This document defines key terms related to cancer biomarkers. It describes cancer as abnormal cell growth and discusses cancer staging and tumor markers. Biomarkers are defined as indicators of biological processes that can be tested from bodily fluids or tissues. Common tumor markers are described, including alpha-fetoprotein, cancer antigen 125, carcinoembryonic antigen, human chorionic gonadotropin, and prostate-specific antigen. The roles of these markers in cancer screening, diagnosis, staging, prognosis, and monitoring treatment are summarized.

1. KEY WORDS AND DEFINITIONS
 Cancer: A relatively autonomous growth of
tissue.
 Cancer Staging: The process by which cancer is
divided into groups of early and late disease;
 useful for prognosis and guiding therapy.
 Carbohydrate Tumor Marker; Antigens
containing a major carbohydrate component
usually found on the surface of cells or secreted by
cells (e.g., mucins or blood group antigens).

2. KEY WORDS AND DEFINITIONS
 Ectopic Syndrome: Production of a hormone by
nonendocrine cancerous tissue that normally does
not produce the hormone (e.g., ADH production
by small-cell lung carcinoma).

3. KEY WORDS AND DEFINITIONS
 Oncofetal Antigen: Proteins produced during
fetal life that decrease to low or undetectable
concentrations after birth.
 They reappear in some forms of cancer because of
the reactivation of a gene in the transformed
malignant cells.

4. KEY WORDS AND DEFINITIONS
 Oncogene: A mutated normal cellular gene (proto
oncogene) that causes the malignant transformation
of normal cells when activated.
 Prognosis: A prediction of the future course and
outcome of a patient's disease based on currently
known indicators

5. KEY WORDS AND DEFINITIONS
 A carcinogen :is an agent that causes cancer.
 A carcinogen may be
 physical (e.g., radiation),
 chemical (e.g., a polycyclic hydrocarbon), or
 biological (e.g., a virus).

6. KEY WORDS AND DEFINITIONS
 Exposure to such an agent may cause cancer
either by producing
 direct genotoxic effects on deoxyribonucleic
acid (DNA) (e.g., as with radiatation) or
 by increasing cell proliferation (e.g., by a
hormone), or
 both (e.g., through the use of tobacco).

7. KEY WORDS AND DEFINITIONS
 Metastatic cancer is cancer that has spread from
the place where it first started to another place in
the body.
 Metastatic cancer has the same name and same
type of cancer cells as the original cancer.
 The most common sites of cancer metastasis are,
in alphabetical order, the bone, liver, and lung.

8. What is Cancer ?
Application of Proteomics in Cancer Research
Tumors: loss of cell cycle control
 de-differentiation and proliferation
benign: encapsulated by connective tissue
rarely life-threatening
malignant: invasive growth
cell shedding  metastasis cancer
life-threatening

9. Application of Proteomics in Cancer
Research
 Molecular basis of cancer
 Causes of cancer: - carcinogens, radiation, viruses, random
- hereditary vs. spontaneous tumors
- multi step process
 Genes and gene products involved in cancer:
 activation of proto-oncogenes to oncogenes
(gain-of-function)
 inactivation of tumor suppressor genes (loss-
of-function)
 altered activity of modulator genes

10. Characteristics of cancer cells
Application of Proteomics in Cancer Research
• general changes: - loss of division limits (immortality)
- uncontrolled proliferation
• genetic changes: - point mutations …
- chromosomal changes
• structural changes: - less organized cytoskeleton
- increased membrane fluidity
• biochemical changes: - altered protein expression
- altered protein modification

11. Cancer facts and treatment
Application of Proteomics in Cancer Research
• > 100 different types of human cancer
•  20 % of the mortalities in industrialized nations
detection  classification and localization
imaging
histology
biomarker
s
surgery
radiation
chemotherap
y
 therapy

12. What is a biomarker?
 Gives us the ability to analyze organ function,
diagnose diseases in a non-invasive way.
 Biomarkers can be any molecule (organic or
inorganic) that acts at the test subject while the
patient is the host to a biological process.
 Biomarkers can be tested from bodily fluids
(blood, urine) or from tissues.

13. Importance
 Biomarkers give scientists and doctors the
ability to ‘work backwards’ and asses organ
function.
 Cancer biomarkers can identify genetic
variations or mutations as well as changes in
gene or protein expression that can be linked to a
disease state or a response to a medical
intervention

14. Uses
Biomarkers can be used to:
• confirm diagnosis of acute or chronic disease
• assess the effectiveness of treatment
• evaluate the prognosis of individual cases.

15. Biomarkers in Cancer Detection
 The Early Detection Research Network has put
growing focus on discovering and validating
biomarkers in their use to diagnose cancer in its
early stages.
 Many patients are diagnosed in late stages of
cancer and it may be too late.
 Could be a huge breakthrough for science if this
non-invasive method can test for cancer.

16. What are tumor markers
 Definition: -
– A tumour marker is a biochemical indicator
selectively produced by the neoplastic tissue
and released into blood and detected in blood
or in other body fluids.
 It may be used to: -
– Detect the presence of a tumour (Diagnosis)
– Monitor the progress of disease
– Monitor the response to treatment
– Prognosis

17. Tumor Markers
• Generally cannot be used alone to diagnose
cancer – must be used with other methods such
as biopsy

18. Characteristics
 Produced exclusively by a cancer cell as a
response to tumor development
– Sensitivity
 Not exclusively by a cancer cell, but has a
sufficient quantities to be distinguished from
production by a normal tissue cell
– Specificity

19. An ideal tumor marker
 The quality should be included
– High sensitivity
– High specificity
– Can be quantified
– Safe
– Convenience
– Low price

20. How to identify tumor marker ?
 On cell
– Cytochemistry, Flow cytometry
 On tissue
– Histochemistry, Cytosol assays
 In body fluids
– Blood, urine, CSF, Amniotic fluid

21. Tumor marker in Oncology
 Screening
 Diagnosis
 Staging
 Prognosis

22. Screening
 Tumor markers play a limited role for tumor
screening, just because….
– relatively low sensitivity
– lack of specificity and relation to tumor size
 Inappropriate for the detection of small in situ
cancer
 In some cases, tumor markers can be equal to
other examinations envisioned for screening
– PSA & prostate cancer
– calcitonin & medullary thyroid cancer

23. Diagnosis
 Tumor is not the key diagnostic examination, but
can be a complementary sign to clinical finding
or medical imaging
– AFP & hepatoma
 Sometimes implicate the existence within the
tumor of an exclusive secretary histological
contingent
– NSE (neurone specific enolase) &
SCLC (small cell lung cancer)

24. Staging
 The tumor markers and medical imaging are
complementary in the pre-therapeutic and post-
therapeutic staging

25. Prognosis
 The pre-therapeutic level of certain tumor
marker can contributes a prognostic factor
because of links with...
– Metabolic activity
– Tumor size
– Invasion
 More valuable in that it is independent or other
usual prognostic factors for the pathology

26.  Allow doctors to refine therapeutic strategy by
selecting groups with risk of failure to response
to treatment
 This property is one of the major aspects of
current use of the tumor marker
– CEA & colon cancer
– CA19-9 & pancreatic cancer
– CYFRA 21-1(Cytokeratin 19 Fragment) & lung
squamous cell cancer

27. During treatment
 High markers level before treatment generally
– Not only correlate very well with the therapeutic
result but are sometimes superior to this result in the
assessment of complete remission
 The assay must be taking into account the
marker half-life when during treatment and all
post-therapeutic re-evaluation

28. During treatment
 Contribute to a valuable mean and lead to
suspicion for...
– local or metastasis
– curable recurrence
– much earlier before clinical or radiological detection
 The protocol of the follow-up must be very strict
– CA15-3 measured every 3 months for 1 year and
then every 6 months in breast cancer patient

29. Tumour Markers: - Classification
 Class 1: Antigens unique to a neoplasm not
shared by other tumours of same histological
type .
 Class 2: Antigens expressed by many or most
tumours of a specific histological type and of
other histological type,
– But not expressed by normal adult tissue.
 Class 3: Antigens expressed by both cancer and
normal adult tissue.

30. NATURE OF TUMOUR
MARKERS
 1.Oncofetal antigens
– Alpha Feto Protein
– CEA
– Pancreatic Oncofoetal Antigen
 2.Proteins
– Casein – By breast carcinoma
– Ferritin- Leukaemia
 3.Enzymes
– Creatine kinase (BB) – Prostate tumour
– Alkaline Phosphatase – Lungs tumour
– Acid Phosphatase – Prostate tumour

31. 4. Receptors
– Oestrogen, Progesterone, Androgen
5. Polyamines
– Spermine, Spermidine, Putridine – leukemia,
lymphoma, colorectal CA
6. Cell Markers
– T cell marker, B cell marker-lymphoma
7. Ectopic Hormones
– HCG, GH, Erythropoetin, Renin

32. Common Tumor Markers
 Alpha-fetoprotein
 CEA
 CA-19.9
 PSA
 CA-125
 -hCG
 VMA
 CA-15.3
 Estrogen receptor
 Progesterone
receptor
 HER-2/NEU
 BRCA1
 BRCA2
 p53

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EKUSILENI CLINICAL
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34. Alfa Feto Protein:-
 After birth AFP usually falls, within 8 to 12
months of delivery to a very low conc. of
10mcg/ml and persists at this low level
throughout life.
 Unexplained and persistent elevation of AFP in
nonpregnant state should be screened, as it may
be due to-
– Hepatocellular Ca, germ cell tumour, hereditary
persistence of AFP, viral hepatitis and cirrhosis .
 In addition to its role in prenatal diagnosis, it is
also widely used in the diagnosis, therapeutic
monitoring and follow up of patients in germ cell
tumours.

35. Germ Cell Tumours Producing AFP
AFP
1. Dysgerminoma --
2. Endodermal Sinus tumour / +
yolk sac tumour
3. Immature tetratoma +/-
4. Mixed germ cell tumour +/-
5. Choreocarcinoma --
6. Embryonal CA --

36. Alpha feto protein (-FP)
 Introduction:
– Oncofetal antigen
– Abundant serum protein normally
synthesized by the fetal liver
– Re-expressed in certain types of tumors

37. AFP continued…
 Clinical Applications:
– Diagnosis, prognosis, and treatment monitoring
of hepatocellular carcinoma (HCC; hepatoma)
– Screening (High-risk; HBV or HCV patients)
– AFP is not completely specific for HCC
– AFP might be increased in pregnancy & benign
liver disease

38. AFP continued…
 AFP be used in conjunction with ultrasound every
6 months in patients at high risk of developing
HCC
 Patients with hepatitis B virus- and/or hepatitis C
virus-induced liver cirrhosis
 Lead period i.e., early detection which is ~ 6
months before clinical manifestations

39. AFP continued…
 A tumor marker for classification and
monitoring therapy for nonseminomatous
testicular cancer
“in combination with -human chorionic
gonadotropin (-hCG)”

40. Cancer Antigen 125 (CA-125)
– Detection of ovarian tumors at an early
stage
– monitoring treatments without surgical
restaging
– CA-125 is not specific for ovarian cancer, as
it may be elevated in:
 Menstruation
 First trimester of pregnancy
 Endometriosis

41. CA-125, continued…
– Currently, CA-125 is the only clinically
accepted serologic marker of ovarian
cancer

42. Carcinoembryonic Antigen
(CEA)
 Introduction:
– CEA is an oncofetal antigen
– It is expressed druing development and then
re-expressed in tumors
– It is the most widely used tumor marker for
colorectal cancer

43. CEA, continued…
 Clinical Applications:
– The main clinical use of CEA is as a tumor
marker for colorectal cancer
– In colon cancer, CEA is used for prognosis, in
postsurgery surveillance and to monitor
response to chemotherapy

44. CEA:-
 It is a glycoprotein of mol.wt 200kda.
 Though it is a tumour marker for GI cancers, it is
also expressed by
– malignant mucinous tumor (100%),
– 100% cases of atypical hyperplasia of endometrium,
– 60% cases of endometrial Ca.
– 50-80% cases of squamous cell of Cx,
– 75-100% cases of adenocarcinoma of Cx.
 It is also produced in pneumonia,
hypothyroidism and pancreatic tumours.

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EKUSILENI CLINICAL
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46. Human Chorionic
Gonadotropin (hCG)
 Introduction:
– hCG is a hormone normally secreted by
trophoblasts in the placenta during
pregnancy
– It is a glycoprotein consisting of - and -
subunits

47. hCG, continued…
 Clinical Applications:
– Detection and follow-up of gestational
trophoblastic diseases (GTDs)
– GTDs include:
 Hydatiform mole (vesicular mole)
 Choriocarcinoma
– It is also elevated in nonseminomas testicular
cancers

48. Molar pregnancy
 Molar pregnancy is an abnormal form
of pregnancy in which a non-viable fertilized
egg implants in the uterus and converts a normal
pregnancy into an abnormal one (which will fail
to come to term.
 A molar pregnancy grows into a mass in the
uterus that has swollen chorionic villi.

49. Molar pregnancy
 These villi grow in clusters that resemble
grapes.
 A molar pregnancy can develop when an
egg that is missing its nucleus is fertilized
and that may or may not contain fetal tissue

50. Choriocarcinoma
 Choriocarcinoma is a malignant, trophoblastic
cancer, usually of the placenta
 It is characterized by early hematogenous
spread to the lungs

51. Prostate Specific Antigen (PSA)
 Introduction:
– PSA is a glycoprotein produced by the
epithelial cells of the acini and ducts of the
prostatic ducts in the prostate
– PSA is a serine protease

52. PSA, continued…
– There are 2 major circulating forms of PSA:
Free
Complexed:
–Complexed to 1-antichymotrypsin or 2-
macroglobulin

53. PSA, continued…
 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

54. PSA, continued…
 To increase the accuracy of the PSA testing, age-
adjusted cutoff values of PSA can be used
 Elevated PSA can be found also in:
– Prostate infection
– Pelvic congestion
– Benign prostatic hyperplasia (enlargement)

55. Common Cancer Terms
Angiogenesis Development of new blood vessels to supply
oxygen and nutrients to cells
Physiological Pathological
The process is transient and tightly
regulated
e.g., Wound healing, Pregnancy,
Menstruation, development
The process is persistent and out of
control
e.g., tumorogenesis & Metastasis
Marker for angiogenesis: e.g.,
Vascular Endothelial Growth
Factor (VEGF)
Follow-up & treatment of
angiogenic cancer
Treatment can target more than
one tumor type

56. HER-2/NEU
 Encodes an Epidermal Growth Factor Receptor
(EGF-R)
 HER2 (from human epidermal growth
factor receptor 2).
 A proto-oncogene that is converted to oncogene
by:
– Mutation (especially point mutation) or
– Altered (over) expression
 Marker for breast and ovarian cancers

57. HER-2/NEU
 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)
– Tests are usually performed on biopsy samples obtained
by either fine-needle aspiration, core needle
biopsy, vacuum-assisted breast biopsy, or surgical
excision.
– Immunohistochemistry is used to measure the amount of
HER2 protein present in the sample.
Alternatively, fluorescence in situ hybridisation (FISH) can
be used to measure the number of copies of the gene
which are present.

58. Tumor suppressor genes, e.g.,
p53
Tumor
suppressor gene
Encodes a protein involved in protecting
cells from unregulated growth
 The gene is located on chromosome 17 (Plus the
genes of BRCA1 and HER-2/NEU)
 Encodes a protein of 53 kDa
 Encodes a protein that normally result in cell
cycle arrest and induces apoptosis
 Upon mutation: loss of function mutation 
cancer

59. Estrogen and Progesterone
Receptors
 Estrogen and progesterone receptors are used in
breast cancer as indicators for hormonal therapy.
 Patients with positive estrogen and progesterone
receptors tend to respond to hormonal treatment.

60. Estrogen and Progesterone
Receptors
 Those with negative receptors will be treated
using other therapies, such as chemotherapy.
 Hormone receptors also serve as prognostic
factors in breast cancer.
 Patients positive for estrogen and progesterone
receptors have a better prognosis.

61. Estrogen and Progesterone
Receptors: Analytical Methodology
 Immunocytochemical assays are used to measure
steroid hormone receptors.
 Immunocytochemical assays use monoclonal
antibodies to detect steroid receptor proteins in;
 frozen tissue sections,
 paraffin imbedded tissue,
 fine,needle aspirates, and
 malignant effu sions.

62. CA125 cancer-antigen 125
 Reference value
– 95% general population < 35 U/ml
 Indication: ovarian cancer
– High sensitivity to serous adenocarcinoma,
lower to mucinous adenocarinoma (associated
with CEA and CA72-4)
– Screening
 not suggested for ovarian cancer but for ovarian
tumor
–Follow-up:
 Post-op: tumor residues is good response to
CA125

63.  Second look surgery: CA125 increase means bulky
peritoneal residues or metastasis, but normal CA125
does not exclude the second look surgery
 Early detection of recurrence: increased more than
50% of CA125 level precedes the clinical diagnosis
of recurrence
 Non-specific increases
– Liver cirrhosis with ascites
– Pleural effusion
– Peritonitis and Pericarditis
– During menstruation
– Third trimester
– Endometriosis
– Ovarian cysts

64. CA15-3 cancer antigen 12-3
 Reference value
– 98.7% general population < 30 U/ml
 Indication: breast cancer
– Most specific tumor marker
– At the time of suspected breast cancer
 Unable to detect localized or metastatic breast cancer
– Prognostic value
 CA15-3 > 50 U/ml = high suspicion of metastasis with poor
prognosis

65. – Follow-up: 6 weeks after surgery
– Clinical follow-up
 3yrs a year then every 6 months
 > 50% of reference value predict reccurence or metastasis
 The association of CA15-3 and CEA assays = increase
sensitivity by 10%
 Monthly assay during chemotherapy in metastasis stages
 High correlation with the clinical response to treatment
 Non-specific increases
– Liver cirrhosis, acute hepatitis, severe chronic
hepatitis (< 50 U/ml)
– Other metastasis: pancreas, ovary, colorectal, lung,
stomach and uterus = rarely > 50 U/ml except
pancreas adenocarcinoma

66. CA19-9 carbohydrate antigen
19-9
 Reference value
– 99.6% general population < 37 U/ml
 Indication
– Digestive tract carcinoma
 Pancreatic and biliary tract cancer: sensitivity 85%,
specificity 95%
 Colorectal cancer: associated with CEA
 Gastric cancer: associated with CEA and CA72-4
– Follow-up
 Monthly assay during the first year, then every two months
during two years, then every six months
 CA19-9 > 1000 ng/ml indicates the metastasis

67. – Remarks
 Combination of CEA and CA19-9 increase the early
diagnostic rate to 90% in patient with high risk with a
mean lead time of 4-6 months before clinical response
 No relation associated with tumor size
 Non-specific increases: benign pathology
– Lung: acute cystic fibrosis
– Digestive tract:
 10% of cholecystitis and 8% of pancreatitis (< 3 times of
normal value)
 Liver cirrhosis
– Other metastatic adenocarcinoma
 usually < 3 times of normal value

68. SCC squamous cell carcinoma
associated antigen
 Known as TA-4 (SCC antigen)
 Origin
– Separate and purify from cervical epithelial cell
 Reference value
– < 1.5 ng/ml
 Indication: SCC, especial in cervical cancer
– > 2.5 ng/ml in 53.6% of cervical cancer

69. – Increase according to the disease progression an
d stage
– Follow-up
Should downhill to normal range within 72
hours after operation
Increasing persist indicating incomplete
resection
– Remark
TA-4 in Lung SCC is 3-4 times to normal
range, but is normal in other types of lung
cancer
Helping tracing tumor and early diagnose in
recurrence

70. CT Calcitonin
 Reference value
– 99% general population < 10 ng/ml
 Indication: Medullary thyroid cancer
– Screening and diagnosis
 very sensitive in screening and early diagnosis in high risk
group ( familial and multiple endocrine neoplasia)
– Follow-up
 Therapy follow-up: repeat assay after operation,
high level indicates incomplete resection or
metastasis
 Clinical follow-up: monthly assay, then every
three months

71.  Non-specific increases
– Neuroendocrine tumors: pheochromocytomas,
carcinoid tumors
– Digestive tract and pancreatic endocrine
tumors
– SCLC (Small Cell Lung Cancer)
– Differentiated thyroid cancer (< 5% of cases)
– Benign condition
 CRF, hyperparathyroidism, paget’s bone disease

72. Conclusion
 The tumor markers contribute to cancer
detection, diagnosis and prognosis is
unquestionable, but they need to be estimated
considerably
 The tumor markers in oncology should be used
depending on knowledge and clinical experience

73. Recommended Tumor Markers
for Specific type of Cancers
Tumor Tumor markers
1. Hepatoma
(HCC)
AFP
2. Ovarian
Cancer
 CA-125
 Inherited ovarian cancer: BRCA1
3. Breast
Cancer
 CA15-3
 CEA
 HER-2/NEU
 Estrogen and progesterone receptors
If inherited: BRCA1, and BRCA2 (on
chromosome 13)

74. Recommended Tumor Markers
for Specific type of
Cancers….continued
Tumor Tumor markers
4. Cancer head of the pancreas CA 19-9
CEA
5. Colorectal carcinoma CEA
CA 19-9
6. Pheochromocytoma Vanillylmandelic Acid
(VMA) in urine

75. Recommended Tumor Markers
for Specific type of
Cancers….continued
Tumor Tumor markers
7. Nonseminomatous
testicular cancer
AFP
-hCG
CEA
8. Vesicular mole &
Choriocarcinoma
-hCG
9. Prostate cancer PSA

76. Benign conditions that may cause
rises (some transient) in serum
tumour marker levels that may lead
to incorrect interpretation
 Acute cholangitis (CA19-9)
 Acute hepatitis (CA125, CA15-3)
 Acute and/or chronic pancreatitis (CA125, CA19-
9)
 Acute urinary retention (CA125, PSA )
 Arthritis/osteoarthritis/rheumatoid arthritis
(CA125)
 Benign prostatic hyperplasia (PSA)

77.  Cholestasis (CA19-9)
 Chronic liver diseases such as cirrhosis, chronic
active hepatitis (CA125, CA15-3,CA19-9,
carcinoembryonic antigen (CEA))
 Chronic renal failure (CA125, CA15-3, CEA,
human chorionic gonadotrophin)
 Colitis (CA125, CA15-3, CEA)
 Congestive heart failure (CA125)

78.  Cystic fibrosis (CA125)
 Dermatological conditions (CA15-3)
 Diabetes (CA125, CA19-9)
 Diverticulitis (CA125, CEA)
 Endometriosis (CA125)
 Heart failure (CA125)

79.  Irritable bowel syndrome (CA125, CA19-9,
CEA)
 Jaundice (CA19-9, CEA)
 Leiomyoma (CA125)
 Liver regeneration (α fetoprotein)
 Menopause (human chorionic gonadotrophin)
 Menstruation (CA125)

80.  Non-malignant ascites (CA125)
 Ovarian hyperstimulation (CA125)
 Pancreatitis (CA125, CA19-9)
 Pericarditis (CA125)
 Peritoneal inflammation (CA125)
 Pregnancy (α fetoprotein, CA125, human
chorionic gonadotrophin) Prostatitis (PSA)

81.  Recurrent ischaemic strokes in patients with
metastatic cancer (CA125)
 Respiratory diseases such as pleural inflammation,
 pneumonia (CA125, CEA)
 Sarcoidosis (CA125)
 Systemic lupus erythematosus (CA125)
 Urinary tract infection (PSA)