Tumor Markers (PART 1)- MIDTERMS W6

MAJOR PROCESS INVOLVED IN CELL GROWTH

1. Proliferation

2. Differentiation

PROLIFERATION

Increased in the number/ population of the new cells

DIFFERENTIATION

Development from primitive and young cell from a mature and complex cell

CANCER

• Is a disease of abnormal growth

• Disease of proliferation and differentiation of the cell

• Refers to uncontrolled growth of cells that can develop into a solid mass or tumor and spread to other areas of the body.

LATIN WORD CANCRUM

Means crab

TUMORGENESIS

• Formation of tumors

• Mutations include activation of growth factors (EGF) and oncogenes (K- ras), in combination with inhibition of apoptosis, tumor suppressor genes and cell cycle regulation genes (BRCA1, p53, cyclins).

METASTASIS

• Spread of cancerous cell into the distant sides of our body

• Additional genetic changes are required such as loss of cell of adhesion proteins (B catenin & E-cadherrin) and activation of angiogenesis gene (VEGF- Vascular Endothelial Growth Factor).

TUMORGENESIS AND METASTASIS OF TUMORS

Are caused by a complex combination of inherited and acquired genetic mutations.

CANCER SEVERITY IS CLASSIFIED BY COMBINATION OF SEVERAL FACTORS WHICH INCLUDES

• Tumor size- larger the side the more aggressive the cancer is

• Histology- distorted has higher grading

• Regional lymph node involvement- indicate metastasis

• Presence of metastasis- only happens on malignant cancers

FOR MOST SOLID TUMORS

(breast, lung, kidney), cancer is broadly classified into four stages (stages I-IV)

HYPERPLASIA AND NEOPLASIA

Involved the increase in the number of cells

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 in transient

NEOPLASIA

• Unregulated and serves no purpose

• Elevation of tumor markers will be a long-lasting phenomenon if not treated

NEGATIVE FEEDBACK

Reversing the process

BENIGN

• Tumor remain at the primary sites and present a smaller risk to the host (do not have metastatic potential)

• At this stage the patient stands a good chance of being successfully treated by the complete removal of the tumor

• Early detection is critical to cancer prevention in general to high-risk families in particular

• Well differentiated and composed of cells resembling the nature of normal cells from the tissue of origin of the neoplasm

MALIGNANT

• Due to genetic instability to tumor cells

• Most tumor cells undergo a benign stage, gradually progress to malignancy, and eventually become metastasized if not treated

ABILITY TO METASTASIZED

It can transfer to other parts of the body

METASTASIS OF MALIGNANT

• Most cancer death are associated with metastatic disease

• Due to multiple genetic changes that result to uncontrolled proliferation

• Tumor cell at the primary site penetrate the surrounding cells then invade blood or lymphatic vessel and are carried to distant sites

VESSELS USED BY CANCEROUS CELLS TO METASTASIZE

• Blood vessels

• Lymphatic vessels

SIGNAL TRANSDUCTION

• It is an orderly and specific transmission of growth regulatory messages from outside the cell to the machinery controlling replication inside the cell nucleus.

• Controls both cell cycle (product is new cells) and apoptosis

• In this pathway, EC stimuli bind and activated receptor is then relayed, amplified, and integrated resulting in biological responses instructing the cell to proliferate or to cease to proliferate.

EC STIMULI

• Hormones

• Cytokines

• Transforming Growth Factor -B

• Epidermal Growth Factor

• C-erbB2

• Nerve Growth Factor

• Antigens

CELL CYCLE

• It involves the passage of a cell through a complete round of replication

• It is one of the most important factors in controlling cell proliferation

• Phases of cell activity divided into G, S, & M.

• These components of the cell cycle are encoded by a separate category of genes that then mutated, will not only increase genetic instability but also accelerate cellular evolution and the progression of malignancy

ABSENCE OF CERTAIN CELL CYCLE CONTROL

Result to Tumor

APOPTOSIS

• A programmed cell death or physiologic death

• It is a natural self-destruct system present in all cells

• Failure of a cell to undergo apoptotic cell death may lead to cancer

• Natural process the body employs for the replacement of cells and the deletion of damaged cells

• Eliminate cells that are produced in excess, developed improperly, have sustained genetic damaged.

MARKERS FOR APOPTOSIS

• P53, Bcl2, and Fas/Fas ligand

• They can be both inducer and inhibitor of cell death

• Potential for diagnosis, prognosis, and therapeutic application

ANGIOGENESIS (FORMATION OF THE NEW BLOOD VESSELS)

• Tumor growth and metastasis are angiogenesis dependent

• New blood vessels are gateway for tumor cells to enter the circulation and to metastasized to distant sites.

MOST WELL KNOWN ANGIOGENIC FACTORS

• VEGF-vascular endothelial growth Factor

• alpha & beta FGF- acidic & basic Fibroblast Growth Factors

• TGF-alpha- transforming growth factor

ADHESION MOLECULES

• These are specific class of transmembrane glycoprotein involved whenever cells are moving and interacting

• Appearance of certain membrane molecules is related to

  • metastatic potential

  • sign of the conversion of normal to malignant cells

THREE CLASSES OF ADHESION MOLECULES

• Selectins

• Integrins

• Immunoglobulin family

TUMOR MARKERS

• Biological substances synthesized and released by cancer cells

• Substance produced by the host in response to cancerous tissue.

• Depending on the marker and the type of malignancy, tumor markers may be used for screening, diagnosis, prognosis, therapy monitoring, and detecting recurrence.

TUMOR MARKERS ARE PRESENT IN

• Circulation

• Cavity fluids

• Cell membranes, Cytoplasm/Nucleus of the cell

APPLICATION OF TUMOR MARKER DETECTION

• Screening

• Prognosis

• Monitoring Effectiveness of Therapy and Disease Recurrence

• Recommendations for Test Ordering

SCREENING

• No tumor marker identified to date can be used to adequately screen asymptomatic populations because most of the clinically used tumor markers are found in normal cells and benign conditions in addition to cancer cells.

• Screening of asymptomatic populations would therefore result in detection of false positive, leading to undue alarm and cost to patients.

• Susceptibility to cancer can be determined using molecular diagnostics

MOLECULAR DIAGNOSTICS

• Breast and Ovarian Cancer- BRCA1 & BRCA2

• Familial Colon Cancers- Adenomatous polyposis coli gene (APC).

EXTRA: ANGELINA JOLIE

Double Preventive Mastectomy

PROGNOSIS

Tumor marker concentration generally increases with tumor progression, reaching their highest levels when tumor metastasize.

MONITORING EFFETIVENESS OF THERAPY AND DISEASE RECURRENCE

• One of the most useful applications of tumor markers is monitoring therapy efficacy and detecting disease recurrence.

• Inpatient with elevated TM at diagnosis, effective therapy results in a dramatic decrease or disappearance of the TM.

• If the initial treatment is effective, the appearance of circulating TM can then be used as a highly sensitive marker of recurrence.

RECOMMENDATIONS FOR TEST ORDERING

• It is important that multiple tests are performed, using the same commercial kits, and follow up testing is based on the half-life of the markers, because they increase with time.

• This ensure marker has time to clear from circulation and that subsequent measurements accurately reflect tumor burden.

TYPES OF TUMOR MARKERS

“EP HOMeR“

1. Enzymes

2. Proteins (most tumor markers are made up)

3. Hormones

4. Oncofetal Antigens

5. Metabolites

6. Receptors

ENZYMES

• A variety of are elevated nonspecifically in tumors.

• Levels tend to correlate with tumor burden, making them clinically useful for monitoring the success of therapy.

TUMOR MARKERS (ENZYMES)

• Prostate Specific Antigen (PSA)

• Lactate Dehydrogenase

• Alkaline Phosphatase

• Neuron- specific enolase

• Lysozyme

• LDH

• Sialyltransferase

• Fucosyltransferase

• Thymidine kinase

• TdT

PSA METHOD

IA (Immunoassays)

PSA CLINICAL UTILITY

Prostate CA screening, Therapy monitoring, and recurrence.

LACTATE DEHYDROGENASE (TUMOR TYPE)

Hematologic Malignancies

LDH AND ALP (METHOD)

Enzyme Assay (EA)

LDH (CLINICAL UTILITY)

Prognostic indicator, elevated nonspecifically in numerous cancers.

ALP (TUMOR TYPE)

• Metastatic CA of the bone

• HCC

• Osteosarcoma

• Lymphoma

• Leukemia

ALP CLINICAL UTILITY

Determination of liver & bone involvement, nonspecific elevation in many bone-related and liver CA

NEURON SPECIFIC ENOLASE (TUMOR TYPE)

Neuroendocrine tumor

NEURON SPECIFIC ENOLASE (METHOD)

• RIA

• IHC

NEURON SPECIFIC ENOLASE (CLINICAL UTILITY)

Prognosticator indicator & monitoring disease progression for neuroendocrine tumors.

LYSOZYME (MALIGNANT DISEASE)

• Colon Cancer

• Monocytic & Myelomonocytic leukemia

LDH (MALIGNANT DISEASE)

• Acute leukemia

• Malignant lymphoma

• Germ cell tumor

• Metastatic colon

• Breast & lung cancer

SIALYLTRANSFERASE (MALIGNANT DISEASE)

Nonspecific

FUCOSYLTRANSFERASE (MALIGNANT DISEASE)

Multiple Malignant Tumor

THYMIDINE KINASE (MALIGNANT DISEASE)

• Hodgkin’s lymphoma

• Small cell carcinoma of the lungs

TdT- TERMINAL DEOXYNUCLEOTIDYL TRANSFERASE (MALIGNANT DISEASE)

• Lymphoblastic lymphoma

• Leukemia

ISOENZYMES

• CK-BB

• Type 2-macro Ck

• Mitochondrial CK 1gA complex

• Placental like ALP(Regan)

• Liver ALP

• Bone ALP

• LD1,LD4, LD5

CK- BB (MALIGNANT DISEASE)

Adenoma carcinoma of the prostate, lungs,and stomach

TYPE- 2 MACRO CK (MALIGNANT DISEASE)

Metastatic liver cancer

MITOCHONDRIAL CK- IGA COMPLEX (MALIGNANT DISEASE)

Prognosticator for patients with advance tumor

PLACENTAL LIKE ALP- REGAN (MALIGNANT DISEASE)

Germ cell tumors, ovarian cancer

LIVER ALP (MALIGNANT DISEASE)

Liver metastasis, seminoma and ovarian cancer

BONE ALP (MALIGNANT DISEASE)

Osteoma, bone metastasis

LD1, LD4, LD5 (MALIGNANT DISEASE)

Testicular germ cell tumor, cancer at advance stage.

SERUM PROTEINS

• Carcinoembryonic proteins- NORMALLY PRESENT ONLY DURING FETAL DEVELOPMENT

• Under normal conditions expression of all protein is subjected to genetic regulation.

TUMOR MARKER (SERUM PROTEINS)

• Serum M- protein

• Serum free Light Chains

• B2- Microglobulin

SERUM- M

CLINICAL UTILITY: Diagnosis, TM of plasma cell dyscrasia

METHOD: Serum Protein Electrophoresis, Immuno Fixation Electrophoresis

SERUM FREE LIGHT CHAINS

CLINICAL UTILITY: Diagnosis, TM of plasma cell dyscrasia

METHOD: Immunoassay

B2 MICROGLOBULIN (TUMOR TYPE)

TUMOR TYPE: Hematologic malignancies

METHOD: Immunoassay

CLINICAL UTILITY: Prognostic marker for lymphoproliferative disorders

HORMONE AND HORMONE METABOLITES

• Usually made up of protein

• Widely used as a specific marker of secreting tumors.

• Increased if the tumors in the hormone producing organs

TUMOR MARKERS (HORMONES AND HORMONE METABOLITES)

• HVA and VMA

• Metanephrines

• Catecholamines

• 5- HIAA & Serotonin

• Calcitonin

• PTH

• GH

• PRL

• ACTH

• Cortisol

• ADH

• Chromogranin

• C- peptide

HVA (HOMOVANILIC ACID) and

VMA (VANILYL MANDELIC ACID)

TUMOR TYPE: Neuroblastoma, pheochromocytoma, paraganglionoma

METHOD: HPLC

CLINICAL UTILITY: Neuroblastoma

METANEPHRINES

TUMOR TYPE: *SAA

METHOD: HPLC

CLINICAL UTILITY: Pheochromocytoma

CATECHOLAMINES

TUMOR TYPE: *SAA

METHOD: HPLC, LC MS, MS

CLINICAL UTILITY: Screening & Diagnosis of Neuroblastoma, pheochromocytoma, paraganglioma

5- HIAA & SEROTONIN

TUMOR TYPE: Carcinoid tumors

METHOD: HPLC

CLINICAL UTILITY: Carcinoid Tumor

CALCITONIN

TUMOR TYPE: MTC & neuroendocrine tumors

METHOD: Immunoassay

CLINICAL UTILITY: Screening, response to therapy & monitoring recurrence of MTC

PTH

TUMOR TYPE: Pituitary adenoma

METHOD: Immunoassay

CLINICAL UTILITY: Dx & postsurgical monitoring of 1’ hyperparathyroidism

GH

TUMOR TYPE: Pituitary adenoma, ectopic GH secreting tumor surgical

METHOD: IA

CLINICAL UTILITY: Dx & post monitoring of acromegaly

PRL (Prolactin)

TUMOR TYPE: Pituitary adenoma

METHOD: IA

CLINICAL UTILITY: Dx& postsurgical monitoring of prolactinoma

ACTH

TUMOR TYPE: Pituitary adenoma, ectopic ACTH-producing tumor

METHOD: IA

CLINICAL UTILITY: DX of ectopic ACTH producing tumor

CORTISOL

TUMOR TYPE: Adrenal tumor

METHOD: IA

CLINICAL UTILITY: Dx of Cushing’s syndrome, adrenal adenoma

ADH

TUMOR TYPE: Posterior Pituitary Tumor

METHOD: IA

CLINICAL UTILITY: Dx of SIADH

CHROMOGRANIN A

TUMOR TYPE: Pheochromocytoma, neuroblastoma, carcinoid tumors, small cell lung CA

METHOD: ELISA, RIA

CLINICAL UTILITY: Aid in Dx of carcinoid tumor, pheochromocytomas, & neuroblastoma

C- PEPTIDE

TUMOR TYPE: Insulin secreting tumors

METHOD: ELISA, RIA

CLINICAL UTILITY: Dx of insulinoma

ANTIGEN

• One of the first tumor markers discovered was the oncofetal antigens

• CEA and AFP are expressed transiently during normal development and are then turned on again in the formation of tumors.

• Monoclonal defined antigens were directly identified from human tumor extracts or cell lines. These are directed toward specific carbohydrates or cancer antigens and are best used for monitoring treatment of tumor that secrete these epitope

TUMOR MARKERS (ANTIGEN)

• CA 19-9

• CA 15-3

• CA 27-29

• CA 125

CA 19-9

TUMOR TYPE: GI CA & adenocarcinoma

METHOD: IA

CLINICAL UTILITY: Monitoring pancreatic CA

CA 15-3

TUMOR TYPE: Metastatic Breast Cancer

METHOD: IA

CLINICAL UTILITY: Response to therapy & detecting recurrence

CA 27-29

TUMOR TYPE: Metastatic breast carcinoma

METHOD: IA

CLINICAL UTILITY: Response to therapy & detecting recurrence *was asked in the board exam-march 2017

CA 125

TUMOR TYPE: Ovarian Cancer

METHOD: IA

CLINICAL UTILITY: Monitoring therapy

RECEPTORS

• Are used to classify tumors for therapy.

• Prototypic examples of such a marker are estrogen and progesterone receptors.

• When solid tumor biopsies are positive for these markers, tamoxifen chemotherapy is more likely to be effective

TUMOR MARKERS (RECEPTORS)

• Estrogen receptor

• Progesterone receptor

• Her-2/ Neu

• Epidermal growth factor receptor

ESTROGEN & PROGESTERONE RECEPTOR

TUMOR TYPE: Breast Cancer

METHOD: IHC

CLINICAL UTILITY: Hormonal therapy indicator

HER- 2/ NEU

TUMOR TYPE: Breast, ovarian, GI tumors

METHOD: IHC, FISH, ELISA

CLINICAL UTILITY: Prognostic & hormonal therapy indicator

EPIDERMAL GROWTH FACTOR RECEPTOR

TUMOR TYPE: Head, neck, ovarian, cervical CA

METHOD: IHC

CLINICAL UTILITY: Prognostic indicator