomel electrode, mercury-mercuric
chloride)
 pCO2 - severinghaus electrode is a modified pH
electrode, glass electrode with weak bicarbonate
solution enclosed in silicone membrane
 pO2 - amperometric/polarographic, clark electrode,
composed of oxygen permeable membrane with
electrode composed of a platinum cathode and silver-
silver chloride anode
 Bicarbonate and Carbon dioxide content - nomogram
from blood gas analyzers
 CO2 content - consists of bicarbonate, undissociated
carbonic acid, dissolved carbon dioxide and
carbamino-bound carbon dioxide
Continuous flow analyzer for Blood Gas Analysis:
 Caprylic alcohol- prevent foaming
 Mercury- separate the sample and other reagent
 Lactic acid 10% - releases CO2 from HCO3
 12% NAOH- for collecting CO2
 Na2CO3- for releasing O2
Alternative method
- involves the release of C02 gas when the sample is
added to H2S04 with subsequent monitoring of this
release with a pair of pCO2 electrodes (reference
and sample electrodes). The rate of change in pH of
the buffer inside the pCO 2 electrodes is a measure
of the concentration of its CO2 In the Sample
CONDITIONS FOR ANALYSIS
1. All procedures should be considered “STAT”- if delayed
20-30 mins, pH lowers by 0.01, avoid glycolysis
2. Specimen must be kept at anaerobic condition
3. Specimen w/c cannot be analyzed immediately must be
placed in an ice slurry
PARAMETERS OF INTEREST
1. Evaluate the pH (normal pH= 7.35-7.45)
 <7.35- acidosis
 >7.45- alkalosis

2. Evaluate the ventilation (Lungs) pCO2= 35-45 mmHg

 <35- respiratory alkalosis
 >45- respiratory acidosis

3. Evaluate the metabolic process (Kidneys) HCO 3 = 22- 26

meq/L
 <21- metabolic acidosis
 >28- metabolic alkalosis

4. Determine which is the primary and compensating

disorder

5. Determine the degree of compensation

 Non-compensation
 Partial compensation
 Complete compensation

6. Evaluate the degree of oxygenation pO2= 81-100 mmHg

(adequate oxygenation)
Hypoxemia:
 Mild - 61-80
 Moderate - 41-60
 Severe - 40 or less

7. Final interpretation
 Degree of compensation
 Primary disorder
 Degree of oxygenation

EXAMPLE:
 7.31-7.34 – acidosis
 7.46-7.49 – alkalosis
 Lesson 2: TUMOR MARKERS combination of inherited and acquired genetic
Major Processes Involved in Cell Growth mutations
 Proliferation CANCER PROGRESSION
 Differentiation  metastasis, loss of cell adhesion proteins (e.g., β-
TUMORIGENESIS catenin and E-cadherin), activation of angiogenesis
 formation of solid mass or tumor genes (e.g.,VEGF)
 activation of growth factors (ex: epidermal growth
factor [EGF])
 activation of oncogenes (ex: K-ras),
 inhibition of apoptosis, tumor suppressor, and cell cycle
regulation genes (ex: BRCA1, p53, cyclins)
HYPERPLASIA
 involves the multiplication of cells in an organ or tissue
which may consequently have increased in volume,
 serves a useful purpose and is controlled by stimuli
 elevation of tumor markers is transient
BENIGN
 tumors remain at the primary site and present a
smaller risk to the host,
 patient stands a good chance of being successfully
treated by the complete removal of the tumor, FACTORS CONSIDERED IN CANCER SEVERITY
 early detection is critical to cancer prevention in 1. Tumor size
general to high risk families in particular, 2. Histology
3. Regional lymph
 well differentiated and composed of cells resembling
4. Node involvement
the nature of normal cells from the tissue of origin of
5. Presence of metastasis
the neoplasm.
CANCER STAGING
NEOPLASIA
1. Four Stages- Roman Numerals I-IV
 involves the possibility of normal cells undergoing
2. Disease severity- higher stages are indicative of
cancerous proliferation,
significant spreading and severe systemic disease
 pathologic hyperplasia,
3. Disease Progression- proliferation and metastasis occur
 unregulated and serves no purpose,
at the expense of normal organ processes, cause of
 elevation of tumor markers will be a long-lasting morbidity and mortality
phenomenon if not treated, also known as cancer
MALIGNANT
 due to genetic instability of tumor cells,
 completely unrestricted and tensed toward metastasis,
spreading into distance organs/sites, characterized by
hyperplasia which tends to accumulate and is usually
associated with invasion of tissues and metastasis
CANCER
 process of uncontrolled, accelerated or uninhibited
division and growth of genetically abnormal cells that
can develop into a solid mass or tumor and spread to
other areas of the body
METASTASIS
 cause of the most cancer deaths,
 due to multiple genetic changes that result to TUMOR MARKERS
uncontrolled proliferation,  produced either directly by the tumor or as an effect
 multistep processes involving numerous tumor cell- of the tumor on healthy tissue (host),
host cell and cell-matrix interactions, USED TO:
 tumor cells at the primary site penetrate their adjacent  differentiate a tumor from normal tissue
surroundings (epithelial basement membrane and the
interstitial stroma.),
 detect the presence of a tumor based on
measurements in the blood or secretion, biochemical
 invade blood or lymphatic vessels to distant sites,
substances elaborated by tumor cells either due to
 venous/capillary beds or solid tissue of a distant organ, the cause or effect of malignant process, substances
a highly selective process, brought about by complex either not normally present in blood or not expressed
 in large quantities that may indicate a particular type
of cancer, not helpful or useful in establishing a
diagnosis or planning therapy because majority of
tumor markers are not specific for a given tumor or
cancer, may be present at low levels in the normal
physiologic state and in non-malignant diseases.
CLINICALUTILITIES OF TUMOR MARKERS
SCREENING
• none of the tumor markers discovered had sufficient
specificity and sensitivity for screening in the general
population, not recommended for most tumor
markers especially in an asymptomatic population
Relative Marker Concentration:
Alpha-Fetoprotein (AFP)-
 the screening of primary hepatoma in Asian
countries is based on the measurement of serum
AFP
 also known as Fetal albumin, normally synthesized by
the fetal liver that is reexpressed in certain types of
tumors, re-expression during malignancies classifies
AFP as Carcinoembryonic Protein,
 elevated in patients with hepatocellular carcinoma
and germ cell tumors, used for diagnosis, staging,
prognosis and treatment of HCC, (a tumor that
originates in the liver, due to chronic disease such as
hepatitis and cirrhosis), not completely specific for
HCC,
 can also be increased in benign conditions such as
pregnancy, liver disease and testicular cancer,
migrates electrophoretically between alpha1 and
albumin region, most abundant protein present in
fetal development, manufactured by fetal
hepatocytes & yolk sac, found in HIGH
concentrations in embryo in the fetus and the level
actually drops at the age of 1, its concentration is
normally present in adult expressed in nanogram
concentration.
 However, in excess amount of Alphafetoprotein,
beyond 500 nanogram per mL of blood indicates
underlying malignancy EXCEPT during pregnancies,
a sensitive marker for early detection of recurring
Hepatocellular Carcinoma even before the clinical symptoms
are evident but entirely not specific for Hepatocellular
Carcinoma, AFP reliable marker for following a patient’s
response to chemotherapy and radiation therapy, levels
should be obtained every 2 to 4 weeks because the metabolic
half-life of AFP in vivo is every 4 days.
Prostate Specific Antigen (PSA)
 first tumor marker recommended for screening for
prostate cancer in men older than age of 50
 the purpose was to detect prostate cancer at early
curable stages, when the tumor is still confined inside the
organ,
 Two major forms: free PSA and PSA-alpha1-
antichymotrypsin (PSA-ACT)
 percentage of free PSA to PSA-ACT ratio may help
differentiate benign prostate hyperplasia (BPH) from
prostate cancer
* secreted in the seminal fluid that is able to regulate
fluid viscosity necessary for the activation of the
sperm cell, produced ONLY in the epithelial cells of
the acini and ducts of the prostatic ducts in the
prostate,
* Prostate Specific Antigen is the ONLY tissue-specific
marker but not specific for Prostate Cancer,
* found in minute or minimal concentration in normal
prostate, useful diagnostic tool despite the overlap
of benign prostatic hyperplasia and prostate cancer,
* it is useful for staging and monitoring prostate
disease, regulates seminal fluid viscosity (enable to
regulate fluid viscosity, needed for the activation of
sperm cells) and instrumental in dissolving the
cervical mucus cap, allowing sperm to enter,
elevated in patients with benign prostatic
hyperplasia (enlargement of prostate), prostate
enlargement, adenocarcinoma of prostate gland
Susceptibility genes
• several familial cancers are associated with germline
mutations in various genes,
• the most prominent are genes for susceptibility to
breast and ovarian cancer, such as BRCA1 and BRCA2
are now available to screen these families for the
identification of carriers.
Monitoring treatment
• one of the two most useful applications of tumor
markers involves their use in monitoring the course
during treatment of the cancer patient
Detection of recurrence
• monitoring tumor markers for the detection of the
recurrence following the surgical removal of the
tumor,
• it is desirable to monitor the patient using a highly
sensitive tumor marker test to detect recurrence as
early as possible.
Prognosis
• determination is based on the assessment of tumor
 aggressiveness which in turn determines how a
patient should be treated,
• prognostic factors measured in the clinical
laboratory also indicate risk and predict the length of
a relapse-free as well as overall survival period at the
time of the primary therapy,
• high levels of serum tumor marker measured during
diagnosis would indicate the presence of a malignant
or metastatic tumor associated with a poor
prognosis.
Early detection
• detecting the phenotypes in the blood circulation
corresponding to early mutations of a cancer allows
the detection of early neoplasm at the curable stage,
• measurement of all mutant phenotypes and risk
factors in the circulation would help to identify
individuals at risk for cancer or detect early tumors
in benign state.
Target therapy
• Previously, drugs used in chemotherapy were
predominantly DNA-active drugs that were
considerably toxic and had limited efficacy,
• inhibition of tumor cell proliferation may also be
effective by introducing agents (or genes) that turn
off the signaling pathway or pathways that
specifically drive proliferation within a given tumor
or tumor type,
• the prevailing new rationale is aimed at the
development of target-selective “smart” drugs on
the basis of characterized mechanisms of action,
• the specific defect of the tumor identified by these
new tumor markers should therefore lead to the
design of more specific drugs including antibodies
and small molecules which inhibit growth factor
receptors tyrosine kinases
FUNCTIONAL CLASSIFICATION OF TUMOR
MARKERS
1. oncofetal antigens- such as AFP and CEA which are
normally expressed during fetal development but do
not occur normally in the tissues or sera of children and
adults
2. proteins occurring in epithelial cells that become
elevated in tissue and serum in adeno- and squamous
cell carcinomas, such as the CA 19-9, CA 125, and CA
15-3 proteins
3. polypeptide hormones- such as the β chain of human
chorionic gonadotropin (β-hCG)
4. specific enzymes- such as the placental isoform of
alkaline phosphatase that become elevated in the
serum of patients with specific tumors
INDIVIDUAL TUMOR MARKERS
α- Fetoprotein
• major fetal serum protein and is also one of the
major carcinoembryonic proteins,
• elevated in patients with primary hepatoma
carcinoma cell (HCC) and yolk-sac-derived germ cell
tumors,
• most useful serum marker for diagnosis and
management of HCC
b2-Microglobulin(b2M)
• nonspecific tumor marker because it is elevated, not
only in solid tumors but also in lymphoproliferative
diseases and variety of inflammatory disorders
including RA, SLE, Sjogren’s syndrome, and Crohn’s
disease,
• normal serum level is 0.9-2.5 mg/L
Cancer Antigen 125 (CA125)
• defined first by a murine monoclonal antibody OC
125 raised against a serous ovarian carcinoma cell
line
• useful for detecting ovarian tumors at an early stage
and for monitoring treatments without surgical
restaging,
• upper normal limit is 35 U/mL,
• mucin-like glycoprotein, expressed on the surface of
certain epithelium and human ovarian carcinoma
cells, elevated in patients with endometriosis (pelvic
inflammation),
• during the first trimester of pregnancy (found in
milk, serum, cervical secretions of pregnant women),
• during menstruation, it is the only clinically accepted
serologic marker of Ovarian Cancer
• women without any ovarian mass or tumor or
Healthy women may show CA125 under physiologic
conditions, marker of choice for Epithelial Carcinoma
of Ovary
Cancer Antigen 15-3 (CA 15-3) and CA 27.29
• >25 U/mL are observed in patients with metastatic
breast cancer
• more sensitive and specific marker for monitoring
the clinical course of patients with metastatic breast
cancer and is more sensitive marker for metastatic
breast cancer than CEA.
Cancer Antigen 19-9 (CA 19-9)
• the highest sensitivity of CA 19-9 was found in
pancreatic and gastric cancers,
• also related to Lewis blood group substances, only
serum antigen from cancer patients belonging to the
Le (α-β+) or Le (α+β-)blood group will be CA 19-9-
positive
• CA 19-5 and CA50 have also been defined by
monoclonal antibodies that are only slightly different
from CA 19-9
CA 72-4
• useful marker for the management of patients with
gastric and colorectal carcinoma
 • proposed as a specific marker for tumor occurrence
of resectable gastric cancer and a prognostic marker
for survival reported to be an independent
prognostic marker for survival in colorectal in
multivariate analysis together with β-hCG and CEA
Carcinoembryonic antigen
• most widely used tumor marker for gastrointestinal
cancer today
• transforming growth factor (TGF)-α, fibroblast growth
factor, and Ras oncoprotein are all increased in
colorectal cancer and decreased after surgical resection
• mutations of DNA mismatch repair genes (e.g. hMSH2,
hMLH1 and hMSH6) are shown to be associated with
hereditary nonpolyposis colorectal cancer
Calcitonin
• one of the circulating peptide hormones that may
become elevated in patients with increased bone
turnover rate associated with skeletal metastases
• ectopically elevated in bronchogenic carcinomas and is
also elevated in medullary carcinoma of the thyroid.
Cytokeratin 19 fragment
• CYFRA 21-1
• elevated serum CYFRA 21-1 have concentrated on
breast cancer and squamous cell carcinoma of the lung
• reflect the tumor mass in multiple studies with
correlation to tumor stage, survival, predictive role in
surgical treatment for early stage disease and
chemotherapy for advanced stage non-small cell lung
cancer
Human Chorionic Gonadotropin
• free β-subunit is useful for the detection of recurrence or
metastasis for choriocarcinoma when the intact hCG may
remain normal
• seminomatous testicular cancer contains both intact hCG
and β-hCG or free αsubunits in equal amounts
• also known as Choriogonadotropin
• normally secreted by trophoblasts in the placenta to
maintain the corpus luteum during pregnancy, commonly
measured to confirm pregnancy and to diagnose ectopic
pregnancy (outside the uterus),
• elevated in patients with trophoblastic tumors,
choriocarcinoma, germ cell tumors of the Ovary and
Testes, marker of choice for gonadal cancers both for
testicular and ovarian cancer as well as in
choriocarcinoma
• it is a prognostic indicator for ovarian cancer, diagnostic
marker for classification of testicular cancer, the most
useful marker for detection of gestational trophoblastic
diseases.
HER2/neu (c-erbB-2) oncoprotein
• elevated in the sera of patients with a number of
different epithelial cell cancers, including breast, lung,
colorectal, and ovarian cancers
Chromogranin A
• useful marker of exocytotic sympathoadrenal activity in
patients with pheochromocytoma,
• medullary carcinoma of thyroid, and small-cell lung
carcinoma
• increased serum chromogranin A levels are detected in
epithelial cancers with neuroendocrine differentiation,
including prostate, breast, ovary, pancreas, and colon
Homovanillic acid
• above normal in tumors originating from neural crest
• useful in detection and monitoring of patients with
pheochromocytoma and diagnosis of neuroblastoma in
children
Lipid associated sialic acid in plasma (LASA-P)
• found elevated in various malignant diseases such as in
the breast, GI or lungs,
• also altered in leukemia, lymphoma, Hodgkin’s disease,
and melamona as well as in nonmalignant inflammatory
diseases.
 Neuron-Specific Enolase (NSE)- can be found in
tumors originating from the neuroendocrine cell
system including glucagonomas and insulinomas
 Progesterone receptor (pgR)- associated with breast
tumor
 Prostate-Specific Antigen (PSA) - major protein in
seminal plasma
Squamous Cell Carcinoma Antigen (SCCA)
• useful in monitoring squamous cell carcinomas of the
head and neck, lung, esophagus, and anal canal
Vanillylmandelic Acid (VMA)
• useful in detection and monitoring of patients with
pheochromocytoma and diagnosis of neuroblastoma in
children
ENZYME TUMOR MARKERS
1. prostate specific antigen
• Tumor type- prostate cancer
• Method- immunoassay
• Specimen- serum
• Clinical utility- prostate cancer screening, therapy
monitoring, and recurrence
2. Lactate dehydrogenase
• Tumor type- hematologic malignancies
• Method- enzyme assay
• Specimen- serum
• Clinical utility- prognostic indicator, elevated
nonspecifically in numerous cancer
3. alkaline phosphatase
 • Tumor type- metastatic carcinoma of bone, • Tumor type- breast cancer
hepatocellular carcinoma, osteosarcoma, lymphoma, • method- IHC
leukemia • specimen- biopsy
• method- FA • clinical utility- hormonal therapy indicator
• Specimen- serum
• Clinical utility- determination of liver and bone 3. Her-2/neu
involvement, nonspecific elevation in many bone- • Tumor type- breast, ovarian, gastrointestinal tumors
related and liver cancers • method- IHC, FISH, ELISA
• specimen- biopsy
4. Neuron-specific enolase
• clinical utility- prognostic and hormonal therapy
• Tumor type- Neuroendocrine tumors indicator
• method- RIA, IHC
• Specimen- serum 4. Epidermal growth factor receptor
• Clinical utility- Prognostic indicator and monitoring • Tumor type- Head, neck, ovarian, cervical cancers
disease progression for neuroendocrine tumors • method- IHC
• specimen- biopsy
CARBOHYDRATE AND CANCER ANTIGEN TUMOR • clinical utility- Prognostic indicator
MARKERS
1. CA 19-9 MONOCLONAL ANTIBODY DEFINED TUMOR
• Tumor type- Gastrointestinal cancer and MARKERS
adenocarcinoma TUMOR MARKER MAJOR MALIGNANT DISEASE
• method- immunoassay CA 125 Ovarian carcinoma
• Specimen- serum CA 19-9 Pancreatic carcinoma
• Clinical utility- Monitoring pancreatic cancer CA 15-3 Breast carcinoma
CA 72-4 Gastric carcinoma
2. CA 15-3 HER2/neu Breast carcinoma
• Tumor type- metastatic breast cancer
• method- immunoassay
• specimen- serum ECTOPIC TUMOR MARKERS
• clinical utility- response to therapy and detecting 1. Alpha-fetoprotein- gastrointestinal, renal, bladder, and
recurrence ovarian carcinoma
2. Calcitonin- endocrine tumors (islet cell, carcinoid,
3. CA 27-29 medullary thyroid, pheochromocytoma), lung, breast,
• Tumor type- metastatic breast carcinoma and ovary carcinoma
• method- immunoassay 3. Chromogranin A- endocrine tumors (islet cell, carcinoid,
• specimen- serum medullary thyroid, pheochromocytoma), prostate cancer
• clinical utility- response to therapy and detecting 4. Free Alpha-hCG- colorectal carcinoma and pancreatic
recurrence endocrine tumors
5. hCG- gastric and pancreatic carcinoma, hepatoma,
4. CA 125
ovarian carcinoma, germ cell tumor of testis
• Tumor type- ovarian cancer
6. PTH- renal cell carcinoma, breast, squamous cell
• method- immunoassay
carcinoma, bladder and ovarian carcinomas
• specimen- serum
7. Thyroglobulin- differentiated thyroid carcinoma
• clinical utility- monitoring therapy

RECEPTOR TUMOR MARKERS

1. Estrogen receptor
• Tumor type- breast cancer
• method- IHC
• specimen- biopsy
• clinical utility- hormonal therapy indicator

2. Progesterone receptor
 Lesson 3: ENDOCRINOLOGY 1
Physiologic Regulatory Systems
1. Endocrine system
• relates to a group of hormones that are typically
produced and secreted by one specialized cell type into
the circulation where the hormonal effect is exerted in
other target cells through the binding of the hormones
to specialized receptors, capillaries serves as a
route/channel for the transport of our hormone a
chemical mediator that travels through our circulation
to target the specific body cell having contain the
specific receptor, specific cell is called Target cell, highly
scattered because it will become the manner of
distribution via general circulation
2. Nervous system
• Neuroendocrine System
TYPES OF GLANDS
ENDOCRINE
• endo means within/interior/inside, ductless glands, the
secretion in endocrine is secreted in the interior or
interstitial fluid and then enter the blood circulation,
the blood circulation serves as the vehicle for the
transport of the secretion of endocrine gland,
enveloped within a multilayer of capillaries that is why
when it is released in interstitial fluid, it is very effective
for the absorption and diffusion of different materials
so that it will then enter the circulation via the
capillaries.
• Therefore, once the hormone is liberated by the
secretory cell of the endocrine gland, the blood will
then serves as vehicle as route of delivery until this
hormone reaches the target cell (is a specific cell
bearing specific receptor, and a highly specific for a
given type of a hormone).
• Once the hormone binds to the receptor, it will form a
complex known as “hormone receptor complex” causes
to trigger the reaction causing to affect the cellular
machinery of the cell (cellular activities), to generate
primary and to clean ductless glands
EXOCRINE
• exo means outside, presence of ducts (tube-like
structure), majority of exocrine gland is responsible for
digestion that aiding the digestion of absorption of
nutrients
MAJOR GLANDS OF ENDOCRINE SYSTEM
1. Pituitary Gland
2. Thyroid Gland
3. Parathyroid Gland
4. Adrenal Gland
5. Pancreas
6. Reproductive Glands (ovaries & testes)
7. Thymus Gland
8. Pineal Gland
HORMONES
• greek word “hormon”  to set in motion
• intercellular chemical signal transported to act on tissues
at another site of the body to influence their activity
• transfer information and instructions from one set of
cells to another, central concept/idea of endocrinology,
chemical mediator/messenger that is release in one part
of the body but it actually regulates the activity of the
cell and the other parts of the body
CHARACTERISTICS OF HORMONES
• Produced by a specific endocrine gland
• Hormones are released directly from the endocrine gland
to the blood circulation and carried to the site of action
as a free hormone or bound to transport protein
• Acts at a specific site (target site) to induce certain
characteristic, biochemical changes
FUNCTIONS OF HORMONES
1. Regulate the chemical composition and volume of the
ECF
2. Help regulate metabolism and energy balance
3. Help regulate contraction of smooth and cardiac muscles
and secretion of glands
4. Help maintain activities of immune system
5. Plays a role in the smooth sequential integration of
growth and development
6. Contribute to the basic processes of reproduction,
gamete production, nourishment of the fetus and
embryo
7. Help maintain homeostasis
METHODS OF HORMONE DELIVERY
Endocrine
- secreted in one location and release into blood
circulation
Paracrine
- secreted by endocrine cells and released into
interstitial space
Autocrine
- secreted in endocrine cells and sometimes released
into interstitial space
Juxtracrine
- secreted in endocrine cells and remains in relation to
plasma membrane
Exocrine
- secreted in endocrine cells and released into the
lumen of gut, affects their function
Neurocrine
- secreted in neurons and released into extracellular
space
Neuroendocrine
- secreted in neurons and released from nerve
endings
FUNCTIONAL TYPES OF HORMONES
 Releasing Hormones- from hypothalamus, promote
secretion of Anterior Pituitary hormones
 Inhibitory Hormones- from hypothalamus & GIT,
suppress the secretion of a particular hormone
 Tropic Hormones- stimulate growth & activity of other
endocrine glands
 Effector Hormones- secreted by all endocrine glands &
w/ non endocrine cells as targets
TYPES OF HORMONES ACCORDING TO
STRUCTURE
STEROIDS
* derived from cholesterol
* transported to blood stream through attachment to
transport protein
* lipid molecules that have cholesterol as their
common precursor, produced by the adrenal glands,
ovaries, testes and placenta, water insoluble
(hydrophobic)
* it requires the presence of carrier proteins in order
to induce its physiologic effect, it has to be free in
order to be in active form, the receptor is
intracellular receptor, transported across the cell
membrane in order to interact with the extracellular
receptor
* ex: aldosterone, cortisol, estrogen, progesterone,
testosterone, androgens
* Mechanism of Action- free hormone is transported
across cell membrane to interact with intracellular
receptor, complex binds to chromatin, producing
mRNA, mRNA initiates production of proteins that
carry out the function attributed to the specific
hormone
* Hormone synthesis regulation- negative Feedback
BIOGENIC AMINES
Tyrosine
* Thyroid hormones
 T3-Triiodothyronine
 T4-thyroxine
* Adrenal hormones
 Epinephrine- produced by the adrenal medulla,
increases plasma glucose by inhibiting insulin
secretion, increasing glycogenolysis, and promoting
lipolysis, released during times of stress
 Norepinephrine/Cathecholamines -
neurotransmitter that transmits signals between
nerve cells
 Mechanism of Action- epinephrine and
norepinephrine do not bind to carrier proteins and
interact with the receptor site on the cell membrane,
thyroxine and triiodothyronine circulate bound to
carrier proteins with the free hormone being
transported across the cell membrane to interact
with the intracellular receptor
 Hormone Synthesis regulation- nerve stimulation,
another hormone (e.g., thyroxine/TSH), negative
feedback
PEPTIDES AND PROTEINS
* synthesized by rough ER
* hypothalamic releasing and inhibiting hormone
* synthesized and stored within the cell in the form of
secretory granules and are cleaved as needed, they
cannot cross the cell membrane due to their large
molecular size and thus produce their effects on the
outer surface of the cells, water soluble, not bound
to arrier protein, packed and the body cleaved it if
necessary
* ex: oxytocin, ADH, insulin, glucagon, GH, calcitonin,
PTH
 Mechanism of Action- hormones interact with a cell
membrane receptor, this activates a second
messenger system to affect the cellular function.
 Hormone synthesis regulation- change in the
analyte, negative feedback
GLYCOPROTEINS
* AA derivatives with CHO groups
* ex: TSH, FSH, LH
EICOSANOIDS
* fatty acids, with 20 carbon atom fatty acid
(arachidonic fatty acid), involved in cellular activity
* ex: prostaglandin
HYPOTHALAMUS
 portion of the brain located in the walls and floor of third
 ventricle
 collection of specialized cells located at the central part
of the brain
 control the pituitary gland by production of chemicals
that stimulate or suppress hormone secretion of
pituitary, serves as the body’s thermostat, link between
the nervous system and the endocrine system
HYPOTHALAMIC HORMONES
Thyrotropin-releasing hormone (TRH)-
 stimulates the release of TSH and prolactin,
synthesized by neurons in the supraoptic and
supraventricular nuclei of the hypothalamus and
stored in the median eminence of the hypothalamus.
When secreted, this hormone stimulates cells in the
anterior pituitary gland to manufacture and release
thyrotropin (TSH).
Gonadotropin-releasing hormone (GnRH)
 GnRH → FSH and LH to target reproductive
hormones, synthesized in neurons situated in the
arcuate nucleus and other nuclei of the hypothalamus
and is released into the portal hypophyseal system
that in turn determines the production of LH and FSH
from the pituitary gland
Growth hormone
 inhibiting hormone/ Thyroid Stimulating Hormone-
inhibiting hormone
GH-RH/Growth Hormone Releasing Hormone
Corticotropin-releasing hormone (CRH)
 releases cortisol, secreted from the hypothalamus in
response to circadian signals, serum cortisol and
stress causing release of stored ACTH which
stimulates transport of free cholesterol into adrenal
mitochondria, initiating steroi production
Dopamine/ Prolactin-inhibiting hormone
 the only neuroendocrine signal that inhibits prolactin
and is now considered to be the elusive Prolactin
inhibitory factor (PIF), any compound that affects
dopaminergic activity in the median eminence of the
hypothalamus will also alter prolactin secretion.
PINEAL GLAND
• attach to the midbrain
• once dubbed the “third eye”
• produces melatonin - which decreases the pigmentation
of the skin, a "natural" sleep aid, and also regulates
circadian rhythm
• secretions are controlled by the nerve stimuli, attach to
the midbrain
Pituitary Gland (hypophysis)
• small egg-shaped gland located at the base of the brain
beneath the hypothalamus,
• master gland
• divided into 2 lobes (anterior & posterior)
• derived from latin and greek word pitui “spit mucus” also
recognized as a transponder
TYPES OF CELLS BY IMMUNOCHEMICAL TEST
1. Somatotroph- secretes growth hormone, acidophil
2. Lactotrophs- secretes prolactin, acidophil
3. Thyrotroph- secretes TSH, basophil
4. Gonadotroph - α and β subunits of FSH & LH, basophil
5. Corticotroph - Proopiomelanocortin (POMC), basophil
 ACTH
 β endorphin & β lipotrophin
FEATURES THAT DISTINGUISH THE FUNCTION OF
PITUITARY GLAND
• Feedback Loops
• Pulsatile Secretions
• Diurnal Rhythms
• Environmental or External Modification of its
performance
ENDOCRINE FEEDBACK LOOP
• Short Feedback Loop- refers to pituitary hormone
providing negative feedback to the hypothalamus,
inhibiting the secretion of the releasing hormone, the
feedback of thyroxine at the level of the pituitary
• Long Feedback Loop- refers to the hormone that was
released from the peripheral endocrine gland inhibiting
pituitary or hypothalamic secretion of releasing
hormone, the feedback at the level of the hypothalamus
• Ultrashort Feedback Loop- hormone inhibits its own
secretion in a paracrine manner, the feedback between
the pituitary and hypothalamus (when present.
Relationship of hormones produced by hypothalamus and
pituitary gland
• open-loop negative feedback system- they are subject to
external modulation and generally influenced or
modified by higher neural input or other hormones.
PULSATILE SECRETION
• a biochemical phenomenon in which chemical is secreted
in a burst-like or episodic manner rather than constantly
 GnRH -- median interpulse interval is 90 to 120 mins.
 LH -- median interpulse interval is 55 minutes,
average peak duration is 40 minutes

CYCLIC NATURE OF HORMONE SECRETION
1. The nervous system usually regulates this function
through external signals, such as light-dark changes or
the ratio of daylight to darkness.
2. Zeitgeber (“time giver”) - process of entraining or
synchronizing these external cues into the function of
internal biologic clocks
3. Pituitary hormones are secreted in different amounts,
depending on the time of day.
PITUITARY HORMONES
Tropic Hormones
• class of hormones from the AL of PG that affect the
secretions of another endocrine gland
• actions are specific for another endocrine gland, the loss
of a tropic hormone (ACTH, TSH, LH, and FSH) is reflected
in function cessation of the affected endocrine gland.
 TSH, thyroid gland, release hormones (T4 or T3)
 LH & FSH- ovary or gonads, if it stimulate the testis
or ovary these gonads will produce other hormones
such as testosterone, estrogen and progesterone
 ACTH- adrenocorticotropic hormone
Direct Effectors
 hormone that directly affects the peripheral tissue and
does not require signal from the PG, act directly on
peripheral tissue, loss of the direct effectors (GH and
prolactin) may not be readily apparent.
 GH- target is bone
 Prolactin- mammary gland or breast, milk production
ANTERIOR PITUITARY GLAND
 composed of three cell
* chromophobe (50%)
* acidophilic (40%)
* basophilic (10%)
 secretes ENDORPHINS that acts on the nervous system
and reduce feelings of pain
 GH, PRL, TSH, FSH, LH, ACTH- regulates the activity of
thyroid, adrenals, and reproductive glands
Adenohypophysis hormones
GROWTH HORMONE (SOMATOTROPHIN)
 Comprise over 1/3 of normal pituitary weight
 stimulated by GHRH,
 secretion is inhibited by somatostatin
 median interpulse interval is 2 to 3 hours,
 peak occurring at the onset of sleep
 structurally related to prolactin and human placental
lactogen,
 GH deficiency in children may be accompanied by
hypoglycemia; in adults, hypoglycemia may occur if both
GH and ACTH are deficient.
 Hormones that influences secretion and metabolic
effects of GH are thyroxine, cortisol, estrogen,
somatostatin, somatotropin releasing fact.
FACTORS AFFECTING GH SECRETION
Hormones that influences secretion and metabolic effects of
GH: thyroxine, cortisol, estrogen, somatostatin, somatotropin
releasing factor
PROLACTIN (PRL)
 pituitary lactogenic hormone, a stress hormone, also
important for parturition
 function in the initiation and maintenance of lactation
 also acts in conjunction with estrogen and progesterone
to promote breast tissue development
 main inhibitory factor is dopamine
 produced by the anterior pituitary gland, it is classified as
a direct effector hormone (as opposed to a tropic
hormone) because it has diffused target tissue and lacks
a single endocrine end organ, has vital functions in
relationship to reproduction
* Specimen consideration- collect 3-4 hours after the
patient awakes, highest level are 4- 8am, 8-10pm
FORMS OF CIRCULATING PROLACTIN
 Non-glycosylated monomer - major form
 Big prolactin - consists of dimeric and trimeric
glycosylated form
 Macro-prolactin - less physiologically active form
Specimen consideration
• Collect 3-4 hours after the patient awakes
• Highest level: 4-8am; 8-10pm
Thyroid Stimulating Hormone (TSH)
 alpha subunit has the same amino acid sequences of LH,
FSH and HCG
 ß subunit carries the specific information to the binding
receptors for expression of hormonal activities
 main stimulus for the uptake of iodide by the thyroid
gland
 it acts to increase the number and size of follicular cells
of follicular cells, it stimulates thyroid hormone synthesis
 directs thyroid hormone production from the thyroid,
also known as thyrotropin, produced by the anterior
pituitary gland particularly by thyrotrophs,
 stimulates the thyroid gland to produce T4 and T3

Follicle Stimulating Hormone (FSH)

 secretion, promotes endometrial changes, SUMMARY:
spermatogenesis, responsible for ovarian recruitment  GH: growth of bone and soft tissues
and early folliculogenesis in women and spermatogenesis  PRL: for lactation
in men, elevation of FSH is a clue in the diagnosis of  TSH: release of thyroid hormones
premature menopause  FSH: growth of the follicle (female) and initial wave of
 growth and maturity of ovarian follicles, estrogen spermatogenesis (male)
secretion, promotes endometrial changes,  LH: ovulation and final follicular growth (female) and
spermatogenesis production of testosterone (male)
Luteinizing Hormone (LH)  • ACTH: release of cortisol
 ovulation and secretion of androgens and progesterone,
initiates secretory phase of mens, formation of corpus
luteum and development of testicular cells
 directs testosterone production from Leydig cells in men
and ovulation in women

Adrenocorticotropic Hormone (ACTH)

 acts on the adrenal cortex to stimulate growth and
secretion of corticosteroids
 follows circadian rhythm
 elevated during times of stress,
 release of cortisol, produced by the anterior pituitary
gland, regulates the adrenal steroidogenesis
 produce in response to low serum cortisol, regulator of
adrenal androgen synthesis
 deficiency of ACTH will lead to atrophy of the zona
glomerulosa and zona reticularis (layers of adrenal
cortex)
 highest level is between 6 to 8 AM, lowest level is
between 6 to 11 PM, RIA is the method of choice for
ACTH analysis

* Specimen for testing should not be allowed to have

contact with glass because ACTH adheres to glass
surface, never use glass tube because of its negative
bias
* specimen requirement is blood should be collected
into prechilled polystyrene (plastic) tubes
* that should be pre-chilled either EDTA or heparinized
plasma, never use whole blood because of unstable
nature of ACTH
* Increased levels- Addison’s disease, Ectopic tumors,
after protein-rich meals