Tumor marker /Cancer Biomarkers (Updated)

A wonderful slide for tumor markers in GI surgery. Cancer biomarkers are often used in monitoring response in cancer.
Tumor marker, biomarkers in common practice.

1. Tumor Markers in GI Surgery Sushil Gyawali MS Resident

2. Tumor Marker Definition: A tumor marker is a substance present in or produced by a tumor or by the tumor’s host in response to the tumor’s presence that can be used to differentiate a tumor from normal tissue or to determine the presence of a tumor based on measurement in the blood or secretions. ( Ind jour Med Ped Oncology 2009) They are surrogate measures of the biology of the cancer. Provide insight into the clinical behavior of the tumor .

3. Cancer Biology   Cancer Biomarkers, by Hala Fawzy Mohamed Kamel et al, 2016 feb

4. Tumor Marker is a biomarker It is a ‘measurable biological indicator’ Cellular , biochemical, molecular, or genetic alterations F ound in bodily fluids (blood urine, stool) or tissues C orrelates with a normal or pathogenic physiological state L.J . Sokoll , A.J. Rai, D.W. Chan, Tumor markers, Tietz Textbook of Clinical Chemistry, fifth ed., W.B. Saunders Company, Philadelphia, PA, 2012 Biochemical indicators of the presence of a tumor

5. History Bence Jones Protein F irst tumor marker in identified by Bence-Jones in multiple myeloma 1846 Amylase Sir Michael Foster who reported the increase levels of serum amylase in patients with cancer pancreas . He suggested urinary amylase as a biomarker for cancer pancreas . 1867 Alpha Feto Protein AFP . 1956 Immunoassay technique 1960 CEA CEA was isolated from human colon cancer and was the first “tumor antigen” discovered 1965 Monoclonal antibody technique monoclonal Abs tech was developed which facilitates the discovery of new tumor markers including CA125, CA15.3, CA19.9 1975 Indian J Med Paediatr Oncol . 2009 Jan-March

6. Cancer Detection Sensitivity Specificity PPV NPV

7. I mportance to correlate with tumor burden to distinguish benign vs malignant disease; it may be prognostic, and it may guide choice of therapy and predict response to therapy.

8. Clinical application

9. Ideal Tumor Marker M.J. Duffy, Tumor markers in clinical practice: a review focusing on common solid cancers, Med. Princ. Pract .(2013) Predict early recurrence and Prognostic

10. Drawbacks

11. Changes in tumor markers during disease course 1 st line therapy 2 nd line therapy

12. Serological/ Circulating tumor markers Tissue/Histochemical markers found in blood, urine, stool, other bodily fluids estimate prognosis assess the response to treatment monitor whether a cancer has become resistant to treatment or recurrent reflects the stage (extent) of the disease prognosis :combined with the results of other tests, such as biopsies or imaging found in the actual tumors themselves, biopsy. used to: diagnose, stage , and/or classify cancer estimate prognosis select an appropriate treatment (eg, treatment with a targeted therapy ) ER/PR (breast cancer), EGFR gene mutation analysis (NSCLC), determine treatment and estimate prognosis;

13. Classification Mishra A , Verma M. Cancer biomarkers: are we ready for the prime time? Cancers 2010;2:190–208 .

14. C ommon classification

15. Biomarkers may be prognostic or predictive. More recently, patterns of gene expression and changes to DNA : potential use as tumor markers. These types of markers are measured specifically in tumor tissues . Most of the traditionally used markers are probably not involved in tumorigenesis, but are likely to be by-products of malignant transformation.

16. Some Tumor Markers Class Examples Enzymes, isoenzymes PSA, PAP,LDH , ALP, CK and NSE Hormones hCG, calcitonin, ACTH, gastrin, and VIP Proteins/peptides β 2 - Microglobulin , NMP22, GFAP, S-100, Ferritin, thyroglobulin Oncofetal antigens AFP and CEA Carbohydrates CA 125, CA 15-3, and CA 27.29 Blood group antigens CA 19-9 and CA 72-4 Receptors ER, PR, EGFR Oncogene Ras , myc , BCR-ABL Tumor Suppressor Genes P53, Rb , BRCA1 , BRCA2, and HER-2/ neu Tumor associated Ag

17. RNA BASED MARKERS : circulating and tissue derived DNA BASED MARKERS : Gene mutation, circulating tumor, epigenetic changes

18. Methods for detection: analysis ENZYME ASSAY IMMUNOASSAY IHC RECEPTOR ASSAY Flow cytometry MASS SPECTROMETRY INTERFACED WITH LIQUID OR GAS CHROMATOGRAPHS MICROARRAYS Molecular methods: PCR, In situ hybridization, cDNA microarrays, fluorescent in situ hybridization Tumor marker Detection/analysis

19. α-Fetoprotein (AFP) A n oncofetal antigen,with single-chain polypeptide Glycoprotein (mass : 700 kDa ) Produced in early fetal life by the yolk sac/liver Elevated in HCC, hepatoblastoma , and NSGCT of the ovary and testis Maternal AFP :detection of neural tube defects.

20. AFP AFP is measured with immunoassay kits. Half-life：4~6 days healthy , non pregnant adult <10 ng/mL Age Level 12~15 th wk POG 30~40 ng/ml At birth 30 ng/ml >1 year (adult ) <10 ng Levels fall to low levels after birth to normal adult value by 18 months

21. Clinical significance Used for diagnosis, staging, prognosis, & treatment monitoring of primary HCC and germ cell tumors U sed for classification tumor staging & monitoring therapy for nonseminatous testicular cancer . Benign Malignant Benign liver disease (eg, viral hepatitis, cirrhosis), HCC (70%) GI tract tumors Nonseminomatous testicular tumors (50-70%) Liver disease and no underlying HCC Intrahepatic cholangiocarcinoma Some colorectal cancer metastases,

22. AFP Levels Benign liver disease can have 200 ng/mL But >1000 ng/mL suggest the presence of cancer A significant rise in serum AFP in a patient with cirrhosis should raise concerns that HCC may have developed. The AFP cutoff of 20 ng/mL has a sensitivity of 60% and a specificity of 90%.

23. Gonzalez, S. A., & Keeffe , E. B. (2011).  Diagnosis of HCC: Role of Tumor Markers and Liver Biopsy. Clinics in Liver Disease

24. AFP types T hree isoforms: AFP-L1, AFPL2, and AFP-L3. AFP-L3 reactivity – a/w liver cancer AFP-L3 %, AFP-L3 as a percentage of AFP: cutoff of 10% (FUJIFILM Wako Diagnostics). Indicated: in patients with CLD to assess the risk of developing HCC and is prognostic HCC carcinoma

25. AFP in HCC S erum levels > 500 μg/L (upper limit in a high-risk patient) is diagnostic of HCC. However , HCC is often diagnosed at a lower AFP level in patients undergoing screening. Can be normal in up to 40 % with small HCCs/ majority of fibrolamellar variant of HCC. Serum levels do not correlate well with size, stage, or prognosis of HCC.

26. AFP association with Liver transplant Despite the issues inherent in using AFP for the diagnosis of HCC, it has emerged as an important prognostic marker, especially in patients being considered for liver transplantation. Patients with AFP levels 1,000 μg/L have an extremely high risk of recurrent disease following the transplant , irrespective of the tumor size.

27. AFP: Screening poor screening tool (sensitivity 31%) For screening purposes in high-risk populations, AFP is used in addition to ultrasound imaging. A cutoff of 100 ng/mL is typically used In a recent metaanalysis of HCC screening for cirrhotic patients: ultrasound and AFP had a sensitivity of 97% picking up HCC (78% ultrasound alone ), although sensitivity for early stage disease for combined ultrasound for AFP screening is predictably lower (sensitivity 63%). Tzartzeva K et al, Surveillance Imaging and Alpha Fetoprotein for Early Detection of HCC in Patients With Cirrhosis: A Meta-analysis. Gastroenterology. 2018 May.

28. AFP: Prognosis AFP correlates with stage and prognosis . AFP concentration reflects tumor size , with levels above 400 ng/mL associated with larger tumors (HCC) AFP doubling time , associated with poorer prognosis . .

29. AFP: Monitoring Declines after resection or ablation or effective chemotherapy Failure to return to normal by 1 month: residual tumor Elevation of AFP after remission suggests tumor recurrence Monitoring of AFP therefore avoids prolonged use of ineffective chemotherapy. AFP is part of the standard surveillance regimen for HCC patients on the transplant list . Effect of pre- and post-treatment α-fetoprotein levels and tumor size on survival of patients with hepatocellular carcinoma treated by resection, transarterial chemoembolization or radiofrequency ablation: a retrospective study Adriana Toro et al. 2016 BMC surgery

30. Recommendation The American Association for the Study of Liver Diseases recommends surveillance (targeted repeated screening in at risk patients) every 6 months for individuals with cirrhosis using liver ultrasound with or without AFP measurements Overall survival is improved with the combined modality.

31. Des-γ-carboxy prothrombin (DCP) DCP is an abnormal form of the coagulation factor prothrombin . In the liver, in the cases of dietary deficiency, vitamin K absence or antagonism , warfarin, DCP is produced. In HCC, gene expression of the enzyme is defective, resulting in DCP . DCP is most commonly used clinically in countries with a high prevalence of HCC, such as Japan, for early detection, monitoring, and recurrence. DCP , and AFP and AFP-L3% are independent markers, DCP correlates with tumor size, although it is less sensitive for detecting small tumors. In a case control study of patients with HCC carcinoma or cirrhosis, clinical sensitivity for cancer detection in early stage disease increased to 78% compared with 53% for AFP alone and 61% for DCP alone. In a multicenter prospective study in 441 subjects with liver disease, the relative risk of developing HCC carcinoma was 4.8 with a DCP cutoff of 7.5 μg/L . Sokoll, L. J . Tumor markers. Contemporary Practice in Clinical Chemistry , (2020).

32. CARCINOEMBRYONIC ANTIGEN (CEA) A n oncofetal protein (1965) L ow concentrations in healthy adults. cell surface anchored glycoprotein (mass 200 kDa) component of the glycocalyx, located on the luminal side of the cell membrane of normal epithelial intestinal cells ., CEA functions as an cell-cell adhesion molecule and may be involved in tumor invasion and metastasis I s able to inhibit apoptosis induced by loss of anchorage to the ECM.

33. CEA CEA is a glycosylphosphatidylinositol cell surface anchored glycoprotein:as functional colon carcinoma L-selectin and E-selectin ligands, which may be critical to the metastatic dissemination of colon carcinoma cells Secreted into the circulation and is also found in the mucous secretions of the stomach, small intestine, and biliary tree. Metabolized in the liver , hence liver damage impairs CEA clearance • CEA has a specificity for colorectal cancer of 90%, but a sensitivity of only 40% to 75%.

34. CEA: Serum Level Levels: Borderline levels : benign disorders such as IBD, pancreatitis , cirrhosis, COPD <2.5 ng/ml Normal 2.5-5 borderline >5 ng/ml Elevated In smokers: <5ug/ml upper limit WHY INCREASE?? Benign Malignant cirrhosis, e mphysema rectal polyps ulcerative colitis benign breast disease DM P ancreatitis CRF, HD Diverticulitis IBS Pneumonia Hypothyroidism any acute or chronic inflammatory state. primary cancers CRC (60-80%) breast, pancreatic, liver, lung, gastric, O varian/uterine Metastatic liver disease False positive CEA : due to the presence of heterophilic antibodies in the specimen

35. CEA: Screening /Diagnosis L acks both sensitivity and specificity Most types of cancer do not produce a high level of CEA Elevated CEA levels : only 5%-40 % of patients with localized disease It is not reliable for diagnosing cancer or as a screening test for early detection of cancer .

36. CEA: PROGNOSIS In CRC, Elevated CEA levels reflect the burden of tumor and correlate with the stage of disease . CEA levels 5.0 ng/mL or greater are associated with an adverse impact on survival that is independent of tumor stage W ith increased values : risk of recurrence and development of metastatic disease .

37. Preoperative CEA values : prognostic significance Preoperative CEA before potentially curative resections : I f do not normalize following surgical resection, by 6 weeks or within 6 weeks of starting treatment. persistent/residual disease /Treatment failure 2. Has prognostic significance. Independent predictor of survival (higher preoperative level poorer survival/prognosis)

38. CEA: Monitoring CEA levels : recommended at baseline and at 2-3 months for 3 years following surgery and then every 6 months until 5 years A CEA level > 5 ng/mL in any patient who has undergone treatment for colorectal adenocarcinoma should be considered tumor recurrence unless proven otherwise. CUT OFF for recurrence - 5-ng/mL sensitivity of 71% and specificity of 88 % - 10 ng/mL sensitivity for of 68% and specificity of 97%. A recent Cochrane review therefore recommends using a 10-mg/mL cutoff during monitoring

39. CEA concentration for monitoring disease course in CRC ff

40. CEA: In Metastatic CRC A lso monitoring response to chemotherapy in patients with metastatic colorectal cancer. An elevated CEA level is an independent factor associated with poor survival and progression on 5-fluorouracil–based chemotherapy in patients with metastatic colorectal cancer. In advanced cancer whose CEA levels fall during chemotherapy survive significantly longer than those whose do not change or increase .

41. CEA: serial measurement Serial measurement of CEA can detect disease recurrence even among patients with an initially normal CEA level, although the sensitivity is lower (between 27 and 50 %). Thus , a postoperative CEA elevation indicates recurrence with high probability, but a normal postoperative CEA level (even if it was initially elevated) is not useful for excluding a disease recurrence . 30-40% of all cases of CRC recurrences are not associated with measurable elevations in serum CEA. The benefit of CEA monitoring is limited to a small number of patients with recurrent CRC and is not cost-effective.

42. CEA: SERIAL TESTING Frequency of Testing The optimal timing is unclear . Although one study suggests better disease-free survival in patients who have a CEA level checked every 1 or 2 months compared to less frequent intervals, these results have not been confirmed by others, and no study has shown a survival benefit for any CEA testing frequency. Adjuvant therapy with a 5-fluorouracil-based regimen may falsely elevate the serum CEA level, possibly because of treatment-related changes in liver function. Thus , waiting until adjuvant treatment is completed to initiate CEA surveillance is advisable ASCO guidelines suggest Postop CEA testing every 3 months for at least 3 years after initial therapy in patients with stage II or III disease, if the patient is a potential candidate for surgery or systemic therapy NCCN guideline : Postop CEA testing every 3–6 months for 2 years and then every 6 months for a total of 5 years . These guidelines suggest that serial testing be limited to patients who have T2 or higher stage and who would be considered potential candidates for resection of isolated metastases .

43. CEA and CA19.9 CEA is not increased in 15%-40 % of patients with colorectal cancer CA 19-9 is also increased in approximately 35% to 40% of patients with advanced colorectal cancer. In contrast to CEA, CA 19-9 is significantly decreased in patients who smoke . There is no significant transient increase of CA 19-9 in patients with colorectal cancer using chemotherapy and patients with high preoperative levels of CA 19-9 might have a poorer survival . A drawback of using CA 19-9 is that patients with poorly controlled diabetes mellitus, even without any malignancy, have a significant greater level of CA 19-9 than healthy people. Therefore , an increase of CA 19-9 in patients with colorectal cancer and diabetes might not be an indication of advanced disease activity : CA 19-9 As a Marker in Addition to CEA to Monitor Colorectal Cancer Jolanda Stiksma et al 2014

44. CA 19-9 As a Marker in Addition to CEA to Monitor Colorectal Cancer l JolandaStiksma https://doi.org/10.1016/j.clcc.2014.09.004 Evaluation of response to chemotherapy , according to the RECIST criteria , should be based on structural imaging such as CT /MRI CEA is most sensitive for hepatic and retroperitoneal metastases , but least sensitive for local recurrence and peritoneal or pulmonary disease . Current guidelines recommend surveillance for CRC using a combination of periodic clinical visits, CEA levels, CT, and colonoscopy . Conventional imaging techniques including CT and MRI are classically used for routine surveillance and decision-making in CRC, but emerging techniques such as PET may be additionally employed.

45. Carbohydrate Antigen 19-9 ( CA 19.9) CA 19-9 is a mono- sialoganglioside , exists as a glycolipid attached to a sialylated Lewis A blood group antigen. In serum, CA 19-9 occurs as a circulating carbohydrate-rich glycoprotein associated primarily with mucin CA 19-9 is considered to be a tumor-associated, rather than tumor-specific antigen

46. CA 19.9 F irst identified by Koprowski and coworkers in 1979 D etected by monoclonal antibodies raised against colon cancer cell lines in a mouse spleen model . H alf-life of approximately 14 h. The CA 19-9 epitope is normally present within the biliary tree. Produced by pancreatic and biliary ductal cells, Secreted by gastric, colonic, endometrial, and salivary epithelia. In pancreatic cancer, CA19-9 serves as a predictive biomarker

47. CA19.9 Biliary tract disease, both acute and chronic, can elevate serum CA 19-9 levels. It is a mucin, does not increase during pregnancy Serum level: < 37 U/mL (immunoassay)

48. Lacks sensitivity/specificity Non secretors : negative Lewis a blood group antigen ( 10% of population) cannot synthesize CA 19-9 . CA-19-9 is not expressed even in those with large tumors. Elevated in benign biliary tract disease Elevated in other cancers. DUPAN2 , MIC1 done is such cases Ca 19.9 elevation Ca Pancreas 71-93% Ca colon 20-40% Ca Stomach 21-42% HCC 7-9% Ca Lung 13-15% sensitivity 90% specificity 70%

49. CA19.9 : False positive CA19-9 is present in fetal tissues and normal gastrointestinal epithelial cells . CA19-9 is not tumor type-specific : malignancies, originating from the colorectum, gastric system, lung, breast, and liver , pancreatic NET. Benign conditions of CA 19.9 elevation Bile duct obstruction and inflammation Colon diverticulitis Interstitial Pulmonary disease Gastric ulcer Pancreatitis (acute/chronic) Pulmonary fibrosis Collagen vascular disease Black tea/ heavy tea consumption Uncontrolled DM Hypothyroidism Endometriosis Roles of CA19-9 in pancreatic cancer: Biomarker, predictor and promoter GuopeiLuo

50. CA 19.9: Cut-off value in diagnosing PDAC in symptomatic patients .  If higher cutoffs are used, the specificity rises so that, at levels greater than 1000 U/ml, the marker's specificity approaches 100%. Tessler DA, et al. Predictors of cancer in patients with suspected pancreatic malignancy without a tissue diagnosis. Am J Surg 2006;191(2):191e7. Sensitivity : 79-80% Specificity : 82-90% Tessler et al.2006 demonstrated : CA 19-9 cutoff > than 37 U/mL had a specificity of nearly 100% for detecting pancreatic cancer in patients with a pancreatic mass, significant weight loss >20 pounds, and bilirubin level 3 mg/ dL . FN : Lewis Ag neg FP : obstructive jaundice( 10-60%) Other conditions

51. DU-PAN-2/ S-PAN-1 Duke Pancreatic Monoclonal Antigen Type  2   ,is the precursor of CA19-9 . DU-PAN-2 CA19-9 Thus, DU-PAN-2 may have the potential to compensate for the diagnostic limitation of CA19-9 in Lewis-negative patients Singh S et al. The clinical utility and limitations of serum carbohydrate antigen (CA 19-9) as a diagnostic tool for pancreatic cancer and cholangiocarcinoma . Dig Dis Sci 2011 Mediated by Lewis Ag CA 50: CA 19-9 and CA 50 complement each other in pancreatic and other carcinomas, used simultaneously, improves sensitivity. DUPAN <150 U/ml Sn Sp SPAN 1 81-92 % 76-85% DUPAN 2 48 to 72% 85 to 94%,

52. CA 19.9 : RESECTABILITY For determining resectability of locally advanced or metastatic disease Important: CA 19-9 is best used in conjunction with clinical evaluation and imaging when determining resectability . Schliemann MG, Ho HS, Bold RJ. Utility of tumor markers in determining resectability of pancreatic cancer. Arch Surg 2003 Preop level >150 U/ml PPV 88% <150 U/ml NPV 64%

53. CA 19.9 : Malignant vs Benign condition Kim and colleagues devised a simple algorithm Kim HJ et al. A new strategy for the application of CA 19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve. Am J Gastroenterol 1999. Suspected biliary tract Ca: 2 groups Cholangitis/Cholestasis Present Not present Cut off : 37 U/ml recommended assessed once acute process has resolved alternative cutoff value of 300 U/mL may be applied.

54. CA19.9 : Biliary drainage If CA 19-9 levels rapidly decrease following biliary drainage indicate a benign biliary condition rather than a malignant process Variations in CA 19-9 levels have been observed to occur anywhere from 48 h to several weeks. After stone extraction, CA 19-9 levels started to decrease and reached normal values 1-28 days later. Mann DV, Edwards R, Ho S, Lau WY, Glazer G. Elevated tumour marker CA 19- 9: clinical interpretation and influence of obstructive jaundice. Eur J Surg Oncol 2000 Dogan ÜB, Gümürdülü Y, G olge N, Kara B. Relationship of CA 19-9 with choledocholithiasis and cholangitis. Turk J Gastroenterol 2011

55. CA19.9 : UDCA Use Unknown mechanism, it is postulated that biliary sludge causes transient increases in pressure within the bile ducts and consequently, temporary production and elevation of CA 19-9 by cholangiocytes . UDCA decreases the pressure within the biliary ductal system, results decreased CA 19-9 levels. In a single study by Cheong et al. on patients GB sludge and elevated CA 19-9, 6/11 (54.5%) of patients displayed normalization of CA 19-9 levels after receiving UDCA treatment compared to 1/4 (25%) of patients who did not receive treatment with UDCA. Median duration of UDCA therapy needed for normalization of CA 19-9 levels was 4.5 months. Cheong JH et al. Endoscopic ultrasonography in patients with elevated carbohydrate antigen 19-9 of obscure origin. World J Gastrointest Endosc 2013;5(5):251e4.

56. CA19.9 : Screening Asymptomatic cases : PPV for pancreatic cancer : 0.9%. (very low) Not useful as a screening tool . In symptomatic patients , increasing levels of CA 19-9 make the diagnosis of pancreatic cancer more accurate. (cutoff level of 100 U/mL , the specificity 98%.)  

57. CA 19.9 : Prognosis C orrelates with tumor burden. higher CA 19-9 levels higher tumor stage. After curative resection, those whose CA 19-9 levels returned to normal survive longer than those whose levels do not. Pre-operative < 37 U/mL) have a prolonged median survival (32-36 months) compared to ( > 37 U/mL) (12-15 months ). A CA 19-9 serum level of <100 U/mL implies likely resectable disease whereas levels >100 U/mL suggest unresectablity or metastatic disease Ballehaninna UK, Chamberlain RS. The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: An evidence based appraisal. J Gastrointest Oncol . 2012 .

58. CA 19.9 : MONITORING Serial measurement monitor response to therapy. After curative resection, a rise in CA 19-9 level has been shown to precede clinical or imaging evidence of recurrence. In patients with unresectable or metastatic disease, failure of CA 19-9 levels to fall with chemotherapy reflects poor tumor response . However, in both settings, the lack of alternative effective therapies limits the utility of serial monitoring of CA 19-9

59. CA 19.9 : PROGNOSIS The degree of elevation of CA-19-9 (both at initial presentation and in the postoperative setting) is associated with long-term prognosis . Furthermore, in patients who appear to have potentially resectable disease, the magnitude of the CA-19-9 level can also be useful in predicting the presence of radiographically occult metastatic disease

60. CA 19-9 may serve as a prognostic marker in the perioperative evaluation of patients with pancreatic cancer . Specifically, high postoperative CA 19-9 levels have been associated with poor survival . Serial CA 19-9 levels may be combined with imaging in evaluating efficacy in patients undergoing treatment of advanced pancreatic cancer. Multicenter, 2010 march

61. CA 19.9 : predictor Predictor 1） Evaluating the efficacy of neoadjuvant therapy 2） Assessing resectability 3） Postoperative CA19-9 for evaluating prognosis 4） Predicting response to adjuvant chemotherapy 5） Evaluating the efficacy of systemic chemotherapy 6） Normal baseline CA19-9 for evaluating long-term survival Roles of CA19-9 in pancreatic cancer: biomarker, predictor and promoter Guopei Luo et al , April 2021 , Reviews on Cancer

62. Colorectal Cancer: Survelliance (CEA/CA19.9) National Academy of Clinical Biochemistry (NACB) recommends : 50 years or older should undergo screening for colorectal cancer . Multiple screening procedures exist : Fecal occult blood test (FOBT) is the most widely used CB in stool CEA estimation is recommended at the beginning of therapy then every 1–3 months all through the therapeutic regimen, it is also the marker of choice for metastatic cases of CRC. CA19-9 has been used as prognostic marker, in surveillance of CRC after surgical resection and as monitoring marker for therapeutic intervention in advanced cases. Cancer Biomarkers, By Hala Fawzy Mohamed Kamel et al, 2016

63. CA Gallbladder  CA 19-9, CEA and CA 125 can predict resectability in GBC and R aised levels of CA 19-9 and CA 125 can predict poor prognosis in patients with elevated levels. Role of CA 19-9 , CEA, and CA 125 as the predictors of resectability and survival in the patients of Carcinoma Gall Bladder Saumya,et al Jour of Carcinogenesis, 2020 AIIMS , India 71 pts January 2018 and Sep 2019  both serum CA 19-9 and serum CA 125 may act as a good adjunct for diagnosis of cases of carcinoma gallbladder along with imaging studies

64. Ca GB Raised CA19.9 and CEA predict metastatic disease in patients with GBC without jaundice with a high specificity (prognostic) CA19-9 was better than CEA in prediction of tumor burden & recurrence .

65. Ca GB 539 patients with Ca GB Seoul National University Hospital, Korea The relationship between tumor marker levels and overall survival (OS) was analyzed CA 19-9 had a stronger association with prognosis than CEA, 65 IU/mL for CA 19-9 may be suggestive in evaluating the prognosis of GBC

66. Carbohydrate antigen 125 (CA 125/ MUC16) is a carbohydrate epitope on a glycoprotein carcinoma antigen. It is present in the fetus and in derivatives of the coelomic epithelium, including peritoneum, pleura, pericardium, and amnion. In healthy adults, CA 125 has been detected by IHC in the epithelium of the fallopian tubes, endometrium, and endocervix. However, ovarian epithelium does not normally express any CA 125.

67. LDH LDH catalyzes lactate  to  pyruvate   LDH3 is involved in tumor initiation and metabolism. LDH 100~250 IU/L high-grade lymphomas: blood levels correlate closely with disease activity and response to therapy  LDH is a marker of metastases especially in liver  and is independent prognostic factor ,increased LDH had reduced survival (metastatic melanoma) Expression of LDH 5 and VEGF in tumors and the stroma has been found to be a strong prognostic factor for diffuse or mixed-type gastric cancers .   Measuring LDH levels can be helpful in monitoring treatment for cancer . Noncancerous conditions that can raise LDH levels include heart failure , hypothyroidism, anemia , pre-eclampsia, meningitis, encephalitis, acute pancreatitis, HIV and lung or liver disease

68. ALKALINE PHOSPHATASE NEURON SPECIFIC ENOLASE(NES) source: Liver ,bone, placenta Primary or secondary liver cancer Metastatic cancer with bone or liver Bronchogenic Ca (SCC) PALP–trophoblast-sera of pregnant women PALP- ovarian, lung,trophoblastic GI cancers, seminoma, Hodgkins disease Found in tumors originating from the neuroendocrine cell system. Neuronal tissue, neuroendocrine tissue , APUD tissue SCLC , Neuroblastoma, pheochromocytoma Carcinoid, medullary carcinoma of thyroid High levels- poor prognosis

69. Chromogranin Chromogranin A,B Secretogranin 2,3,4&5 Found in neuroendocrine cells Its wide distribution & co-secretion make it an excellent histochemical &plasma marker of NET eg : carcinoid tumors neuroblastoma , pheochromocytoma IMMUNO ASSAY Carcinoid tumours can be monitored by urine levels of 5-hydroxyindoleacetic acid (5HIAA), and polypeptides such as gastrin or glucagon are useful in the management of rare gastrointestinal tumours .

70. GENETIC MARKERS Oncogenes- Activation of proto oncogenes- Suppressor genes- Loss of gene-deletion or monosomy IMMUNOHISTOCHEMISTRY Oncogenes Tumor suppressor genes Ras Leukemia, lymphoma Rb gene RB C- myc Leukemia, lymphoma, SCLC P53 Colorectal, breast, lung Her-2/ neu Breat , Ovarian , GI APC Colon RET Papillary thyroid Ca BRCA1,2 Breast , Ovarian BCR ABL CML DCC Colon

71. P53 tumor suppressor gene negative regulator of cell growth most frequently mutated genes in human cancers p53  mutations occur in 0 to 77% of stomach cancers enhances the self-renewal ability of gastric epithelial cells and results in an increase in undifferentiated cells in the gastric epithelia Can be measured in either tissue, fibroblast, white cell, or serum. Busuttil RA.et al; Role of p53 in the progression of gastric cancer. Oncotarget . 2014 Dec

72. Genomics Proteomics The study of patterns of DNA changes (or mutations) is called genomics. Study of entire set of genes in a genome By looking for DNA changes in blood, stool, or urine, scientists may be able to find cancers very early. Looking at the patterns of changes is likely to prove more useful than looking for single DNA changes. This technology looks at the patterns of all the proteins in the blood instead of looking at individual protein levels . study of all the proteins expressed by the genome. Allows to look at thousands of proteins at one time This information could then be used to develop a blood test that might look only at these important proteins. Then, blood or a tissue sample could be checked for the protein pattern as a way to find cancer.

73. When ordering a tumor marker Sharma S. Tumor markers in clinical practice: General principles and guidelines. Indian J Med Paediatr Oncol . 2009

74. Hook effect The Prozone effect ( antigen excess   ) O bserved when a very high amount of an analyte(Ag) is present in the sample but the observed value is falsely lowered. M ore commonly in sandwich assays. The mechanism of this significant negative interference is the capability of a high level of an analyte (antigen) to reduce the concentrations of “sandwich” ( antibody 1: antigen : antibody 2) complexes that are responsible for generating the signal by forming mostly single antibody:antigen complexes. β-hCG , prolactin, calcitonin , aldosterone , cancer markers (CA 125, PSA), etc.

75. Take home message G ood history Physical examination. Use confirmatory investigations: Histopathology, ultrasonography, CECT. Considering half life while interpreting the result Do serial testing Use a battery of markers(> 1 marker/tumor ) Panel testing is better than testing a single marker Tumor marker Organ Use Carcinoembryonic antigen (CEA) Colorectal/hepatic Monitoring therapy Prognosis Detecting recurrence Screening for hepatic metastases CA 19-9 Pancreatic Monitoring therapy Alfa-fetoprotein HCC Diagnosis Detecting recurrence Monitoring therapy No ideal tumor marker is known so far

76. Test combinations that will give more exact results

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