CLINICAL CHEMISTRY- LABORATORY

MIDTERM- TUMOR MARKERS

Mr. Rodmie Oliver E. Pumaras

TUMOR MARKER  encompass an array of diverse molecules such as serum proteins, oncofetal antigens,
are proteins, oncofetal antigens, hormones, metabolites, receptors and enzymes produced hormones, metabolites, receptors, and enzymes.
by the tumor or is an effect of the tumor in surrounding cells. ENZYME TUMOR MARKER
-For detection and monitoring of cancer. Tumor marker Tumor TYPE CLINICAL UTILITY
2 major process: Prostate-specific antigen Prostate cancer -Prostate cancer screening,
1. Proliferation (PSA) therapy monitoring, and
2. Differentiation recurrence
KEY TERMS Lactate dehydrogenase Hematologic malignancies - Prognostic indicator;
(LD) elevated non- specifically in
 CANCER -refers to uncontrolled cell growth that often numerous cancers
forms a solid mass or tumor (neoplasm) Alkaline phosphatase Metastatic carcinoma -Determination of liver and
and spread to the other areas of the body. (ALP) of bone, HCC, Osteo- bone involvement;
 Tumorigenesis -Tumor formation sarcoma, lymphoma, nonspecific elevation in
 Mestastasis -Tumor spreading leukemia many bone-related and liver
cancers
 neoplasia -Uncontrolled cell that serves with no Neuron-specific enolase Neurosndocrine Tumors Prognostic indicator and
purpose; it can have a long lasting effect of monitoring disease
marker elevation if left untreated. progression for
 Oncogene -Encodes a protein that, when mutated, neuroendocrine tumors
promotes uncontrolled cell growth
 Tumor suppressor gene -Encodes a protein involved in protecting ENDOCRINE TUMOR MARKERS
cells from unregulated growth Tumor marker Tumor TYPE CLINICAL UTILITY
CANCER SEVERITY
1. tumor size ACTH Pituitary adenoma, ectopic Diagnosis of ectopic
2. histology ACTH- producing tumor ACTH-producing tumor
3. regional lymph node involvement, and
ADH Posterior pituitary tumors Diagnosis of SIADH
4. presence of metastasis
Calcitonin MTC and neuroendocrine Screening, a response to
tumors therapy, and monitoring
Cancer is broadly classified in to 4 stages
recurrence of MTC
- presented In Roman Numerals.
Chromogranin A Pheochromocytoma, Aid in diagnosis of
- Correlate to their disease severity
neuroblastoma, carcinoid carcinoid tumors,
a. Stage I
tumors, small cell lung pheochromocytoma, and
 (LOCALIZED PRIMARY TUMOR)
cancers neuroblastomas
b. Stage II
 (Invasion of primary tumor through epithelium and into blood
vessels) Cortisol Adrenal tumors Diagnosis of Cushing’s
c. Stage III syndrome, adrenal adenoma
 Migration of tumor into regional lymph nodes HVA Neuroblastoma, Diagnosis of neuroblastoma
d. Stage IV pheochromocytoma,
 Metastasis and invasion of tumor to distant tissues paraganglioma
TYPES OF TUMOR MARKERS VMA Pheochromocytoma, Diagnosis of neuroblastoma
 TUMOR MARKERS are produced either directly by the tumor or as an effect of the paraganglioma,
tumor on healthy tissue (host). neuroblastoma

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MONTALBAN, KIMBERLY N.
MED21B
CLINICAL CHEMISTRY- LABORATORY
MIDTERM- TUMOR MARKERS
Mr. Rodmie Oliver E. Pumaras

RECEPTOR TUMOR MARKERS  ADVANTAGE:

Tumor marker Tumor TYPE CLINICAL UTILITY  Ease of use and automation.
Estrogen receptor BRCA Hormonal therapy indicator
Progesterone receptor BRCA Hormonal therapy indicator  Factors to be considered
Her-2/neu Breast, ovarian, Prognostic and hormonal o Linearity – span of analyte concentration with relationship of analyte and
gastrointestinal tumors therapy indicator signal
Epidermal Growth Factor Head, Neck, Ovarian, Prognostic indicator o Antigen excess (Hook effect) – Phenomenon where excessively high
Receptor Cervical Cancer tumor markers can result in falsely low measurements.
o Heterophile antibodies – can be seen in patients that have received
CARBOHYDRATE TUMOR MARKERS monoclonal cancer therapy and can cause erroneous results.
Tumor marker Tumor TYPE CLINICAL UTILITY  Common analytical errors:
CA 19-9 Gastrointestinal cancer and Monitoring pancreatic  Icteric, Hemolyzed and Lipemic samples.
adenocarcinoma cancer  Antibody cross reactions
CA 15-3 Metastatic breast cancer Response to therapy and  High level carryover for automated machines – INADEQUATE
detecting recurrence WASHING.
CA 27-29 Metastatic breast cancer Response to therapy and HIGH PERFORMANCE LIQUID CHROMATOGRAPHY
detecting recurrence - Used to detect hormones, hormonal metabolites and catecholamines in plasma and
CA-125 Ovarian cancer Monitoring therapy urine.
- Important for diagnosing neuroblastomas, pheochromocytomas and carcinoid
APPLICATION OF TUMOR MARKER TESTING tumors.
• For diagnosis, tumor markers are used in combination with clinical signs, symptoms and  Homovanillic acid
histology.  Vanyllimandelic acid
• TUMOR MARKERS are a basis also for screening, prognosis, recurrence and monitoring the  Epinephrine
response to treatment.  Norepinephrine
TUMOR MARKER UTILIZATION  Dopamine
SCREENING Diagnosis Prognosis Monitoring Detection of  5’ HIAA
Treatment Recurrence
IMMUNOHISTOCHEMISTRY AND IMMUNOFLUORESCENCE
Biopsy indication High level -High levels Monitor efficacy Increase
indicative of associated with of chemotherapy; associated with - Fine needle aspirates or biopsy samples.
disease poor prognosis Residual disease relapse - Specific antibodies are incubated with the tissue sections to detect the presence or
-Receptor status after surgery absence of antigens using colorimetric or fluorescent secondary antibodies
used for  Estrogen receptors
medication of  Progesterone receptors
chemotherapy
ENZYME ASSAYS
 LABORATORY CONSIDERATIONS - Used for detecting or diagnosing cells underwent necrosis
- Testing for tumor markers have two main considerations - PSA is a Serine Protease but is detected using immunoassays and is the only
• 1. Wide concentration range of tumor markers enzyme with a specific feature for an organ/site of tumor (Prostatic cancer).
• 2. Lack of harmonization & standardization of manufacturers - Commonly tested enzyme assays:
 ALKALINE PHOSPHATASE – bone, liver, leukemia &
IMMUNOASSAYS FOR TUMOR MARKERS sarcomas
IMMUNOASSAYS  CK-BB – prostate, small cell lung, breast, colon, ovarian
- Most commonly used method for Tumor marker testing.  LACTATE DEHYDROGENASE – liver, lymphomas,
- Eg. RIA, ELISA, EIA leukemia
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MONTALBAN, KIMBERLY N.
MED21B
CLINICAL CHEMISTRY- LABORATORY
MIDTERM- TUMOR MARKERS
Mr. Rodmie Oliver E. Pumaras

 PSA– prostate cancer — These monoclonal antibodies recognize distinct non-

FREQUENTLY ORDERED TUMOR MARKERS overlapping regions of the CA-125 epitope.
1.AFP  DNA analysis (Western blot)
2.CA-125 3. CARCINOEMBRYONIC ANTIGEN (CEA)
3.CEA - Most widely used for COLORECTAL CANCER.
4.HCG - INCREASED IN: Gastrointestinal, Breast and Lung tumors.
5.PSA - Normal levels: 2.5 – 5.0 ng/ml in serum
1. Alpha-FEROPROTEIN  Malignancy - >10 ng/ml
- Synthesized by the FETAL LIVER and is involved in oncotic pressure in fetus.  Half life : 2-8 days
- Re-expressed in certain types of tumors  MAIN APPLICATION : Marker for CEA
- Used for diagnosing, staging, prognosis and treatment for HEPATOCELLULAR o Prognosis in post surgery surveillance
CARCINOMAS (>500 ng/ml)  TNM Staging system
- Can also be used for classification and monitoring therapy of TESTICULAR  T- tumor size and involvement/ invasion of nearby tissue
CANCER  N- regional Lymph Nodes involvement
o 2 subtypes:  M- metastasis; extent of tumor spreading from one tissue to
 Seminomatous – directly from malignant germ cells another.
 Non seminomatous - AFP + Beta HCG o Response to chemotherapy
 Embryonalcarcinoma o Not used for screening CEA due to non-specificity
 Teratoma  METHODOLOGY:
 Choriocarcinoma  Assays for Monoclonal anti-CEA antibodies – Automated
 Yolk sac tumors  Tissue biopsy with TNM staging
- INCREASED : Hepatocellular carcinoma & Germ cell tumors (Testicular)  Serial monitoring of Serum CEA every 2-3 months – To
- Normal Limit: approximately 15 ng/ml in serum avoid recurrence
 METHODOLOGY: 4. HUMAN CHORIONIC GONADOTROPIN (HCG)
 Sandwich immunoassays – measures the AFP antigens in - Dimeric hormone normally secreted by trophoblasts (45-kD glycoprotein)
between two monoclonal/polyclonal antibodies. - Promotes implantation of blastocyst and placenta to maintain the corpus luteum
o ***Blood collection in pregnant females are preferably done during 15th- during the third trimester of pregnancy.
20th week of pregnancy. - INCREASED : Choriocarcinoma and Germ cell tumors (Testis & Ovary)
- Normal pregnancy: >100,000 mIU/Ml
 Most useful marker for Gestational Trophoblastic diseases (GTD’s)
2. CANCER ANTIGEN 125 (CA-125)  4 distinct types:
- Murine monoclonal antibody against a serous ovarian carcinoma cell line.  Hydatidiform mole
- INCREASED: Endometriosis, Ovarian cancer  Persistent/Invasive gestational trophoblastic neoplasia
- Normal Limit: 35 U/ml in serum  Choriocarcinoma
- Average Half life: 4.5 days  Placental site trophoblastic tumor
- Not normally found in serum.  SERUM : the following forms are found
- Ovarian cancer can be categorized into the following: • Sex cord tumors:  Intact hCG & Free B-subunit (B-hCG )– Increased in
 Stromal tumors malignancies and non seminomatous testicular cancer.
 Germ cell tumors  Nicked hCG
 Epithelial cell tumors  Hyperglycosylated form
- Should not be used for Asymptomatic patients.  Free B-hCG cant be detected in Healthy patients
 METHODOLOGY:  METHODOLOGY
 Immunoassay using OC125 and M11 antibodies.

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MONTALBAN, KIMBERLY N.
MED21B
CLINICAL CHEMISTRY- LABORATORY
MIDTERM- TUMOR MARKERS
Mr. Rodmie Oliver E. Pumaras

o Automated immunoassay – Monoclonal capture and Tracer antibodies CA-15-3 Elevated in Metastatic Breast Serum Immunoassays
for B-hCG. cancer
o Urine Test kits – For Pregnancy CA-125 Ovarian cancer monitoring Measures Antigens to epithelial
neoplasms in serum
o Quantitative Serum tests- Unaffected by hemolysis
CALCITONIN Increased in Small cell lung Serum Immunoassays
5. PROSTATE SPECIFIC ANTIGEN (PSA) cancer and neuroendocrine
- glycoprotein produced in the epithelial cells of the acini & prostatic ducts. tumors
- Serine protease: KALLIEKREIN gene C-myc DNA Increased levels in Burkitt’s Detected by FLOW
- Functionally regulates sperm viscosity and in dissolving the cervical mucus cap for lymphoma, ALL and B cell CYTOMETRY
the sperm to enter. lymphomas • Ploidy analysis - Diploid
- Normal value: <4 ng/ml tumors = Better prognosis
• Cell cycle analysis – Higher S
- INCREASED: Benign prostatic hyperplasia & Prostatitis
phase fraction = Poor prognosis
- Other causes: • Proliferation index – High
 Recent ejaculation index = High relapse
 Prostate infections FERRITIN Low levels in effective Serum
- Healthy men: Low levels of PSA is detected prognosis of Head and neck
- 2 forms: malignancy, Elevated in
o FREE PSA Hodgkin’s lymphoma.
o Complexed PSA (a1-Antichymotrypsin or a2- macroglobulin) GASTRIN >1000pg/ml diagnostic of 12 hours FASTING
Gastrinomas
- TOTAL PSA detection : Screening for Prostatic cancer
5’HIAA( 5-Hydroxy-indol- – >15mg/kg/24hours = Quantitative analysis in Urine
- Free PSA : Low levels in patients with malignancy acetic acid) ARGENTAFFINOMA
- MEN from 45-50 y/o are recommended to be screened annually for Prostate GLUCAGON Differentiates alpha cell tumors
cancer >900 mg/dl-
 For men with <2 ng/ml should be screened at a 2 year interval with Digital Rectal GLUCAGONOMA
examinations. NSE (Neuron Specific Enolase) Monitors Neuroendocrine RIA and Serum Immunoassays
 Post prostatectomy – PSA levels are expected to be undetectable tumors
 METHODOLOGY: PHILADELPHIA Presence confirms CML
CHROMOSOME
 Automated Immunoassays - Detects both Free PSA &
THYROGLOBULIN Elevated in Follicular RIA and Serum immunoassays
Complexed PSA to a1-antichymotrypsin carcinoma
 EIA PRO-INSULIN C PEPTIDES Elevated in insulinomas and
 Fluorescence islet cell tumors
 Chemiluminescence
 PROSTATE CANCER GENE 3 detection in urine alongside REFERENCE:
PSA levels. Bishop, M. (2013). CLINICAL CHEMISTRY : principles, techniques, and correlations. Jones & Bartlett
OTHER TUMOR MARKERS Learning.7th Ed. CHAPTER 32
TUMOR MARKERS Measured by
ACID & ALKALINE Increased in skeletal metastasis Enzyme Assays
PHOSPHATASE
ACTH (Adrenocorticotropic Increased in Pituitary adenomas Serum Immunoassays
hormone)
BCL-2 To differentiate different B cell ONCOGENE analysis
lymphomas and follicular
lymphomas
B-2 Microglobulin Elevated in Serum Immunoassays
Lymphoproliferative disorders

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MONTALBAN, KIMBERLY N.
MED21B