2.  Tumor markers are the substances that can be
detected in higher than normal amounts in the
serum, urine, nipple aspirate fluid or tissues of
patients with certain types of cancer
 Poduced either by cancer cells themselves or by
the body as a response to the cancer.

3. Tumor markers are indicators of cellular,
biochemical, molecular or genetic
alterations by which neoplasia can be
recognized.
A substance, released in to the circulation
by tumor tissue, whose detetion in the
serum indicates the presence of tumor.

4. Three defining characteristics
1. Expressed exclusively by the tumor
2. Collection of specimen for the tumor
marker assay is easy
3. The assay itself is
Reproducible
Rapid
Inexpensive
Currently there is no one tumor marker fulfills all these criteria

5.  Diagnostic
 Distinguish benign from malignant disease
 Correlate with the amount of tumor
(Tumor burden)
 Allow subtype classification
 Allow accurate staging
 Prognostic
 Guide choice of therapy
 Predict response to therapy

6. Porteins
• Hormones
• Enzymes
• Oncofetal antigens
• Tumor associated proteins
Genetic mutations
Epi-genetic changes

7. Protein tumor markers
First type of tumor markers identified
Called as classic tumor markers
Poor sencitivity & specificity
Serum/plasma concentrations correlate
with tumor burden as they are shed from
the expanding neoplasm.

8. DNA Base tumor markers
Single nucleotide polymorphisms (SNPs)
Chromosomal translocations bcr-abl 9:22 (philadelphia) (CML)
Changes in DNA copy number
Microsatellite instability
Epigenetic changes (e.g., differential promotor region methylation
RNA Based markers
Overexpressed/ underexpressed transcripts
Regulatory RNA (e.g., micro-RNA

9. Tumor marker Cancer Non-neoplastic
condition
β-HCG Gestational
trophoblastic disease
oHydatiform mole
oChoriocarcinoma
Gonadal germ cell
tumor
oNon seminomatous
testicular tumors
Pregnancy
Calcitonin Medullary cancer of
thyroid -
Catecholamines Pheochromocytoma
-

10. Tumor marker Cancer Non-neoplastic
condition
Alpha-fetoprotein
(AFP)
Hepatocellular carcinoma
Gonadal germ cell tmor
Cirrhosis
Hepatitis
Carcino embryonic
antigen
(CEA)
Adenocarcinoma Pancreatitis
Hepatitis
Inflammatory bowel disease
Smoking
Pancreas
Lung
Breast
ovary

11. Tumor marker Cancer Non-neoplastic
condition
Prostate specific antigen
(PSA)
Prostate cancer Prostatis
Prostatic hypertrophy
Neuron – specific enolase Small cell cancer of lung
Neuroblastoma
Lactate dehydrogenase Lymphoma
Ewing’s Sarcoma
Hepatitis
Hemolytic anemia
Many others

12. Tumor marker Cancer Non-neoplastic conditions
Prostate specific antigen Prostatic cancer Prostatitis
Prostatic hypertrophy
Monoclonal immunoglobulin Myeloma Infection
MGUS
CA – 125 Ovrian cancer
Some Lymphomas
Menstruation
Peritonitis
Pregnancy
CA – 19-9 Ca Colon
Ca Pancreas
Ca Breast
Pancreatitis
Ulcerative colitis
CA 15-3 Ca Breast
Ca 72-4 Ca stomach
CD 30 Hodgkin’s disease
Anaplastic large cell lymphoma -
CD 25 Hairy cell leukemia

13.  Most studied tumor marker
 Onco-fetal protein
 Normally present during fetal life
 Low concentrations in healthy adults
 Structurally
• Glyco-protein
• Molecular weight – 200 kd
• Component of the glycocalyx in cell membrane, located on the luminal
side of the normal intestinal epithelial cells

14. Secreted in to the circulation
Found in mucous secretions of
Exact function unknown
Involved in inhibition of apoptosis
• By anchoring the cell to the ECM
Stomach
Small intestine
Biliary tree

15.  Testing Immunoassay
 Normal serum levels
• Non smokers 0.0 to 3.4 ng/ml
• Smokers 5 ng/ml
 Borderline
 2.5 ng/ml – 5 ng/ml
• Benign disorders
 Inflammatory bowel disease
 Pancreatitis
 Cirrhosis
 COPD
 Elevated >5 ng/ml
• Carcinome colon, pancreas, lung, breast, ovary
• 75 % of the patients with recurrent colo rectal cancers elevate CEA levels before developing
the symptoms

16. Screening
low sensitivity
• early stage diseases – elevated CEA – 5% - 40 %
Prognosis
• Reflect burden of tumor
• Stage of the disease
• Elevated Pre-op level - Predictor of poor survival
& recurrence

17. Monitoring
Recurrent disease
Metastasis
• Hepatic
• Retroperitoneal
• Local
• Pulmonary
• peritoneal
Sensitive
Less sensitive
75 % of the patients with recurrent colo rectal cancers elevate CEA levels
before developing the symptoms

18. Oncofetal antigen
Single chain poly-peptide
Molecular weight – 700 kd
Elevated levels in fetus, pregnancy
decrease sharply after birth
Synthesized by Hepatocytes
Endodermally derived GI tissue

19.  Testing
 Immuno assay/ RIA
 Normal
 < 15 ng/ml
 Elevated
• HCC
• non-seminiferous testicular cancer
 10 to 20% HCC do not have detectable AFP levels
 Elevated in non cancer conditions
• Hepatitis
• Inflammatory bowel disease
• cirrhosis

20.  Screening
 Sensitivity 25% to 75%
 Specificity 76% to 94%
 Positive predictive value 9% to 50%
 Combination of AFP & USG improves the efficacy of the
screening
 In combination with β-HCG useful in classification &
monitoring therapy of non-seminiferous testicular carcinomas

21. Prognosis
AFP concentration reflects tumor size
Larger tumor > 400 ng/ml
AFP correlates the stage & prognosis

22.  Monitoring
 AFP level drop < 10 ng/ml, after complete resection
 If AFP does not drop below 20 ng/ml potoperatively
suspect early recurrence.
 AFP levels decline in response to effective
chemotherapy.
 Ineffective chemotherapy can be avoided with AFP
monitoring

23.  Mucin type glycoprotein expressed on the surface of
the pancreatic cells
 Normally present within the biliary tree
 Both acute/ chronic biliary tract disease can elevate CA
19-9 levels.
 Widely used Serum tumor marker for Ca pancreas
 Not a diagnostic marker
 Limited use in monitoring the response to therapy

24.  Testing
 Immunoassay
 Normal 37 U/ml
 Pancreatic cancer
• Sensitivity 67% to 92%
• Specificity 68% to 92%
 Limitations
 Patients with –ve Lewis blood group antigen (10% of the population) can not synthesize CA
19-9
 Benign biliary tract disease can have up to 400 U/ml (significant number of acute/ chronic
pancreatitis)
 Elevated in other cancers Biliary tree - 95%
Stomach – 5%
Colon – 15%
HCC – 7%
Lung – 13%

25.  Screening
 Not a useful screening modality
 Low sensitivity in early stage disease
 With increasing levels diagnosis of pancreatic cancer
becomes more accurate
 > 1000 U/ml almost diagnostic of pancreatic cancer
 Not useful in distinguishing benign from malignant
distal CBD strictures.

26.  Prognosis
 Levels correlate with the tumor burden
 > 95% of unresectable have > 1000 U/ml
 Whose levels returned to normal after
curative resection survived longer than those
whose levels fell but never normalized.

27.  Monitoring
 Serial monitoring
 Raised levels after curative resection precede
clinical/ CT evidence of recurrence by 2 to 9
months
 Failure of CA 19-9 levels to fall with chemotherapy
reflects poor tumor response.

28.  Serine protease – formed in the prostatic
epithelium and secreted in to the prostatic
ducts
 Function
• To digest the gel that is formed in seminal fluid after
ejaculation
 Under normal circumstances - only small
amount of PSA leak in to the circulation

29. • There are 2 major circulating forms of
PSA:
Free
Complexed:
 Complexed to 1-antichymotrypsin or 2-macroglobulin

30.  Serum PSA increase
• With enlargement of the gland (BPH)
• Distortion of its architecture
 PSA is considered as a tissue specific marker than
prostate cancer specific marker.
 Useful marker
• Curative radical prostatectomy

31.  Testing
 Normal range – increase with age
• 2.5 ng/ml – 40 to 49 yr
• 3.5 ng/ml - 50 to 59 yr
• 4.5 ng/ml - 60 to 69 yr
• 6.5 ng/ml – 70 yr or older
• Rate of PSA increase in a normal 60 yr old – 0.04 ng/ml/yr
 Intermediate
• 4 to 10 ng/ ml
 Suspicious for malignancy
• . 10 ng/ ml

32. Testing
Immunoassay
• Elevated PSA
 BPH
 Prostatitis
 Prostatic massage
 Prostatic biopsy
 Digital rectal examination

33. PSA Density
Higher PSA densities are more suggestive
of malignancy than BPH
PSA
Prostatic volume
=

34.  PSA Velocity (PSA slope)
 Rate of change in the concentration of PSA over time
 Individuals with initial levels lower than 4 ng/ml a PSA
slope greater than 0.75 ng/ml/yr is significant
 Individuals with initial levels higher than 4 ng/ml a PSA
slope greater than 0.4 ng/ml/yr is significant

35.  Screening
 Widely used as screening tool for Ca Prostate
 Enables early detection & diagnosis
 Risk of over diagnosis
• Autopsy studies
 Ca prostate found in 55% of men in their 5th decade
 Ca prostate found in 64% of men in their 7th decade
 Indicating that significant proportion of these cancers are not lethal
 Only 1 in 8 screening detected cancers is likely to kill its host if left
untreated.

36. Screening
 Annual PSA for screening of prostate cancer:
• in men over 50 years old
• in younger men at high risk: e.g.,
 Those with a family history of prostate cancer
• Total PSA: Screening for and in monitoring of
prostate cancer
• Free PSA:
Differentiate levels of PSA that are in the grey zone
Patient with cancer prostate have a lower % of free PSA
 .

37.  Monitoring
 Response to therapy
• After radical prostatectomy
 PSA level expected to normalize in 2 to 3 weeks
 If PSA remained elevated for 6 months – recurrent disease developed eventually
• Radiotherapy
 Takes 3 to 5 months for normalize PSA
 Failure to normalize predicts relapse
• A rise in PSA is usually a first sign of
 Recurrence
 Metastatic progression

38.  Carbohydrate epitope on a glycoprotein carcinoma antigen
 Present in fetus & its derivatives of coelomic epithelium
• peritoneum
• pleura
• pericardium
• amnion
 Normal adults – CA 125 found in the epithelium of
• fallopian tubes
• endometrium
• endocervix
 Neithe fetal nor adult ovarian epithelium expresses CA 125

39.  Testing
 Immunoassay
 Normal
• Serum < 35U/ml
• Peritoneal fluid < 200 U/ml
 Elevated levels in 80% of ovarian cancer
 Ovarian masses with elevated CA 125 has a sensitivity of 75% & specificity of 90% for
malignancy
 Also detected in other malignancies
• Gynaecological
 Fallopian tube
 Endometrium
 cervix
• Non gynaecological
 Pancreas
 Colon
 Lung
 liver

40.  Testing
 Benign conditions with elevated CA 125
• endometriosis
• adenomyosis
• uterine fibroids
• PID
• cirrhosis
• Ascitis
 CA 125 is adjunt to diagnos Ca Pancreas
rather diagnostic iself

41. Screening – post menopausal women
Poor specificity
Alone is not useful in diagnosing ovarian
cancer
Positive cases are further screened with
transvaginal USG

42. Prognosis
At the time of diagnosis elevated CA 125
have worst prognosis
Percentage of patients with elevated levels
• 50% of Stage I
• 70% of Stage II
• 90% of Stage III
• 98% of Stage IV

43.  Monitoring
 > 95% of patients levels decrease with partial/ complete
response therapy
 Recurrent cases levels elevated 3 months before
clinical/imaging evidence.
 Rising level is an indication for second look laparotomy – 95%
times recurrent disease found
 Peritoneal fluid level is more sensitive than serum level

44. • Beta HCG is a hormone normally secreted by
trophoblasts in the placenta during pregnancy
• It is a glycoprotein consisting of - and -
subunits
• Detection and follow-up of gestational trophoblastic
diseases (GTDs)
• GTDs include:
 Hydatiform mole (vesicular mole)
 Choriocarcinoma

45. Non-seminomatous testicular cancers
• β-HCG
 > 90% choriocarcinomas
• AFP
 90 to 95% yolk sac tumors
 20% of teratomas
 10% of embryonal carcinomas

46.  Diagnosis
 Non-seminiferous testicular germ cell cancers
• 50% will have elevated β-HCG
• 60% will have elevated AFP
• 90% will have elevated β-HCG/AFP
 Few cases of spuriously elevated HCG/AFP
without testicular cancer

47.  Diagnosis
 elevation of HCG/AFP without signs of testicular
cancer in younger than 4o yr - Extra testicular
germ cell cancer
 Useful in identifying biologically distinct categories
of morphologically similar tumors.

48.  Prognosis
 Poor
• AFP > 500 ng/ml
• HCG > 1000 ng/ml
 Monitoring
 Rate of marker decline (half life) calculated weekly after initiation of
chemotherapy, used for early detection of poor response to therapy
 Half life
• > 3.5 days for HCG
• > 7 days for AFP
• Increase half life Indicates very aggressive therapy is required.

49. Intermediate size protein filament found in
connective tissue
It make up the cytoskeleton in eukaryotes
along with microtubules and actin
microfilaments
Over expressed in mesodermal tumors
 Sarcomas
Studied by immuno histochemistry

50.  Marker for breast cancer
 HER2 gene is a proto-onco gene located at the long arm of
human chromosome 17(17q21-q22)
 Encodes an Epidermal Growth Factor Receptor (EGF-R)
 HER2 is a cell membrane surface-bound tyrosine kinase receptor
and is normally involved in the signal transduction pathways
leading to cell growth and differentiation.

51.  proto-oncogene converted to oncogene by:
• Mutation (especially point mutation) or
• Altered (over) expression
 It is now routinely measured in breast cancer (IHC and
FISH) to determine the type of therapy:
• Breast cancer positive for HER-2/NEU is responsive to
treatment (Herceptin – monoclonal antibody -
Trastuzumab)

52.  Tumor marker for Medullary carcinoma thyroid
 32-amino acid linear polypeptide hormone
 Produced by para-follicular cells (C-cells) of the
thyroid
NMR solution structure Salmon
calcitonin in SDS micelles
Cys-Gly-Asn-Leu-Ser-Thr-Cys-Met-Leu-Gly-Thr-Tyr-Thr-Gln-Asp-Phe-Asn-Lys-Phe-His-Thr-Phe-Pro-Gln-Thr-Ala-Ile-Gly-Val-Gly-Ala-Pro

53.  Production regulated by CALC1 gene
 regulates blood Ca2+ levels in four ways:
• Inhibits Ca2+ absorption by the intestines
• Inhibits osteoclast activity in bones
• Inhibits phosphate reabsorption by theKidney tubules
• Inhibits tubular reabsorption of Ca2+,leading to increased rates of its loss
in urine
 Secretion of calcitonin is stimulated by:
• an increase in serum [Ca2+]
• Gastrin & pentagastrin

54. Normal levels
• Male 3 – 26 ng/L
• Female 2 – 17 ng/L
Prognosis
• Calcitonin doubling time
 < 6 months

55. • The gene is located on chromosome 17 (Plus the genes
of BRCA1 and HER-2/NEU)
• Encodes a protein of 53 kDa protein involved in
protecting cells from unregulated growth
• Encodes a protein that normally result in cell cycle arrest
and induces apoptosis
• mutation:  Breast cancer

56. Tumor Tumor marker
Hepatoma (HCC) AFP
Ovarian Cancer CA-125
 Inherited ovarian cancer:
BRCA1
Breast Cancer CA15-3
 CEA
 HER-2/NEU
 Estrogen and progesterone
receptors
 If inherited: BRCA1, and
BRCA2 (on chromosome 13)
Medullary carcinoma thyroid Calcitonin
CEA

57. Tumor Tumor marker
Ca Pancreas CA 19-9
CEA
Colorectal carcinoma CEA
CA 19-9
pheochromocytoma Catecholamines
(VMA) in urine
Nonseminomatous testicular cancer AFP
-hCG
CEA
Vesicular mole & Choriocarcinoma -hCG
Prostate cancer PSA

58.  Tumor marker for carcinoid
 {enterochromaffin (Kultschitzsky) cells of the small
intestine}
 main metabolite of seratonin.
 24-hour urine samples combined with an acidic
additive to maintain pH below 3.
• >25 mg - strong evidence for carcinoid.

59.  Neuro endocrine tumor of the adrenal medulla (originating in
chromaffin cells)
 Plasma
• Catecholamines
• Chromogranin A
• Metanephrines
 Urinary
• Metanephrines
• Vanillyl mandelic acid (VMA)
 end-stagemetabolite of the catecholamines

60. Bence Jone protein
• Monoclonal globulin protein – in blood or urine
• Molecular weight 22 – 24 kd
• Diagnostic of Multiple myeloma
• Present in 2/3rd of Multiple myeloma cases.

61.  Still at an early discovery stage
 Not yet reached the clinic
 It has a great potential
• DNA assays for aberrent methylation are easier & more sensitive than
those for point mutations
• Cancer specific DNA methylation patterns can be detected in tumor
derived free DNA in the blood stream & in the tumor cells shed in to the
lumen. - detection & monitoring
• DNA –methylation profiles are more chemically & biologically stable than
RNA or most proteins.

62.  Targeted biologic fluid sources of DNA
• Serum/plasma
• Urine – blader cancer
• Sputum
• Saliva
 High sensitivity & specificity
 Applications
• Early detection
 Abnormal DNA methylation patterns in histologically normal cell
• Predict response to therapy
• prognostication

63. No ideal tumor marker is known so far
Therefore, the best approach is:
• good history
• thorough physical examination.
• Use a battery of markers (>1 marker/tumor)
• Use confirmatory investigations:
 Appropriate scan, Histopathology

67. β-HCG
Alfa feto protein
LDH
Placental Alkaline Phosphatase
Commonly used