Tumour Markers

Anna Milan

Principal Clinical Scientist
Department of Clinical Biochemistry & Metabolic Medicine
Royal Liverpool & Broadgreen University Hospital NHS Trust
Liverpool
anna.milan@rlbuht.nhs.uk

Introduction
Think outside of the box!

Broadly defined as
Measurable analyte produced by a tumour which can help
to diagnose the disease, provide prognostic information,
identify correct treatment and monitor treatment

National Cancer Institute
substance found in tissue, blood or other body fluids that
may be a sign of cancer or certain benign conditions

Tumour markers can be produced by the tumour
or by non-tumour cells as a response to the
tumour

Overview Stages of Disease
Screening

Diagnosis

Prognosis and Treatment

Monitoring therapy

Detecting Relapse
General Principles
Relatively low clinical sensitivity
Results may be within normal limits in patients with
malignancy

Relatively low clinical specificity
Results may be increased in patients without cancer

Tumour markers are best used in post-
treatment follow-up

Tumour markers require careful interpretation
of results
Physiological / analytical interferences
Screening
Ideal situation would be markers which
enable early detection enabling treatment,
limited spread and good outcomes

Currently there is still no marker acceptable
for population screening in UK
?Total population screening
Too many false positives (low specificity)
Not elevated significantly in early disease

Targeted screening in genetic linked
disease
BRCA1 and BRCA2 in breast cancer
Diagnosis
Ideal would be marker
with 100% specificity
and sensitivity.
Sensitivity of test is true
positives in disease
Specificity is true
negatives in health

In reality used in
conjunction with other
parameters

Most tumour markers
are poor for diagnosis
Prognosis & Treatment
If tumour load is related to tumour markers
then can be used for survival estimate
e.g. HCG and AFP prognostic indicators in
testicular teratoma
P53, E-cadherin, nm23H1 and MMP-2 used
together to predict outcome of node-negative
breast cancer

Some receptors used in deciding treatment
Most notorious is HER-2 and if patient positive
then treated with Herceptin
Oestrogen receptors in tumour tissue if positive
then may respond to hormone therapy
Monitoring Therapy
Most useful role for classical tumour markers

Requires quantitative relationship between tumour
burden and tumour marker levels

Enables assessment of efficacy of treatment

Detection of drug/chemo resistance and response

Can lead to being classified as in remission (?cured)

However, if the tumour marker isnt raised it cant be
used for monitoring, e.g. some bowel cancers do not
have raised CEA levels.
Effectiveness of Treatment
Pre-treatment level should be high enough
for a fall to be monitored
Assay sensitivity

Knowledge of half-life enables response to
be monitored by decline in levels
No change tumour marker >50% t
0
value
Improvement - <50% t
0
value
Response - <10% t
0
value
Complete response tumour marker within RR
Monitoring Relapse
Useful function of tumour markers

Debate regarding frequency of
measurements in remission
Cost v clinical effectiveness

Rate of rise post resection of primary can
indicate metastases
e.g. CEA, if quick then liver/bone; slower rise
brain/soft tissue/skin more likely
Types of Tumour Markers
General non specific markers and
analytes

Functional markers

Classical tumour markers

Haematological malignancies

Molecular markers
Where are they measured?
Serum/plasma/whole blood

Urine and other fluids

Faeces

Sputum

Cell scrapes

Tissue
General Tumour Markers - Routine
Calcium - Hypercalcaemia in malignancy

ESR - Inflammation somewhere in body - ?infiltration

Sodium - Mineralcorticoid XS Conns

LDH - Cellular/tissue damage


2
Microglobulin
Severity and spread of multiple myeloma and some
lymphomas
Present in other conditions such as Crohns and hepatitis

ALP - Bone/Liver metastases

Phosphate PTHrP effect on phosphate excretion
Functional Tumour Markers
Pituitary
Prolactin
ACTH
GH
TSH

Parathyroid
PTH

Adrenal cortex
Aldosterone
Cortisol

Adrenal Medulla
Catecholamines
Metabolites

Ovary
Oestrogens
Testosterone

GI Tract
Insulin, glucagon
VIP, Gastrin
5HIAA
Pituitary Tumours
Thyrotroph <1%
Gonadotroph <5%
Corticotrophs 5-8%
Somatotroph
20-23%
Non-Functional
20-25%
Prolactinoma
50-55%
Prolactinoma
Benign tumour of pituitary gland

Most common type pituitary tumour

Symptoms caused either by
Hyperprolactinaemia
In females - amenorrhea, infertility, lactation, loss libido
In males, ED, loss libido, infertility
Low oestrogen may lead to osteoporosis
Pressure of prolacinoma on surrounding tissues
Headaches, vision

Treatment with cabergoline, bromocriptine, norprolac
Cushings Syndrome
GH Excess
90% of cases of acromegaly
are primary
GH excess produced by
benign pituitary tumour

Few cases by tumours of
lungs, pancreas and adrenal
Produce GH or GHRH

Rarely IGF secreting tumours

Single GH measurement not
useful

IGF-1 more sensitive

Glucose tolerance test
In normal patients GH
suppresses
In acromegaly GH remains
detectable
Medullary thyroid carcinoma (MTC)
First neoplastic manifestation of MEN-2 and
significant cause of death
Rare tumour of the C cells of the thyroid
gland
Multifocal C cell hyperplasia MTC
Progression from C cell hyperplasia to
carcinoma is variable
Metastasis is common
Secretory product of C cell hyperplasia/MTC
is calcitonin
High levels are used as a tumour marker
The thyroid cancer in MEN-2 is considerably more
aggressive, and develops early in life, than when
thyroid cancer develops in non-MEN patients
Patients identified with the MEN-2 gene should
have their thyroid surgically removed before they
are in their mid-teenage years.

Thyroid lobes
showing MTC
lesions
PTH
PTHrP
Related in function to PTH
Increase Ca resorption from bone
Reduced Ca excretion in urine
Reduced renal PO
4
re-absorption

Shares same N-terminal as PTH

Involved in cell signalling during development
Important physiological roles in growth and
development

Reportedly secreted by some lung, breast, prostate
tumours and in some instances of myeloma
Hypercalcaemia sometimes first sign of malignancy

PTHrP measurement can be useful if raised total/ionised
Ca, N/L PTH and exclusion of XS Vit D, sarcoid, TB etc
Conns Syndrome
Primary
hyperaldosteronism

Although documented as
rare, in hypertensive
population the occurrence
is up to 15%

Benign adenoma (one
adrenal)

Hyperplasia (both adrenal
glands)

In Conns - aldosterone is
high and renin low /
undetectable
Phaeochromocytoma
Tumour of Chromaffin cells in the adrenal medulla (unilateral
or bilateral)

Chromaffin cells produce catecholamines adrenaline,
noradrenaline

Ability to suddenly produce large amounts of catecholamines
rise in blood pressure

Patients present with headaches, sweating, tachycardia, palpitations,
and in rare cases sudden death

Usually presents after MTC in MEN syndromes

Only present in MEN-2A and -2B, not MEN-1

10% Tumour
Malignant (90% are benign)

Bilateral (found in both adrenal glands: 90% arise in just
one of the two adrenal glands)

Extra-Adrenal (found within nervous tissue outside of the
adrenal glands)

In Children (90% are in adults)

Familial (10% will have a family member with the same
type of tumour)

Recur (10% or slightly less, will come back 5 to 10 years
later)

Associated with MEN-2 syndromes

Present with a stroke (10% of these tumours are found
after the patient has a stroke)



Gut Hormone Tumours
Islet cell tumours of the pancreas

Inappropriate hormone secretion
Insulinoma
Gucagonoma
Gastrinoma
VIPoma

Carcinoid Tumours
Arise from argentaffin cells located in foregut,
midgut and hindgut
66% arise in midgut with appendix being most
common, followed by small bowel
Predominance of carcinoids in midgut may be
incidental following appendectomy

Carcinoid in association with MEN-1 arise in
the foregut

Approx 2500 new cases/annum malignant
carcinoid (USA)
50% survive >5years

Carcinoid Tumours
Overall incidence 1-2 per 100,000

Commonly develop bronchi,
stomach, small intestine, appendix
and rectum

Classification based on
embryological origin e.g. foregut,
midgut, hindgut

One of best characteristics of
carcinoid tumours is ability to
secrete serotonin and the
association with carcinoid syndrome

Carcinoid tumours have also been
found to secrete ACTH, histamine,
dopamine, substance P, neurotensin,
prostaglandins, and kallikrein
Carcinoid Syndrome
Release of serotonin and other vasoactive substances into
the systemic circulation is thought to cause the carcinoid
syndrome

Manifested by episodic flushing, wheezing, diarrhoea and
eventual right-sided valve heart disease (33%)

Associated primarily with midgut carcinoid tumors, and
occurs almost exclusively in the setting of metastatic, rather
then localized disease

Occurrence and severity of carcinoid syndrome are directly
related to tumour size in an area with direct access to
circulation
Progression of Carcinoid Disease
5-HIAA
Levels not elevated with other types
of tumours

Produced as breakdown product of
serotonin

Sensitivity 73%, specificity 100%

However, the level of 5-HIAA only
becomes elevated when carcinoid
tumors have metastasized to the
liver, making the potential for a cure
unrealistic

5-HIAA testing is useful to estimate
the extent of disease and survival

False-positive test with foods rich in
serotonin e.g.
Bananas, Walnuts, Plantains, Hickory
nuts, Pineapple, Pecans, Kiwi fruit,
Avocados

Drugs, many that are contained in

cough and cold medicines also cause
raised 5-HIAA e.g.

Acetaminophen (such as Tylenol)*

Salicylates (aspirin)

Guaifenesin (found in some cough

medicines)

l-dopa (used to treat Parkinson's

disease)
Chromagranin A (CgA)
Chromogranin A is considered as
the best test for detecting
carcinoid tumours, and for
monitoring their activity.
Elevated levels of CgA are found
in 80-100% of patients with
carcinoid tumors

Positive test result does not
always indicate carcinoid tumours
are present, because CgA levels
can also be increased by
neuroendocrine tumors.
Further testing must be done to
make a definitive diagnosis of
carcinoid syndrome.

Types of Tumour Markers
General non specific markers and
analytes

Functional markers

Classical tumour markers

Haematological malignancies

Molecular markers
Classical Tumour Markers
AFP, hCG, S100, SP1

CA125, inhibin A, CA15.3

CEA, CA19.9

CA211

Calcitonin, thyroglobulin

Chromogranin A, NSE

NMP22

PSA
Testicular Cancer
Seminoma 40%
10% produce hCG
50% produce
placental-like ALP at
presentation
75% at recurrence
LDH may also be raised
non-specific but ?role
in monitoring
If AFP produced,
elements of germ cell
tumour are present
which changes
treatment /
management
Non-seminomas 60%
90% produce AFP +/-
hCG
Both of value in
determining type,
prognosis and therapy
Where positive they
are essential for
monitoring response,
detecting residual
tumour and recurrence
Testicular Cancer
Depending on stage and pathology,
recommended that AFP +/- hCG
Measured 4-12 times annually (year 1)
Twice annually (year 5)
Annually thereafter
Hepatocellular carcinoma - AFP
Malignancies with elevated AFP
Non seminomatous germ cell tumours of testis, ovary
and other sites
Hepatocellular carcinoma
Hepatoblastoma (children, v rare in adults)

Benign conditions with elevated AFP
Hepatitis, cirrhosis, biliary tract obstruction, alcoholic
liver disease etc

Dont forget high levels in pregnancy and in
first year of life
Levels in infants should fall to adult levels by 1 year
old
AFP Clinical Applications
In combination with hCG for NSGCT

Independent prognostic marker for NSGCT

Diagnostic aid for hepatocellular carcinoma
(HCC) and hepatoblastoma in patients with
cirrhosis and a focal lesion >2cm with arterial
hypervascularization
AFP >200 ug/L suggestive of HCC
AFP >400 ug/L strongly suggestive of HCC

AFP is not useful for liver mets CEA is
preferable marker
CA125 Ovarian Cancer
Main application is monitoring treatment

Also useful in distinguishing benign from
malignant pelvic masses
Especially in post-menopausal women
Mass already identified

Elevated in 80-85% epithelial ovarian cancer but
only 50% elevated in early stage (1) cancer

Recommended in conjunction with transvaginal
ultrasound for early detection in women with
hereditary symptoms
At risk population with adjunct tests
CA125

Benign disease
Endometriosis (24%)
Benign ovarian tumours
(10%)
Acute salpingitis (40%)
Cirrhosis (67%)
Cirrhosis with ascites
(100%)
Chronic active hepatitis
(10%)
Acute pancreatitis (32%)
Renal failure (15%)
Other malignancy
Endometrial cancer(32%)
Cervical cancer (25%)
Breast cancer (20%)
Colorectal cancer (15%)
Pancreatic cancer (55%)
Lung cancer (30%)
Liver cancer (60%)
Gastric cancer (30%)
Biliary tract cancer (46%)
Miscellaneous
Normal pregnancy
Menstruation
Following disruption
to the peritoneum
(e.g. laparoscopy)
NICE Guidelines Ovarian Cancer
Recommendations
Check CA125 if symptoms suggest ovarian cancer
If CA125 > 35 kU/L refer for ultrasound
Calculate risk of malignancy index (RMI), if >250
refer to specialist
Symptoms in guidelines include
Frequent and persistent (e.g. >12x per month)
Abdominal bloating
Early satiety
Loss of appetite
IBS like symptoms
NOT an invitation to screen asymptomatic
women!!
Breast Cancer
Tissue markers are considered mandatory in all
breast Ca patients
Oestrogen and progesterone receptors measured to
identify those who can be treated with endocrine
therapy
HER/2 receptors measured to determine those who
can be treated with Herceptin

BRCA1
Variations of BRCA1 gene lead to increased risk of
breast cancer
BRCA1 or BRCA2 mutations have up to 60% risk of
developing breast cancer by age 90 and increased
risk of ovarian cancer
Herceptin (Trastuzumab)
Monoclonal antibody which interferes with HER2/neu receptor

HER receptors embedded in cell membrane and regulate growth,
survival, adhesion, migration and differentiation

In some breast cancers HER2 is over-expressed resulting in
overproduction of breast cells via EGF

Herceptin binds to HER2 preventing cell overproduction

Studies showed improved survival in late stage metastatic breast
cancer from 20.3 to 25.1 months
Conflicting data regarding effect in early stage cancer
Very expensive

If patient doesnt have overactive HER2 receptors then herceptin will
have no effect difficult for patients to perceive
Only 1 in 5 have tumour sensitive to herceptin
Side effects relating to increased hear disease prevent patients with pre-existing
heart disease from getting treatment
CA15.3
Increased in breast Ca especially with distant
mets
Sensitivity of 0-36% in early stages
Sensitivity of up to 100% in advanced disease

Rarely elevated in patients with local breast
cancer

Major use in post-treatment monitoring

Can also be raised in benign and malignant
disease of lung, GI and reproductive systems and
also in liver disease

CEA
Glycoprotein, 60% carbohydrate, MW 200kDa

CEA and colorectal malignancy
70% but often not in early stage disease
Most useful in post-treatment monitoring
Early indicator of recurrence (but not in 30% of patients)

Also raised in other malignancies such as breast, lung,
pancreas etc

Can be raised in benign conditions such as liver disease,
obstructive jaundice, Chrons disease, pancreatitis, renal
disease

Can be mildly elevated in healthy individuals who smoke
Screening for colorectal cancer
National scheme
http://www.cancerscreeni
ng.nhs.uk/bowel/
All individuals >60 years
should be screened
1 in 20 in UK will develop
bowel cancer during
lifetime
3
rd
most common cancer
in UK and 2
nd
leading
cause of cancer deaths
Screening shown to
reduce risk of dying from
bowel cancer by 16%
Uses faecal occult blood
test (FOB)
CA19.9
Primary malignancy is pancreatic cancer
Low sensitivity and specificity limit use in early diagnosis
Main use in monitoring treatment

Also known as sialyated Lewis antigen patients who lack
Lewis antigen (blood type protein on RBC 10% Caucasian
population) will not express CA19.9

Can be elevated in
Colorectal, oesophageal and hepatocellular cancers
In benign conditions such as pancreatitis, cirrhosis and
diseases of bile ducts
PSA
Although prostate CA is considered the only malignancy
which leads to elevated PSA, it isnt completely prostate
specific

Benign prostate hypertrophy (BPH), UTI, urinary retention,
acute and chronic prostatitis can lead to elevated levels

Transient elevation can be seen following TURP, prostate
biopsy, prostate massage, ejaculation etc

Main applications
With DRE can aid in diagnosis
Prognosis
Surveillance following diagnosis
Monitoring therapy
PSA
Ca Prostate v BPH

Total v Free
Malignant prostate cells produce more bound PSA
Low level of free in relation to total might indicate
cancer
High level of free indicates normal prostate, BPH
or prostatitis

Popularity of PSA is a huge public health
disaster (New York Times March 2010)
Annual bill in USA $3 billion
16% chance of being diagnosed with prostate Ca
3% chance of dying from prostate Ca
Points to Consider
Diagnostic sensitivity and specificity

Systems / analysers / plate assays

Hook effect

Free v Bound forms

Pre-analytical problems

Internal and external QC

Anatomical considerations
References & Reading
BMJ 2009; 852-858 Serum tumour
markers: how to order and interpret
them

Guidelines for use of tumour markers
Irish ACB 2010
http://www.acbi.ie/Downloads/Guidel
ine-tumour-markets-4th.pdf