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• Balasthavath Kreeda aasaktah
• tarunasthaavath taruneesaktah
• vriddhasthaavath chintaasaktah
• Parame brahmani kopinasaktah
• As medical students we were playful wasted time
• As young doctors, were preoccupied with family,
  spouse
• As older docs, we have enough worries, nothing
  goes in
• Alas, when are we to gain an update of our
  knowledge!!

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Tumor Markers
www.drsarma.in
Dr R V S N Sarma MD., M.Sc. (Canada),
FIMSA Cardio-Metabolic Specialist And Consultant
Physician
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Tumor GeneticsTumor ImmunologyTumor Markers
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Tumor GeneticsTumor ImmunologyTumor Markers
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(No Transcript)
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Chromosome Abnormalities
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DNA Abnormalities
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RNA Abnormalities
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Protein Abnormalities
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Tumor GeneticsTumor ImmunologyTumor Markers
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Etiology of Cancers
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Etiology of Cancers

• Inherited Expression of inherited oncogene
• e.g. viral gene incorporated into host gene
• Viral Human papilloma, herpes type 2, HBV, EBV
  (DNA) - Human T-cell leukemia virus (RNA)
• Chemical
• - Poly cyclic hydrocarbons cause sarcomas
• - Aromatic amines cause mammary carcinoma
• - Alkyl nitroso amines cause hepatoma
• Radiological Ultraviolet ionizing irradiation
• Spontaneous Failure in cellular growth control

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Tumor Immunology

• Pathological Ca cell masses are formed by
• Abnormal uncontrolled expansion of clones of
  single cell
• Transformation of normal cells to cancer cells
• Spontaneous mutation during daily cell division
• It may be induced by carcinogens (chem, virus)
  
• Ca cell antigens are different from normal cells
• Recognized and destroyed by immune system

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Immune Surveillance System

• During neoplastic transformation, new Ag develop
• The host recognizes them as non-self antigens
• Cell mediated immune reactions attack these
  non-self tumor cells
• Immune response acts as surveillance system to
• Detect and eliminate newly arising neoplastic
  cells

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Immune Surveillance System

• This system include
• 1. Natural killer (NK) cells
• They kill directly tumor cells, helped by
  Inf, IL-2
• 2. Cytotoxic T-cells
• They also kill directly tumor cells
• 3. Cell mediated T-cells (effector T-cells)
• They produce and release a variety of
  lymphokines
• a-Macrophage activation factor, activates
  macrophage
• b-Gamma interferon and interleukin-2 that
  activate NK
• c-Tumor necrosis factor (cachectine)

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Immune Surveillance System

• 4. B-cells
• - Tumor associated antigens stimulate
  production of
• specific antibodies by host B-cells
• - These specific antibodies bind together on
  tumor cell
• surface leading to destruction of tumor
  through
• a- Antibody mediated cytotoxicity
  
• Cytotoxic T-cells kill IgG-coated tumor
  cells
• b- Sensitized T-cells activate macrophages
  and release
• macrophage activating factor
• c- IgG-coated tumor cells attacked by
  macrophages, in turn
• d- Activation of classical pathway of
  complement leading
• to lysis of tumor cells

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Tumor Escape

• Tumor escape of immune defenses
• 1. Reduced levels or absence of MHCI molecule
• on tumor - they cant be recognized by
  CTLs
• 2. Some tumors stop expressing the antigens
• These tumors are called antigen loss
  variants
• 3. Production of immunosuppressive factors by
  tumor e.g. transforming growth factor (TGF-ß)
• 4. Tumor antigens may induce specific immunologic
  tolerance by the immune system

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Tumor Escape

• 5. Tumor cells have an inherent defect in antigen
  processing and presentation
• 6. Blocking of receptors on T-cells by specific
  antigen antibodies complex (after shedding of
  tumor Ag) prevents them from recognizing and
  attacking tumor cells
• 7. Antigens on the surface of tumors may be
  masked by sialic acid-containing
  mucopolysaccharides
• 8. Immune suppression of the host as in
  transplant patients who show a higher
  incidence of malignancy

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Tumor GeneticsTumor ImmunologyTumor Markers
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What are Tumor Markers?

• Biological substances synthesized and released by
  cancer cells themselves or
• Produced by the host in response to the presence
  of tumor
• Most tumor markers are proteins
• Detected in a solid tumor, in circulating tumor
  cells in peripheral blood, in serum, lymph nodes,
  in bone marrow, or in other body fluid (urine,
  stool, ascites)

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Definition

• Glyco/lipoproteins produced by
• malignant cells
• normal cells in response to tumor
• inflammatory cells and tissues
• found in serum, urine, body fluids
• react with man-made antibodies or
• combine with man-made antigens
• cyto/histocompatibility reaction to form
• cyto/histocompatibility complexes

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When are they useful ?
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The Various Putative Utilities

1. Screening To identify early cancer risk
2. Diagnosis To corroborate the diagnosis
3. Staging To assess stratify the risk
4. Prognosis To predict the outcome
5. Localization To locate the primary
6. Therapy To target the therapy
7. Surveillance To detect recurrence in F-Up
8. Monitoring To evaluate response to Rx.

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Tumor Markers - Drawbacks

1. Cancer heterogeneity
2. Lack of Specificity false positives
3. Lack of Sensitivity - false negatives
4. Benign diseases - positive CA 125 or CEA
5. Smokers have raised CEA
6. Normal persons also have small amounts
7. Higher levels only with large tumor volume
8. Some cancers never have higher levels

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Tumor Markers
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Types of Tumor Markers

• Tumour-Associated Proteins (TAP)
• Cell membrane receptors
• Hormones
• Immunoglobulins / Cellular antigens
• Polyamines
• Protein clusters and fragments
• Chromosomal material
• Genes (single, clusters)
• Genetic material (DNA, RNA, mRNA)
• Cell modulators (transducers / suppressors)

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Tumor Associated Antigens

• 1. Viral Antigen
• a- Viral proteins and glycoproteins
• b- New antigens produced by virally infected
  host cells under control of viral nucleic acid
• 2. Tumor specific antigens
• - Tumor cells develop new antigens specific
  to
• their carcinogens
• 3. Tumor specific transplantation antigens
• - Tumor cells express new MHC antigens due to
  
• alteration of normally present MHC antigens

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Tumor Associated Antigens

• 4. Oncofetal antigens
• a- Carcino-embryonic antigens (CEA)
• - Normally expressed during fetal life on
  fetal gut
• - Reappearance in adult life
• GIT, pancreas, biliary system and cancer
  breast
• b- Alpha fetoprotein
• - Normally expressed in fetal life
• - Reappearance in adult life hepatoma

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Tumor Products

• A. Hormones
• Human Chorionic Gonadotrophins (HCG) are
  secreted in Choriocarcinoma, Ovarian Ca
• Thyroxin is secreted in thyroid cancer
  
• B. Enzymes
• Acid phosphatase in prostate cancer
• Alkaline phosphatase, lipase and amylase
  
• enzymes in cases of cancer of pancreas

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Specific Classes of Tumor Markers

• Enzymes (PSA, NSE, VMA, HVA)
• Cell membrane receptors (ER, PR)
• Tumor antigens (CEA, AFP)
• Antibodies (IgA, IgG, IgM, IgD)
• Antigens (p53, ki-62)
• CA-specific proteins(CA 19-9, CA 124)
• Gene mutation products (BR CA 1, 2)

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Specific Classes of Tumor Markers

• Tissue-specific proteins (PSA, hCGH)
• Special hormones (b-hCGH, h-CGH)
• Catecholamines (VMA, HVA, ACTH)
• Polyamines
• Cytoplasmic / Nucleic material (DNA)
• Products of cell turn-over (TNF)
• Cellular modulators (ki-62, c-erb-2)

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How to Detect Tumor Markers?

• ELISA
• Immuno-histochemistry (IHC)
• Polymerase chain reaction (PCR)
• Fluorescence in situ hybridization (FISH)
• Cluster Kits ( All-in-One Kit)
• Detects profiles
• Patterns
• Prototypes
• Constellations

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Methods of Analysis

• Expression of single proteins
• Expression of multiple proteins
• Chip analysis All-in-One
• Expression of protein profiles
• (Proteonomics)
• Gene methylation at DNA level
• Genes / mutations (Genomics)
• G-scan (genome ID scan)

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Common Markers In Clinical Practice

1. hCGH (specific)
2. beta-hCGH (specific)
3. CEA (NS)
4. AFP (NS)
5. Bence-Jones (MM)
6. Beta-2-M (S)
7. BTA (Bladder) (S)
8. CgA (Chromogranin-A)

• CA-15-3 (NS)
• CA-19-9 (NS)
• 11. CA-72-4 (NS)
• 12. CA-27.29 (NS)
• 13. CA-125 (NS)
• ER / PR (Breast)
• 15. HER-2 neu (c-erbB-2)
• BR CA-1 / BR CA-2

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Some more Markers In Clinical Practice

1. Alk. ptase (mets)
2. Alpha Amylase
3. SIADH, ACTH, ADH
4. GT-II (NS)
5. VMA, HVA (S)
6. Polyamines (NS)
7. Genes (k-ras, ki-62)
8. Chromosome (p53)

1. LASA-P (S)
2. NM-22 (S)
3. PSA (Prostate-S)
4. PSMA (Prostate-S)
5. S-100 (Melanoma)
6. TA-90 (NS)
7. TgA, IgA, D, G, M
8. TPA (NS)

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Tumor Markers PSA

• Prostate Specific Antigen(PSA) is a glycoprotein
• Ideal as a tumor marker, high tissue specificity
• High sensitivity for prostate cancer
• Also elevated in BPH prostatitis
• Useful in
• Dx. follow up of prostate Ca, Prognostic factor
• To monitor recurrence response to treatment
• ? For screening of prostate cancer along with
  DRE

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Prostate Cancer PSA

• Free PSAPSA not bound to the plasma anti
  proteases a1-antichymotrypsin a2-macroglobulin
• An ?in ratio of free/total PSA is associated with
  increased probability of prostate cancer
• 97 specificity, 96 sensitivity for prostate Ca
• For population screening and diagnosis an
  increase of 0.75 ng/ml per year in any given
  patient has high sensitivity and specificity for
  prostate cancer vs BPH, especially when combined
  with DRE and TRUS

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Tumor Markers CA-125

• 80 of non mucinous ovarian cancer detected by
  the monoclonal antibody to CA-125
• Elevated in Ovarian, Endometrial, Pancreatic,
  Lung, Breast, Colon cancers and also in
• Menstruation, Pregnancy, Endometriosis and other
  gynecological and non gynec conditions.
• Useful in monitoring ovarian Ca recurrence Rx.
• Screening of high risk population (BRCA1-2
  Carriers) Not useful for routine screening

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Ovarian Cancer CA-125

• Cell surface glycoprotein, present during
  embryonic development of coelomic epithelium is
  present in adult structures derived from it
• For follow up, an increase may predict recurrent
  disease, precedes clinical recurrence by months
• gt80 of epithelial ovarian cancer, cell types
  serous gt endometriod, clear cell gt mucinous
• Correlates with tumor bulk,
• In Endometriosis most common
• ? levels also found in PID, 1st trimester

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Tumor Markers AFP

• Alfa Feto Protein is a serum fetal protein
  synthesized by the liver, yolk sac,
  gastrointestinal tract a glycoprotein
• In Hepatocellular Cancer It is diagnostic (gt500)
  and also useful for screening of high risk
  population (HBV, HCV)
• Benign conditions hepatic parenchymal
  inflammation, hepatic necrosis, pregnancy,
  primary biliary cirrhosis, extra hepatic biliary
  obstruction give positive test.
• Testicular germ cell tumor (embrional or
  endodermal)
• Diagnosis, Prognosis, to monitor recurrence
  response
• The absolute AFP level correlates with tumor bulk
• Cancers of pancreas, colon, stomach
  bronchogenic Ca

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Tumor Markers CEA

• Complex glycoprotein that is associated with the
  plasma membrane of tumor cells, from which it
  may be released in to the blood
• Elevated specially in Colon cancer, Adeno. Ca
  uterus
• Normal pre Rx CEA indicates no metastasis
• Also in Pancreatic, Gastric, Lung, breast
  Ovarian Ca
• Also in cirrhosis, inflammatory bowel disease,
  chronic lung disease, pancreatitis, fibrocystic
  breast disease
• 19 of smokers, 3 of healthy population
• Not satisfactory for screening for a healthy
  population
• Good for monitoring recurrence to monitor Rx.

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Tumor Markers CA 19-9

• CA 19-9 is elevated in
• In 21-42 patients of gastric Ca
• In 20-40 patients of colonic Ca
• In 71-93 patients of pancreatic Ca
• For DD of benign from malignant disease
• Dx, FU, Relapse, 70 specificity 90
  sensitivity
• It is a mucin, does not ? during pregnancy
• Monitor patients who do not express CA 125,
  mucinous (76) gt serous (27)

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ßeta HCG

• Human chorionic gonodotropin (ßHCG)
• Glycoprotein synthesized by syncytio
  trophoblastic cells of normal placenta
• Serum and urine HCG ? in early gestation and peak
  in the first trimester (6090 days)
• Elevated in Gestational trophoblastic disease (a
  progressive rise in after 90 days of gestation ?
  highly suggestive), choriocarcinoma
• Elevated in testicular cancer, ßHCG after surgery
  
• Monitor treatment response, relapse recurrence

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Breast Cancer and ER

• Estrogen Receptor (ER)
• 2 isoformsERa and ERb
• ERa ? better prognosis, predictor of relapse
• useful when deciding on adjuvant hormone
  treatment
• As diagnostic marker when it is a primary unknown
  tumor
• ERb ? Good prognostic factor, correlates with low
  grade and negative axillary LN status

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Breast Cancer Oncogenes

• HER-2/neu oncogene (using monoclonal antibody) -
  over expression related to poor prognosis in
  breast cancer
• Oncogene c-erbB-2 geneover expressed in 30 of
  breast cancers, correlation between c-erbB-2
  gene positivity, positive axillary node status,
  reduced time to relapse and reduced overall
  survival
• BRCA1 gene on chromosome 17qfamilial
  breast-ovarian cancer syndrome, and breast cancer
  in early-onset breast cancer families ? high risk
  screening

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Breast Cancer and CA15-3

• - To monitor Rx. to detect recurrence BR Ca
• ? in 20 with localized breast cancer, 80 with
  metastatic disease, esp. if with bone involvement
• Specificity of 86, sensitivity of 30
• Also ? in gastric, pancreatic, cervical lung
  cancer
• c-erbB-2 overexpression should be evaluated on
  every primary breast cancer either at the time of
  diagnosis or at the time of recurrence.

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Melanoma

• Tyrosinase
• Use RT-PCR to detect hematogenous spread of
  melanoma cells from a solid tumor in peripheral
  blood
• S100B protein
• For confirmation of amelanotic malignant melanoma
  by immunohistology
• ?in 70 with stage IV metastasized melanoma
• MIA (melanoma inhibitory activity)
• Preoperative 59 at stage III, 89 at stage IV

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Thyroid Cancer

• Thyroglobulin
• Tissue-specific, glycoprotein produced by thyroid
  follicular cells
• Also increased in breast or lung cancer
• Thyrocalcitonin
• From thyroid C cells medullary thyroid cancer
• Effective to screen patients with 1st degree
  relatives affected by medullary thyroid cancer
  and multiple endocrine neoplasia type 2 (MEN2)

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Lymphoma

• Burkitts type lymphoma and leukemia
• T (814) due to juxtaposition and activation of
  the c-myc gene
• CD 25 most sensitive serum marker for tumor
  burden
• CD 44 high concentration indicates poor prognosis
• Lactate dehydrogenase (LDH)
• Normal 100250 IU/L
• High-grade lymphomas, blood levels correlate
  closely with disease activity and response to
  therapy

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Neuroendocrine Tumors

• Neuron-specific enolase (NSE)
• A neuronal isoenzyme of cytoplasmic enzyme
  enolase, in neuroendocrine cells
• As a prognostic factor in neuroblastoma
• Occurs in neuroendocrine tumors medullary
  carcinoma of the thyroid, pheochromocytoma,
  carcinoid tumors immature teratoma, small cell
  carcinoma of lung, non-small-cell cancer,
  melanoma. Correlate with stage and bulk of
  disease
• N-myc oncogene in neuroblastoma N-myc copy number
  is associated with stage and prognosis

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Tumor Specific Proteins

• Expressed only in tumor cells
• Example an oncogene is translocated and fused
  to an active promoter of another gene ? fusion
  proteins ? constant active production ?
  development of malignant clone
• Philadelphia chromosome in CML, t(922)
• (q34q11) bcr/abl translocation
• t(821) acute non-lymphocytic leukemia,
• t(1517) in APL
• Hematological malignancies

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Philadelphia Chromosome

• Abnormal Chromosome
• Due to translocation
• t (922) Ph short Chrom
• bcr/abl fusion gene
• This takes place in a single bone marrow cell
• Creating fusion proteins
• Detected by FISH technique
• Philadelphia chromosome in ALL - poor prognosis

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Philadelphia Chromosome
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New Frontiers

• Genomics Gene structure
• Proteonomics Protein structure
• Pharmacogenomics
• Gene-based drugs structuring and delivery
• G-scan Human genome mapping
• New treatment modalities
• Individualised treatment modalities
• Early detection of malignant change
• Greater sensitivity and specificity
• Better monitoring and follow-up care

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Common Tumor Markers

• 1. Alpha fetoprotein antigen (AFP) in hepatoma
• Carcino-Embryoinic Antigen (CEA) in GI tumors
• CEA in tumors of biliary system and cancer breast
• 4. Cancer Antigen 125 (CA 125) in ovarian
  carcinoma
• Cancer Antigen 15-3 (CA15-3) in breast cancer
• Cancer Antigen 19-9 in colon and pancreatic tumor
• 7. Prostatic specific antigen (PSA) -
  prostatic tumors

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Common Tumor Markers
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