general oncology from devita presentation

1. TUMOR BIOMARKERS
&
VASCULAR ACCESS

2. Tumor Biomarkers

3. What is tumor biomarker?
• a molecular or tissue-based process
• provides information about the future behavior of a cancer
• requires a special assay that is beyond routine clinical, radiographic,
or pathologic examination.

4. Ideal tumor marker : a dream?
• Highly specific : low false positivity
• Highly sensitive : low false negativity
• Correlate with viability of tumor
• Reproducible
• Available, cheap
• Present in all patients with a given malignancy
• Detectable in occult disease
• Absent in benign disease

5. What / How to test?
Tissue of origin Regional lymph nodes
In circulation Gene assays

6. Specimen
• Measured at multiple levels:
– DNA
• Gene mutations, deletions, amplifications, or methylation
– RNA
• Micro RNA,mRNA
– Protein
• Overexpression, under expression, or qualitative abnormalities
– Cells or Tissue
• Presence of cells outside their milieu e.g in circulation
• Demonstration of neovascularization in tissue specimen

8. Clinical Usefulness
•
• Risk determination
–Adjust risk categorization for individual not affected bydisease
–E.g. BRCA 1 & 2 mutationanalysis
Screening
– Prostate specific antigen for carcinoma prostate
• Differential diagnosis
– Analysis of circulating α-fetoprotein (AFP) or β–human chorionic
gonadotropin (β-hCG) in males with poorly differentiated malignancies
of uncertain origin
• Prognosis
– Presence of involved local-regional lymph nodes associated with
subsequent distant recurrence
•
• Prediction
– Estrogen-receptor content for endocrine therapy
Monitoring

9. Some General Points About Tumor
Biomarkers
• No serum marker in current use is specific for malignancy
• Generally, serum marker levels are rarely elevated in patients with
early malignancy
– With a few exceptions, high levels are usually found only when
patients have advanced disease.
• No cancer marker has absolute organ specificity
– PSA relatively specific for prostate tissue, but not for prostate
cancer

10. General Points…..
• No marker is elevated in 100% of patients with particular malignancy
– Exception: hCG in choriocarcinoma
• Requesting of multiple markers (such as CEA and the CAseries of antigens)
in an attempt to identify metastases of unknown primary origin is rarely ofuse
• Tumour markers assays should not be carried out on biological fluids e.g
(peritoneal fluids, pancreatic juice and ovarian cystic fluids) as reliable
reference ranges currently unavailable

11. General Points…
• Reference ranges for cancer markers are not well defined and are used only
for guidance
• Level below the reference range does not exclude malignancy while
concentrations above the reference range does not necessary mean the
presence of cancer
• Changes in levels over time are likely to be more clinically useful than
absolute levels at one point in time
• As many tumour markers lack agreed International Reference Preparations
(e.g CA125, CA15-3, CA19-9), different assay kits may give different
results for the same sera
• Laboratories carrying out tumour marker tests should state the assay used
on their report form

12. Some Tumor Bio Markers

13. Alpha Feto Protein
• glycoprotein homologous to albumin
• Forms in serum:
– Exhibits micro heterogeneity due to varying levels of
glycosylation
– AFP produced by malignancies more highly fucosylated than
formed by normal tissues
– Existing assay do not differentiate between various forms
• Half life: 5-7 days

14. Alpha Feto Protein
• Mainly confined to 3 malignancies, i.e.
a. Germ cell tumours (NSGCT) of testis, ovary and other sites
b. Hepatocellular carcinoma (HCC)
c. Hepatoblastoma (in children, extremely rare in adults)
• Benign conditions
– Hepatitis
– Cirrhosis
– Biliary tract obstruction
– Alcoholic liver disease
– Ataxia telangiectasia
– Hereditary tyrosinaemia
Physiological
conditions with
elevated levels:
• Pregnancy
• 1st year of life

15. AFP: Clinical Applications
• In combination with hCG, for monitoring patients with NSGCT
• Independent prognostic marker for NSGCT (e.g. of the testis)
• Diagnostic aid for HCC and hepatoblastoma.
– In patients with cirrhosis and a focal lesion > 2 cm with arterial
hypervascularization, an AFP level >200 µg/L is suggestive of HCC,
and AFP>400 µg/L is strongly suggestive ofHCC
• Screening for HCC in high risk populations (e.g. in patients with cirrhosis
due to hepatitis B or C)
– 6-monthly AFP measurement and abdominal ultrasound, withAFP>200
µg/L and rising
Not a useful marker for liver metastases

16. CA125
• Protein detected by this antibody is Muc16
• Physiological function: None established
• Malignancies with elevated levels:
– Epithelial ovarian cancer; 80 - 85% of all cases; but increased inonly
half of early (stage 1) cancer
– May be elevated in any adenocarcinoma with advanced disease
• Benign conditions with elevated levels:
– Endometriosis
– Acute pancreatitis
– Cirrhosis
– Peritonitis
– Inflammatory pelvic disease
– Presence of ascites (of non-malignant origin)
Physiological conditions with elevated
levels:
• Menstruation & pregnancy(usually
< 100 kU/L)

17. CA-125
• Reference range: 0 - 35 kU/L (most frequently usedrange)
• Half life : Approx. 5-7days
• Clinical application:
– Measurement in postmenopausal patients with pelvic masses may help
differentiate malignant from benign lesions
– Rate of decline during initial therapy is an independentprognostic
indicator in ovarian carcinoma
– Monitoring treatment with chemotherapy
– Surveillance following initial treatment
• Unclear impact on survival

18. CA 19-9
• Mucin reacting with monoclonal antibody 111 6 NS 19-9
• Physiological function: Involved in cell adhesion
• Reference range : Very variable, from 0 - 37 kU/L to 0 - 100 kU/L
• Half life in serum: Approx. 1 day (can vary from <1 day to 3 days)

19. CA-19-9
• Malignancies with elevated levels
– Most pancreatic adenocarcinomas
– Approx. 50% of gastric carcinomas
– approx. 30% of colorectal carcinomas.
• Benign conditions with elevated levels
– Acute and chronic pancreatitis
– Hepatocellular jaundice ;Cirrhosis
– Acute cholangitis
• Main clinical applications
– As diagnostic aid for pancreatic carcinoma
• Inadequate sensitivity & specificity limit the use in early diagnosis
– Monitoring treatment of patients with pancreatic adenocarcinoma
– Diagnostic aid in gastric and cholangio carcinomas

20. CA 15-3
• Transmembrane glycoprotein encoded by MUC1 gene
– Defined by reactivity with 2 monoclonal antibodies, i.e., DF3
and 115D8 in sandwich immunoassay
• Physiological function: Involved in cell adhesion & cancer
pathogenesis
• Reference range :0 – 25 to 0 – 40 kU/L
• Half life in serum :Unknown

21. CA15-3
• Malignancies with elevated levels :
– Breast adenocarcinomas, especially with distant metastasis
• Rarely elevated in patients with local breast cancer
• Benign diseases with elevated levels
– Benign liver disease
– Benign breast disease (possibly)
• Main clinical applications:
– Preclinically detecting recurrences in asymptomatic patients with
diagnosed breast cancer
• Controversial
– For monitoring the treatment of patients with advanced breast
cancer

22. CEA
• glycoprotein
• Physiological function: Role in cell adhesion & inhibition of
apoptosis
• Reference range: 0 - 3.5 µg/L to 0 - 5.0 µg/L.
• Half life in serum :Approx. 3 days but can vary from 1 to 5 days

23. CEA
• Malignancies with elevated levels
– Elevated in almost any advanced adenocarcinoma, i.e., where distant
metastases present
• Almost never elevated in early malignancy
• Benign diseases with elevated levels:
– Involving liver :Hepatitis, cirrhosis, alcoholic liver disease
– Obstructive jaundice
– Ulcerative colitis, Crohn’s disease
– Pancreatitis
– Bronchitis, emphysema
– Mildly elevated in smokers
• Main clinical applications
– In surveillance following curative resection of colorectalcancer
– In monitoring therapy in advanced colorectal cance

24. Human Chorionic Gonadotropin (hCG)
• Heterodimer composed of 2 glycosolated sub-units (alpha & betachains)
– Alpha chain is almost identical to alpha chain in TSH, FSH & LH
– Beta chain is distinct from corresponding chains
• Distinctive 24 amino acid carboxy-terminal extension
• Forms in serum: Multiple forms
– Intact 2-chain peptide
– Free alpha and beta chains
– Various degradation products (e.g., beta core fragment)
• Physiological function: to maintain progesterone production by corpus
luteum during early pregnancy
– Can be detected as early as one week after conception

25. hCG
• Malignancies with elevated levels
– Virtually all patients with gestational trophoblastic disease (GTD)
(i.e., complete and partial molar pregnancy, choriocarcinoma and placental
site trophoblastic tumours)
– Non-seminomatous germ cell tumours (NSGCT)
– Seminomatous germ cell tumours of testis (approx. 20%).
• Benign Diseases with elevated levels
– Ectopic pregnancy
– Pituitary adenoma
• Main clinical applications
– For monitoring patients with GTD
– In conjunction with AFP, for determining prognosis and monitoring
patients with NSGCT of testis, ovary and other sites

26. hCG
• Type of sample for assay
– Serum or urine
• Reference range : Serum: 0 - 5 IU/L
• Half life in serum: Approx. 16 - 24 hours; decline may be biphasic
with a second half life of 13 days

27. Prostate Specific Antigen (PSA)
• single chain chymotrypsin-like serine protease containing237
amino acids
• Forms in serum
– PSA complexed with
• A1antichymotrypsin (PSA-ACT) (major)
• A1 -antitrypsin (trace quantity)
• A2 -macroglobulin (undetectable by current immunoassays)
• Non-complexed free form (fPSA) represents 5 - 40% of the“total”
PSA
• Physiological function
– Partially responsible for the liquefaction of semen to promotethe
release and motility of spermatozoa

28. PSA…..
• 5-alpha-reductase inhibitors used to treat BPH reduce PSA levels by
approx. 50%
• Half life in serum: Approximately 2.5 days after radical prostatectomy;
• Reference range: 0 - 4 µg/L (most frequently used)
Effects of urological manipulations on PSAlevels
• DRE: May cause minor increases ; rarely of clinical significance.
• Prostate massage: May cause minor elevations
• TURP: Increases PSA levels significantly. Wait >/=6 weeks before testing
• Needle Biopsy: Increases PSA levels significantly. Wait >/=6 weeks before testing
• Cystoscopy: No change by flexible cystoscopy but rigid cystoscopy may increase levels

29. Prostate Specific Antigen (PSA)
• Main clinical applications
– In combination with digital rectal examination PSA can aiddiagnosis
of prostate cancer
– Determining prognosis in patients with prostate cancer
– Surveillance following diagnosis of prostatecancer
– Monitoring therapy in patients with diagnosed prostatecancer
– As screening tool : Controversial
– No significant reduction in mortality from prostatecancer1
– 20% reduction in mortality but at expense of overdiagnosis2
• PSA Density - Normalized to prostate volume
• PSA Velocity - Change in PSA over time (e.g., more than 15% peryear)
• Free PSA/Total PSA - lower ratio suggests cancer, since more free PSA
from normal prostate is degraded (< 10% - biopsy)

31. Biomarkers in Ca Breast

32. Biomarkers in Ca Breast

33. ER
• ER is a ligand-activated transcription factor belonging to the nuclear
transcription receptor superfamily.
• Two isoforms of ER exist, ER-α and ER-β. ER-α is known to be directly
involved in pathological processes, including breast cancer.
• one of the most informative biomarkers in breast cancer.
• Tumours that express ER are dependent on oestrogen supply for growth
and survival and are generally well-differentiated, less aggressive, and have
a better prognosis

34. • ER-positive tumours have a better prognosis
• Immunohistochemistry (IHC) is the standard assay
• ESMO and ASCO/CAP guidelines recommend the cut-off to define ER-
positive cases as ≥1% ER-positive tumour cells.
• Although the presence of wild-type ER is predictive of benefit from
endocrine treatment, specific mutations in the ER (ESR1) gene appear
to be associated with acquired resistance to endocrine therapy

35. PR
• The original rationale for measuring PR alongside ER was based on
the observation that PR was induced by oestrogen
• Presence of PR was thus proposed as a biomarker for a functional Er
• Unclear role of PR as independent predictor for adjuvant endocrine
therapy
• Several studies in ER-positive patients have reported that it provides
independent prognostic information for predicting the risk of
recurrence
• Expert panels therefore recommend measurement of both ER and PR
in all cases of breast cancer

36. HER2
• Overexpression of HER2 drives tumor growth by constitutive
activating the MAPK and PI3K/AKT signalling pathways, which in turn
enhances cell proliferation, invasion and metastasis
• current utility is mainly for predicting response to anti-HER2 therapy
• Tested by IHC commonly (0+, 1+ negative 2+ equivocal 3+ positive )
• Equivocal results tested by FISH/CISH

37. uPA ; PAI-1
• simpler and less expensive test.
• involves the measurement of 2 proteins by ELISA in extracts of fresh
or freshly frozen breast cancer
• high levels of these 2 proteins have a significantly worse outcome
than those with low levels.
• For patients with lymph node-negative disease, the uPA/PAI-1 test has
been validated using a multi-centre prospective randomized trial
• the ASCO guidelines recommend that if a node-negative patient has
ER/PR-positive, HER2-negative breast cancer, uPA/PAI-1 may be used
to guide decisions on adjuvant systemic therapy

38. Biomarkers in colorectal cancer

39. Biomarkers in colorectal cancer

41. Her 2 in Gastric cancer
• There is mounting evidence of the role of HER2 overexpression in patients with
gastric cancer
• solidly correlated to poor outcomes and a more aggressive disease.
• a higher rate of HER2 expression in intestinal histologic type than in diffuse type
• GEJ cancers express HER2 with more frequency than gastric cancers do.
• In experimental models, trastuzumab suppresses the growth of human gastric
cancer with HER2 overexpression in vitro and in vivo. Potential for targeted
therapies

45. MiRNA in Cancer Diagnosis and
Prognosis

46. MicroRNA Profile in Diagnosis and Prognosis
•miRNAs are small non-coding RNAs which play key
roles in regulating translation & degradation of mRNAs
•Genetic and epigenetic alteration may affect miRNA
expression, thereby leading to aberrant target gene(s)
expression in cancers

47. The role of microRNAs in cancer diagnosis
• With the application of in situ RT-PCR, it was shown that the
aberrantly expressed miR-221, miR-301 and miR-376a were
localized to pancreatic cancer cells but not to stroma or normal
acini or ducts.
• Aberrant miRNA expression offered new clues to pancreatic
tumorigenesis and might provide diagnostic biomarkers for
pancreatic cancer.

48. The role of microRNAs in cancer prognosis
• The expression pattern of miRNAs in pancreatic cancer were
compared with those of normal pancreas and chronic
pancreatitis using miRNAmicroarrays.
• Differentially expressed miRNAs were identified which could
differentiate pancreatic cancer from normal pancreas, chronic
pancreatitis, or both.
• High expression of miR-196a-2 was found to predict poor
survival of more than 24 months

49. The role of microRNAs in cancer prognosis
• Expression of let-7 miRNA was frequently reduced in
human lung cancers, and that reduced let-7 miRNA
expression was significantly associated with shorter
postoperative survival.

50. microRNAs Tumorigenesis Diagnosis Prognosis
miR-9
miR-10b
miR-15, miR-15a
miR-16, miR-16-1
miR-17-5p, miR-17-92
miR-20a
miR-21 Pancreatic
cancer
Neuroblastoma
miR-29, miR-29b
miR-31
miR-34a
miR-96
miR-98
miR-103
miR-107
miR-125a, miR-125b
miR-128
miR-133b
miR-135b
miR-143
miR-145
miR-146
Neuroblastoma
Breast cancer
Leukemia, pituitary adenoma
Leukemia, pituitary adenoma
Lung cancer, lymphoma
Lymphoma, lung cancer
Breast cancer, cholangiocarcinoma, head & neck
cancer, leukemia
Leukemia, cholangiocarcinoma
Colorectal cancer
Pancreatic cancer
Colorectal cancer
Head & neck cancer
Pancreatic cancer
Leukemia, pancreatic cancer
Neuroblastoma, breast cancer
Glioblastoma
Colorectal cancer
Colorectal cancer
Colon cancer
Breast cancer, colorectal cancer
Thyroid carcinoma

51. Markers of
Pharmacogenomics
• Difference due to :
– Inherited, germ-line differences in genes either responsible for
• Metabolism of drugs
• Target of drugs
– Play important role in assessing benefits & risks for specific
therapeutic strategies

52. Some Examples
Drug Enzyme /genes Effect
5 fluorouracil/capecitabine dihydropyrimidine
dehydrogenase (DPD)
Increased side-effects if
defective enzymes
6-mercaptopurine, 6-
thioguanine, azathioprine
Thiopurine
methyletransferase (TPMT)
Increased side-effects if
defective enzymes
Tamoxifen CYP2D6 Lack of efficacy
Irinotecan UGT1A1 Increased side-effects if
defective enzymes
Gemcitabine,Ara-C NT5C3, FKBP5 (genes) Increased expression
associated with better
response

54. CTCs, ctDNAs : Liquid Biopsies
• Estimated half life of CTCs : 1 to 2.4 hrs
• Released both via passive tumor shredding & active dynamic
intravasation
• CELL SEARCH system used to detect CTCs
• Used for prognostication (breast cancer) , response to therapy
assessments (prostate), monitoring early disease

64. Vascular Access

65. CENTRAL ACCESS
EXTERNAL
CATHETERS
NONTUNNELED
DEVICES
TUNNELED
CATHETERS
PERIPHERALLY
INSERTED
CATHETERS (PICC)
IMPLANTABLE
DEVICES
PORTS INFUSION PUMPS

66. Indications for central vascular access
• Nutrition
• Vasopressor support
• Haemodialysis
• Central pressure monitoring
• Peripheral access not available
• Prolonged hospitalization with long duration of intravenous access
requirements
• Chemotherapy

67. Contra indication to central venous access
• NO ABSOLUTE C/I
• RELATIVE C/I :
• Coagulopathy
• Platelet dysfunction
• Ongoing local site infection
• Venous thrombosis

68. External catheters : nontunneled
• used for acute central venous access
• the simplest and fastest to place.
• typically used in the short term and are safe for up to 14 days of use.
• direct entrance through the skin  have an increased rate of local
and catheter-based infections.

69. External catheters : tunneled
• creation of a subcutaneous tunnel, which the proximal portion of the catheter traverses from the insertion
site to the venepuncture.
• This limits movement of the catheter and decreases catheter infection by increasing the natural barrier
distance from skin entry site and the vein.
• Additionally, tunneled catheters have a Dacron cuff affixed to the catheter located near the skin entry site.
• allows further fixation of the catheter by promoting tissue ingrowth in the subcutaneous tract
• E.g. Hickman, Broviac, Leonard, and Groshong
• Attempts at decreasing the rate of infection :
• cuffs that are impregnated with bacteriostatic agents such as silver or antibiotics
• catheters treated with these agents
• two-way valves that function to reduce reflux of blood into the lumen
• No proven benefit
• Can be removed at bedside

71. Internal JugularVein
Right side preferred-lower pleural dome and thoracic ducton
left
Trendelenburg position(10-15 degrees)
Head rotated approximately 150 to the left
At the cricoid level while palpating the carotid pulse,
introducer needle into the apex of the sternocleidomastoid-
clavicular triangle at a30-400 angle to the skin.Aim the needle
caudally towards the patient’s ipsilateralnipple.

72. SubclavianVein
Right side preferred
- Supine position, head neutral, armabducted
- Trendelenburg position (10-15degrees)
- Shoulders neutral with mildretraction
Junction of the medial and middle thirds of the clavicle.
The site of needle insertion lies about 1 cm inferior to the
clavicle allowing for the needle to passunder the clavicle.
• Needle should be parallel to skin
• Aim towards the supraclavicularnotch

74. FemoralVein
Supine/Flat position
Palpate the femoral artery’s pulse just distalto
the inguinal ligament.
Thefemoral vein lies just medial tothis.

75. Seldingertechnique
Useintroducing needleto
locate vein
Wire is threadedthrough
the needle
Needle isremoved
Skinand vesselare dilated
Catheter is placedover
the wire
Wire is removed
Catheter is securedin
place

76. US guided CV line insertion
: brief six step approach

77. PICC
• a long silastic catheter can be inserted from the peripheral upper extremity veins and terminate
at the superior vena cava (SVC).
• basilic vein being the most preferred site
• it is relatively superficial and has the largest diameter,
• the straightest route to the SVC
• the greatest blood flow of the peripheral arm veins.
• the cephalic, medial cubital, and brachial are also options for access.
• should be placed above the antecubital fossa to limit mechanical issues related to movement at
the joint.
• avoids the risk of a pneumothorax or vascular injury

78. • similar rates of catheter-based infections
• increased thrombotic complications compared to centrally placed
catheters
• longer course to the SVC : PICCs have increased resistance ; less
suitable for rapid infusions.
• Midline PICC catheter :
• shorter in length and typically range from 8 to 20 cm and terminate no further
than the proximal axillary vein.
• should not be used for longer than 30 days.
• Short- to moderate-term use of total parenteral nutrition, antibiotics, and
chemotherapies can be safely administered via a midline catheter

79. Implantable Ports
• Catheter portion of the device is the same as external devices
• The access port, surgically implanted in a subcutaneous pocket and
connected to the catheter.
• This port is then accessed by percutaneous puncture.
• Designed with either nonferrous metal or plastic housing also called
the “portal” and a central silicone diaphragm
• Silicone allows for puncture via a specialized Huber needle that is
noncoring.
• The needle tip should be pushed until it makes contact with the back
wall of the diaphragm.

81. Power-ports
• ability for rapid infusion for contrast-enhanced computed
tomography (CT) scans.
• CT regularly used for re-evaluation and follow up assessments;
selection of a “power” port affords convenient and reliable access.
• Ports such as Power Port allow for rapid infusion rates of up to 5 mL
per second via the port and eliminates the need for peripheral access.

82. Advantages of chemo port
• long-term durable access
• The port is low maintenance, is low profile
• Good cosmesis
• Subcutaneous placement allows for a natural skin barrier
• prevents exposure of hardware

83. Implantable infusion pumps
• Continuous infusion implantable pumps allow for self-contained mobile delivery of treatment.
• a central venous catheter is connected to a sealed chamber.
• This chamber is implanted in a subcutaneous pocket in the abdominal subcutaneous tissue.
• These devices also contain a silicone diaphragm that is accessed through a Huber needle.

84. • it leads to a larger reservoir where a volume of the infusate can be filled. Surrounding the
reservoir is chamber filled with gas-phase fluorocarbon.
• When the reservoir is filled, the gas is compressed and transitions to its liquid state.
• The pressure of the compressed gas exerts a constant measurable force as its slowly transitions
back to a gas state.
• These pumps can be attached to other catheters and are useful for other application such as
intrathecal analgesia, insulin, parenteral nutrition, or intraarterial chemotherapy.
• In addition to these pumps, on-demand, motor-driven implantable pumps offer the advantage of
changes to delivery rate.
• In the case of continuous arterial chemotherapeutic infusion, surgical cannulation of the
gastroduodenal artery connected to an implanted pump allows higher concentrations of
chemotherapies into the hepatic arterial circulation.

86. Bits and pieces
• Not to use syringe less than 10 ml
• Pressure not greater than 25 psi
• MRI safe & nonsafe varities individual port type
• Two to six years durability
• To be flushed every 4 to 6 weeks

88. Tip position and path

89. Pinch off syndrome

90. Complications of central venous access
devices
• Immediate
• Pneumothorax 1-30% MC : Subclavian
• Vascular injuries <1% MC : Femoral
• Arrythmias
• Venous Thrombosis
• Up to 50%
• 5-10%symptomatic
• Altered flow dynamics, infection induced endothelial injury
• No recommendations for prophylactic anticoagulation

91. Airembolism
Deadly complication associated with CVC’s
Signsand Symptoms
Respiratory changes: sudden shortness of breath,
cyanosis
CVSchanges: sudden onset of chest pain, ↑HR,
↓BP
CNSchanges: altered neurological signs, dizziness,
confusion, loss of Consciousness

92. Management
Left lateral decubitus with head low Position(Durant
maneuver and Trendelenburg position)
Clamp the Central VenousCatheter
100%O2
Direct removal of air from the venous circulation by
aspiration from acentral venous catheter in theright
atrium may be attempted

93. Tominimize the chance of air enteringthe system:
Ensurethe lumen is clamped prior to openingthe
system
Position the patient sothat the insertion siteis at
or below the level of the heart during insertion
and removal of catheter

94. Port related / catheter related complication
• Catheter kinking
• Catheter breakage
• Chamber leakage
• Silicone membrane coring
• Pinch off syndrome
• Positional flow
• Too deep/ too superficial

95. CLABSI