Recommendation in Laboratory Diagnosis of Cancer
Clinical signs and symptoms in patients suffering from cancer are
often related to the presence of tumor.
Cachexia and pyrexia can be the only evidence of tumor presence.
Sometimes the clinical features may be those of endocrine syndrome:
 Insulinoma  hypoglycemia
 Adrenal carcinoma  Cushing’s syndrome.
Cushing Syndrome
• A group of signs and symptoms caused by abnormally high
concentration of cortisol (hyper-cortisolism).
• The cortex of the adrenal glands produces cortisol. Cortisol is a
steroid hormone that breaks down fat and protein and
stimulates liver glucose production. It helps the body react to
physical and emotional stress, helps to regulate blood pressure,
to control inflammation, and can affect cardiovascular function.
• The adrenal cortex produces the steroid hormones cortisol,
aldosterone and the adrenal androgens, primarily
dehydroepiandrosterone (DHEA).
In many cases the endocrine syndrome is caused by secretion of the
hormone by the tumor = called ectopic hormone secretion
Paraneoplastic endocrine syndromes = systemic manifestation of
cancer not directly related to the physical presence of the primary
tumor.
Non-endocrine tumors associated with hormone secretion
Small cell carcinoma of bronchus – an example of an APUD tumor
(amine precursor uptake and decarboxylation).
In fact the products of most of these tumors are low molecular
weight peptides (many of them hormones).
Adrenal or ectopic tumors - phaeochromocytoma and
neuroblastoma can secrete catecholamine: adrenaline,
noradrenaline (sometimes dopamine)
Hormone secretion by tumors not always causes an endocrine syndrome.
The most frequent paraneoplastic endocrine syndromes are:
 Dilutional hyponatremia
 Hypercalcemia
 Cushing’s syndrome
Cushing’s Syndrome
 The effect of exposition of tissues to supraphysiological
concentration of glucocorticoids.
 Ectopic secretion of ACTH by non-endocrine tumors is common.
 In up to 50% of patients with small cell carcinoma of bronchus
massive secretion of ACTH is shown (5-6x over normal)
Ectopic antidiuretic hormone (ADH) secretion
 Secretion of ADH (vasopressin) by the tumor is uncontrolled 
water retention and results in dilatational hyponatremia.
 Ectopic ADH secretion is most common in small cell carcinoma
of bronchus (sometimes carcinoid tumors and pancreatic
adenocarcinomas).
Tumor-associated hypercalcemia
 Hypercalcemia – common in malignant disease. Bony metastases
contribute to hypercalcemia.
 PTH-related Peptide is most frequently responsible for
hypercalcemia in SCC of bronchus (squamous cell carcinoma),
renal adenocarcinoma.
 Hypercalcemia – common in hematological malignancies
(myeloma) due to release of osteoclast-activating cytokines (IL1, TNF-β)
Tumor-associated hypoglycemia
Usually associated with large mesenchyme tumors, probably due to
secretion of IGFs by the tumors
Cancer cachexia
 Syndrome of weakness and generalized wasting – common in
malignant disease (in large widespread and small tumors).
 Cytokines (TNF-α = cachectin), produced by activated
macrophages within tumor tissue, may be responsible; TNF-α
increases body energy expenditure.
Gastrinoma and Glucagenoma (Derive from neuroendocrine cells of the gut)
Gastrinoma (Increased gastrin secretion):
Gastrin is a hormone produced by "G-cells" in the stomach. It
regulates the production of acid in the stomach during the digestive
process.
Zollinger-Ellison’s syndrome and G-cells hyperplasia leads to
strongly increased HCl secretion. Diagnosis of gastrinoma – HCl
measurement or better gastrin measurement.
Glucagenoma (proliferation of pancreas α-cells):
Increased glucagon secretion (actions oppose that of insulin):
 ↑ Glycogenolysis
 Gluconeogenesis
 Ketogenesis in the liver
 Lipolysis in AT
Diagnosis – glucose intolerance and increased serum glucagon
concentration.
Carcinoid tumors
 Found mostly in the appendix, gallbladder, biliary and pancreatic
ducts, in the bronchi.
 Carcinoid syndrome = result of liberation of vasoactive amines:
serotonin, and peptides from the tumor into the circulation.
 Serotonin = 5-OH tryptamine is converted to 5-OH-indoleacetic
acid (5-HIAA).
 Screening test for carcinoid tumors: 5-HIAA in 24h urine
collection, or plasma chromogranin A (more sensitive, less
specific)
#Cancer diseases
(The second cause of death after CVD, with a tendency to increase)
Causing factors:
 Environmental toxicity (responsible for 70-80% of cases)
 Prolonged longevity
 Progress in the diagnosis - a paradox
Tumor markers
Are substances whose presence reflects the presence of tumors and
whose concentration can be measured as an aid to the diagnosis or
monitoring of the disease.
An ideal secreted tumor marker can be used for:
 Screening
 Diagnosis (confirmation or diagnosis of metastasis)
 Prognosis
 Monitoring treatment
 Follow-up to detect recurrence
Serum tumor marker concentration depends on:
 Expression and synthesis in the cell
 Release from the cell
 Vascularization (blood and lymphatic vessels) around the
tumor tissue
 Kidney clearance
 Coexisting diseases (liver dysfunction, cholestasis)
Circulating tumor markers:
 Antigens specific for the proliferating tumor cells
 Polypeptide hormones derived from ectopic secretion by the
tumors ACTH, ADH, TSH, calcitonin, PTH, PTHrP
 Other substances secreted by tumor cells (paraproteins,
enzymes)
A single antigen can be regarded as a tumor marker if:
 Its increased conc. is mostly found in subjects with cancer than
subjects without malignant disease
 Its concentration is directly related to the number of cancer
cells
 After surgical removal of a tumor a decrease of marker conc. is
observed within a period of its half-life while a disease
progression is followed or preceded by an increase of the
marker conc.
(1) An ideal tumor marker should be characterized by 100%
specificity and 100% sensitivity.
(2) Only some tumor markers are organ specific
 PAcP
 PSA (prostate cancer)
 Thyreoglobulin and calcitonin – thyroid cancer (breast
carcinoma)
(3) Tumor markers should be characterized by
 High NPV = high probability of no disease in cases with
negative test result
 High PPV = high probability of cancer disease in cases with
positive test result
Prognostic value of tumor markers:
 CEA in colon cancer (relation of CEA concentration before
tumor removal and after the operation)
 -2-microglobulin in lymphoma and myeloma
 CA 125 in ovarian cancer
 Her-2/neu in breast cancer, which helps to guide treatment
and determine prognosis
AFP α-fetoprotein
Glycoprotein present in the fetal liver and gut, yolk sac.
In adults normal concentration <10 µg/L
Valuable marker for hepatocellular carcinomas (HCC) and
testicular teratomas – active synthesis of AFP.
In 90% of HCC patients AFP is increased.
In patients with seminoma increased AFP in 60-70%. AFP can be
combined with -HCG – sensitivity increases up to 86%.
AFP (+liver USG) can be used as a screening marker in diagnosis of
HCC (specially in those with HBV and HCV infection; monitored at 6
months intervals).
AFP>20µg/L at negative USG- Dangerous!
AFP is increased in normal pregnancy.
CEA carcino-embryonic antigen
Increased in pregnancy and cigarette smokers, non-malignant
conditions:
 Liver disease
 Pancreatitis
 Inflammatory bowel disease.
Present in elevated concentration in 60% of patients with colorectal
cancer.
Present also in cervical cancer and liver metastases.
CEA – disadvantages:
 Low sensitivity
 Normal value does not exclude the presence of cancer
Ref. range < 3-5 ng/ml;
Heavy smokers 3-10 ng/ml
CEA – the best clinical utility in monitoring of treatment and prognosis.
Persistently normal values after treatment – good prognosis, increase
in concentration means recurrence or metastasis.
NACB and EGTM recommendation for using of tumor marks in colon cancer
 CEA not recommended in screening for colon cancer
 CEA should be measured before the surgery to estimate the stage
of cancer and plan the course of treatment.
 CEA should not be assayed directly after surgery as it can be
released to the circulation during the operation.
 After surgery CEA should be measured for monitoring purposes to
avoid liver metastasis or progression of the disease.
Placenta antigen – hCG-human chorionic gonadotropin
β-subunit specific of hCG
The presence of hCG in the plasma indicates the presence of
abnormal trophoblastic tissue or a tumor secreting the hormone
ectopically.
Assay for hCG as a tumour marker should measure both intact
molecule and β-subunit.
β - hCG is synthesized by:
 Seminomas
 Testicular teratomas
 Ovarian cancer
 Choriocarcinoma (may develop from hydatidiform mole in
pregnant)
hCG sensitivity in trophoblastic tumors is 100%.
(Ref. range < 5 IU/ml.)
Other hormones as tumor markers
 Catecholamine – in pheochromocytoma
 Metabolites of serotonin – in carcinoid syndrome
 Calcitonin –
o In medullary cell carcinoma of the thyroid (eutopic
secretion)
o In carcinoma of the breast (occasionally)(ectopic
secretion).
Marker of prostatic cancer - PSA
PSA - 33kDa glycoprotein serine protease, currently its diagnostic
value is questioned!!! :
Present in plasma of normal men, increases with age and benign
prostatic hypertrophy.
PSA increases after surgery, biopsy of the gland.
High seasonal variation up to 20% ( + ~10% CV), limited use for the
evaluation of Ag dynamics.
The likelihood of cancer increases with PSA > 10 ng/mL
PSA
The best diagnostic value is to estimate the ratio:
 fPSA/ tPSA <10% (<0,1) increased probability of prostate cancer
 fPSA (↑) / tPSA > 25% (>0,25) benign prostate hyperplasia
NACB and EGTM recommendation for use of PSA in prostate cancer
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PSA – determine together with DRE.
Prostate gland biopsy not recommended if PSA < 4 ng/ml
Cut-off values age-dependent.
Used in differential diagnosis in cases with PSA 4-10 ng/ml and
negative DRE result.
 Blood for PSA should be collected before DRE and several wks
after inflammatory state has been cured.
 PSA should be measured with ultrasensitive methods.
To screen for prostate cancer is not recommended actually (NACB,
EGTM, ESClin Oncology)
Enzyme as tumor markers
 Increase of enzyme activities is rather tumor related than tumor
derived.
 Alkaline phosphatase (↑ in patients with biliary obstruction) is
increased in bone metastases.
 In cases with testicular seminoma – placental isoform of ALP is
increased. Measurement of this isoform can be used in
monitoring treatment (sensitivity 70-90).
NSE-neuron specific Enolase
(Marker of small cell carcinoma of bronchus)
Can be measured in combination with CEA – prognostic value.
Recently a new marker of SCC of bronchus has been proposed - pro
GRP- gastrin releasing propeptide.
Carbohydrate antigen markers CA
 High molecular weight glycoproteins:
o CA 125 – marker of ovarian cancer
o CA 19-9 - for adenocarcinoma of the pancreas (also for
colorectal and gastric carcinomas)
o CA 15-3 – for breast cancer
o CA 50 – colorectal carcinoma
CA 125 marker of ovarian cancer
 Unlike breast cancer, endometrial cancer and most
gastrointestinal tumors. Epithelial Ovarian Cancer is not easily
accessible to endoscopic or percutaneous biopsy.
 CA125 + TVUS (for screening purposes);
o Actually the results of several trials are not satisfactory to
recommend screening.
 Disadvantages:
CA 125 may be increased in normal pregnancy and non-malignant
diseases of pancreas and liver.
CA 125
 Recently CA 125 + HE4 are measured for epithelial ovarian
cancer and low malignant ovarian tumors with high NPV 93,2%.
 HE-4- human epididymis protein 4 emerged as one of the most
promising biomarkers in gynecologic oncology.
 Risk of Ovarian Malignancy Algorithm (ROMA) combines
menopausal status and the results of serum HE4 and CA 125.
 In premenopausal women HE4 alone gives the same diagnostic
performance as ROMA.
 Available evidences support the utility of this new cancer
biomarker for risk stratification, prognosis and monitoring of
epithelial ovarian cancer and of endometrial cancer
HE4
 Its concentrations are age-dependent, affected by smoking or
renal function.
 Interestingly HE4 unlike CA125 is not increased in patients with
endometriosis, offering a potential differential diagnosis between
this benign disorder and EOC.
 In EOC patients increased HE4 is associated with poor prognosis.
 High concentrations of HE4 were observed in patients with lung
cancer and renal failure and liver cirrhosis.
 Practically all tumor markers currently used in clinical practice,
including CA125 and HE4, are known to be increased in benign
disorders and no evidence of malignancy. This represents an
important limitation when using tumor marker measurement in
the diagnostic work-up.
NACB and EGTM recommendation for use tumor markers in ovarian cancer
 CA 125 – should not be used in screening.
 CA 125 + TV USG recommended every 6 month in Female with
family history of breast or ovarian cancer, with mutations of
BRCA1, BRCA2.
 CA 125 – measured in F with tuberosity in small pelvis to
distinguish between benign or malignant lesions.
 CA 125 – measured before and during therapy for estimation of
prognosis.
CA 19-9
Glycoprotein released from epithelial cells is markers for
adenocarcinoma of the pancreas (also for colorectal and gastric
carcinomas)
 Sensitivity for adenocarcinoma of pancreas - 80%
 Sensitivity for gastric, colorectal, hepatic cancer -60%
Disadvantages:
Positive results in non-malignant primary sclerosing cholangitis (can
 to cholangiocarcinoma).
CA 15-3 (mucin - like Ag) (Marker of breast cancer)
Monitoring after treatment – normal values show the effectiveness of
treatment.
Disadvantages:
CA 15-3 concentration increases late, in the invasive stage, in patients
with metastases; increases in other non-malignant or malignant
diseases and during pregnancy.
NACB and EGTM recommendation for use of tumor markers in breast cancer
 Evaluate the presence of ER and PR to select patients susceptible
for hormone therapy.
 CA 15-3 or CA 27.29 helpful for early detection of recurrence in
patients with stage II and III after surgery.
 CA 15-3 decrease reflects good response for treatment. Persistent
CA 15-3 increase occurs with progression of disease. Additional
CEA measurement for detection of metastases.
 Increased CA 15-3 can occur in some patients with other cancers,
and in non-malignant diseases, which excludes usefulness of CA
15-3 in screening or evaluation of cancer stage in breast cancer.
 Usefulness of CA 27.29 – limited to monitoring of disease course
in advanced stages of breast cancer.
Her-2/neu
• Her-2/neu is an oncogene - a gene that codes for a receptor
protein for a particular growth factor that promotes cell growth.
• Normal epithelial cells contain two copies of the Her-2/neu gene
and produce low levels of the Her-2/neu protein on the surface of
their cells.
• In about 20-30% of invasive breast cancer (and ovarian and
bladder cancer), the Her-2/neu gene is amplified and its protein
is over-expressed.
• Such tumors tend to grow more aggressively and resist endocrine
(anti-hormone) therapy and some chemotherapy.
• People with Her-2/neu positive breast cancers tend to have a
poorer prognosis, but this tumor characteristic also makes them
candidates to receive treatment specific for Her-2/neu-positive
cancers.
• To determine if a tumor is positive for Her-2/neu, a biopsy is
taken.
• There are two main ways to test Her-2/neu status:
o Immunohistochemistry (IHC)
o Fluorescent in situ hybridization (FISH).
• IHC measures the amount of Her-2/neu protein present. FISH
looks at the genetic level for actual gene amplification – the
number of copies of the gene present.
• IHC is currently the most widely used initial testing method;
however, if it is indeterminate or negative, then the FISH method
is often done as a follow-up test.
• A Her2/neu test blood test is also available.
• The amount of Her-2/neu protein present in the serum is loosely
associated with the amount of Her-2/neu -positive cancer present.
• This test is not used for screening purposes and is not a substitute
for tissue testing but may be ordered to help assess a person's
prognosis and to monitor the effectiveness of treatment.
• After an initial diagnosis of metastatic breast cancer is made, this
blood test may be performed and, if the initial level is greater than
15 ng/mL, then the test may be used to monitor treatment.
SCC Ag
Squamous cell carcinoma - marker for
• Cervical cancer
• Lung cancer
• Head and neck tumors.
Disadvantages:
Increased concentration of this marker is found in renal insufficiency
and gynecologic diseases.
CYFRA 21-1
(Cytokeratin fragments)
Marker of non-small cell bronchial cancer.
NACB and EGTM recommendation for use of Tumor markers in lungs cancer
• CYFRA 21-1 for NSCC, CEA for NSCC and NSE for SC lungs cancer
o No use in screening (low specific).
• CYFRA 21-1, CEA, NSE –measured before treatment.
• If no surgery and no biopsy can be performed- increased NSE can
suggest SC lungs ca.
• Tumor markers may be useful for monitoring early recurrence.
• NSE – in monitoring treatment in patients with SCCL and
detecting progression.
• Preanalytical factors important; avoid hemolysis.
NMP-22
(Urinary bladder cancer marker)
Beta –2 - microglobulin
(Marker of lymphoma)
Eliminated by the kidneys (kidney function effects on the results).
Ferritin
(Marker of hypochromic anemia)
Elevated in:
• Leukemia
• Breast
• Ovarian cancer
Tyreoglobulin and calcitonin
• Thyroid cancers
• Breast carcinoma (calcitonin).