tumor markers

1. MONITOR THE DYNAMICS OF
TUMOR RESPONSE TO
THERAPY
BY
SUMMAR ELMORSHIDY
ASSISTANT LECTURER OF CLINICAL
ONCOLOGY
CLINICAL ONCOLOGY DEPARTMENT
ASSIUT UNIVERSITY

3.  TUMOR MARKER is produced by a tumor or by
the host in response to a tumor which is used
to differentiate a tumor from normal tissue or to
detect the presence of a tumor based on
measurements in blood or secretions.
 They are found in cells, tissues or body fluids.
 Measured qualitatively or quantitatively by
chemical immunological or molecular biological
methods.
 They are biochemical or immunologic
counterparts of differentiation states of tumor.

4.  Cancer a multigene disease (cluster of
diseases)which arises as a result of mutational
& epigenetic changes coupled with activation of
complex signaling networks.
 It involves alteration of three main classes of
genes – 1)ProtoOncogenes 2)Tumor
suppressor genes 3) DNA repair genes.
 This contribute to development of cancer
genotype & phenotype.
 This alterations resist the natural & inherent
death mechanisms embedded in
cells(apoptosis) coupled with dysregulation of
cell proliferation events.

5.  These genetic alterations include gene
rearrangements, point mutations & gene
amplifications leading to disturbances in
molecular pathways regulating cell
growth, survival & metastasis.
 When these changes manifest in majority
of patients with specific type of tumour
this can be used as tumour markers (
Biomarkers ) .

7.  This new tumor markers include a broad
range of biochemical entities such as:
1. nucleic acids
2. proteins
3. sugars
4. lipids
5. small metabolites
6. cytogenetic & cytokinetic parameters
7. whole tumor cells
8. cancer stem cells

8. Ideal Tumour Marker should
be….
Highly specific i.e. detectable in only one tumor,
not detectable in benign disease and healthy subjects
 Highly sensitive i.e. detectable when only a few cancer
cells are present
 specific to a particular organ
 Correlate with the tumour stage or tumour mass
 correlate with the prognosis
 have a reliable prediction value
 But ideal tumour marker doesn’t exists

9. Clinical applications of tumor
markers
screening Diagnosi
s
prognosi
s
Monitor
of
treatme
nt
Diagnos
is
Detectio
n of
recurren
ce

10. Types of tumor markers
 Cell surface markers: essential for typing and diagnosis of certain
malignancies An important example is the cluster of differentiation(CD)
antigens on cells which are useful in diagnosis of haematological malignancies
 Hormones :
HUMAN CHOROINIC GONADOTROPIN : CHORIOCARCINOMA,
EMBRYONAL
CALCITONIN :MEDULLARY CA THYROID
VASOACTIVE INTESTINAL PEPTIDE :PHEOCHROMOCYTOMA,
NEUROBLASTOMA
ACTH :CUSHING’S SYNDROME,LUNG CANCER
 cancer Antigens: CA 125, CA15-3, CA 19-9

11.  Enzymes:
ALKALINE PHOSPHATASE :BONE, LIVER
LEUKEMIA
PROSTATIC ACID PHOSOHATASE
:PROSTATE
NEURON SPECIFIC ENOLASE : SMALL CELL LUNG
CANCER,
NEUROBLASTOMA,MELANOMA
LACTATE DEHYDROGENES : LYMPHOMA ,
LEUKEMIA
 Oncofetal Proteins:
 AFP : HEPATOCELLULAR ,GERM CELL TUMOR,
 CEA : COLORECTAL, GASTROINTESTINAL, LUNG, BREAST
,PANCREATIC
 Receptors: ER ,, PR: indicators of hormonal

12. Genetic :
 Sister chromatid exchanges & translocations give
rise to structural aberrations are scored using
various banding techniques. Philadelphia
chromosome is associated with CML due to
translocation between chromosomes 9 & 22.
 Mutations & loss of heterozygosity within several proto-
oncogenes can lead to microsatellite instability .
Detection of this MSI in pathological tissue samples &
comparison with normal tissue represents a valuable
tool for early detection , at pre neoplastic stage.

13. Classification according to Potential
uses for cancer biomarkers
 Estimate risk of developing cancer
:BRCA1germline
mutation (breast and ovarian cancer)
 Screening : Prostate specific antigen
(prostate cancer)
 Differential diagnosis :Immunohistochemistry
to determine tissue of origin
 Determine prognosis of disease 21 gene
recurrence score (breast cancer),,,,KRAS
mutation and anti-EGFR antibody (colorectal
cancer)

14.  Predict response to therapy HER2 expression
and anti-Her2 therapy (breast and gastric)
Predict response to therapy,,,,,Estrogen receptor
expression (breast cancer)
 Monitor for disease recurrence:CEA (colorectal
cancer) AFP, LDH, βHCG (germ cell tumor)
 An important distinction should be made
between biomarkers and targets, since in
many cases these are not equivalent. For
example, as mentioned above, KRAS is an
excellent biomarker in colorectal cancer, even
though it is not the actual target of therapy.

15. Cells as Biomarkers
Circulating Tumor Cells [CTCs] :
 Distant metastasis is the main cause of tumour-related death, but
the occult spread of isolated tumour cells (ITCs) in the earliest
stage of breast cancer remains undetected by conventional
imaging technologies.
 ITCs in secondary sites, such as blood and bone marrow (BM),
are assumed to be precursors of (micro)metastatic disease.
The phenomenon of haematogenous dissemination in the
metastatic cascade was recognised by several researchers in 19th
century .
Therefore, detection and characterisation of these cells have
become a major focus of translational cancer research. Sensitive
assays enable reproducible evaluation of disseminated tumour

16.  As demonstrated by a large pooled analysis, the presence of DTCs in
BM at the time of diagnosis is associated with reduced survival . In
recent years, numerous research groups have endeavoured to
replace the invasive and painful BM biopsy with a simple blood test
which is the CTC .( Liquid biopsy )
 The low frequency of ITCs, estimated at one tumour cell/107–108 blood
cells in patients with advanced cancer, explains the need for
extremely sensitive detection assays and tumour cell enrichment .
Currently, antibody-based and molecular methods are the main
techniques for CTC detection.

17.  Antibody-based CTC detection
The majority of translational research trials use antibodies
against markers absent from other blood cells; due to the lack
of breast cancer-specific antigens, commonly used markers
are of epithelial origin (e.g., EpCAM and CKs) . CTCs are then
identified by the staining pattern and morphological criteria.
 positive selection leads to the enrichment of CTCs
through the use of an antibody targeted against, e.g.,
cytokeratins (CKs) or epithelial cell adhesion molecule
(EpCAM); or (c) negative selection, where the antibody is
targeted against a leucocyte antigen (e.g., CD45).

18.  Circulating tumor cells, disease recurrence and
survival in newly diagnosed breast cancer
Bas Franken1, Marco R de Groot1, Walter JB Mastboom2, Istvan Vermes3,
Job van der Palen4,5, Arjan GJ Tibbe6 and
Leon WMM Terstappen7*
 Abstract
Introduction: The presence of circulating tumor cells (CTC) is an independent prognostic
factor for progression free survival and breast cancer-related death (BRD) for patients with metastatic
breast cancer beginning a new line of systemic therapy. The current study was undertaken to explore
whether the presence of CTC at the time of diagnosis was associated with recurrence-free survival
(RFS) and BRD.
 Methods: In a prospective single center study, CTC were enumerated with the CellSearch system
in 30 ml of
peripheral blood of 602 patients before undergoing surgery for breast cancer. There were 97 patients
with a
 benign tumor, 101 did not meet the inclusion criteria of which there were 48 patients with DCIS, leaving
404 stage I to III patients. Patients were stratified into unfavorable (CTC ≥1) and favorable (CTC = 0)
prognostic groups.
 Results: ≥1 CTC in 30 ml blood was detected in 15 (15%) benign tumors, in 9 DCIS (19%), in 28
(16%) stage I, 32
 (18%) stage II and in 16 (31%) patients with stage III. In stage I to III patients 76 (19%) had ≥1 CTC of
whom 16(21.1%) developed a recurrence. In 328 patients with 0 CTC 38 (11.6%) developed a
recurrence. Four-year RFS was 88.4% for favorable CTC and 78.9% for unfavorable CTC (P = 0.038).
A total of 25 patients died of breast cancerrelated causes and 11 (44%) had ≥1 CTC. BRD was 4.3%
for favorable and 14.5% for unfavorable CTC (P = 0.001).
 In multivariate analysis ≥1 CTC was associated with distant disease-free survival, but not for overall
recurrence-free survival. CTC, progesterone receptor and N-stage were independent predictors of
BRD in multivariate analysis.

19. ONCOTYPE DX
 Although patients diagnosed with axillary node–negative estrogen receptor–
positive breast cancer have an excellent prognosis, about 15% of them fail
after 5 years of tamoxifen treatment.
 Clinical trials have provided evidence that there is a significant benefit from
chemotherapy for these patients, but it would be significant overtreatment if
all of them were treated with chemotherapy. Therefore, context-specific
prognostic assays that can identify those who need chemotherapy in addition
to tamoxifen, or those who are essentially cured by tamoxifen alone, and can
be performed using routinely processed tumor biopsy tissue would be
clinically useful.

20.  a 21-gene recurrence score (RS), based on
monitoring of mRNA expression levels of 16 cancer-
related genes in relation to five reference genes, has
been developed. The RS identified approximately 50%
of the patients who had excellent prognosis after
tamoxifen alone. Subsequent study suggested that
high-risk patients identified with the RS preferentially
benefit from chemotherapy.
 A prospective study—the Trial Assigning
Individualized Options for Treatment (Rx)
(TAILORx)—to examine whether chemotherapy is
required for the intermediate-risk group defined by

21. TPS (a circulating tumor marker in
breast cancer.)
 Tissue polypeptide specific antigen (TPS) measures an
antigenic determinant associated with human cytokeratin 18.
 TPS is the only test that specifically measures cytokeratin
18.
 TPS is a marker of tumor cell activity in contrast to
markers related to tumor burden.
 The value of detecting circulating TPS lies in the early
detection of recurrence by serial determinations and in the
rapid assessment of the efficacy of the treatment.
Pretreatment levels of TPS in patients with
metastatic breast cancer are related with prognosis.
Decreasing TPS levels during therapy monitoring indicate
response and a fast response is correlated to favourable
prognosis.

22. TPS for monitoring and
follow up
 According to studies published during the last
15 years TPS have been shown to have the
strongest association with clinical response .
 In total ,studies of more than 3000 patients
have been reported.
 TPS has been found to be a better indicator of
disease progression than CA 15-3.
 In a study by Van Dalen et al sensitivity of TPS
to detect progressive disease was found to be
83% compared to 30% for CA 15-3.

23.  TPS has also been shown to be the marker
that exhibits the most frequent and rapid
decrease when the applied therapy is effective
.
 Low baseline levels of TPS indicates a better
prognosis .

24. Summary of tumor markers
 Beta-tubulin NSCLC IHC
High expression of beta-tubulin confers worse
prognosis
 BRCA1 Breast IHC
High expression of BRCA1 confers worse prognosis
in untreated patients
 CA19-9 Pancreatic IHC
Higher preoperative CA19-9 levels are associated
with lower resectability, more advanced stage
and inferior survival

25.  CAIX RCC IHC
High expression of CAIX is associated with a better
prognosis
 CD44 Bladder RT-PCR
Expression of CD44 is associated with poor
prognosis
 CEA CRC IHC
preoperative CEA levels in resectable colorectal
cancer is associated with poor prognosisIHC
 c-KIT GIST patients have a better
prognosis if they harbor a mutation in exon 11 of
the c-KIT gene

26.  ColoPrint CRC Prognosis for colorectal cancer patients
 CTC Melanoma
Increased number of circulating melanoma cells is associated with poor
prognosis
CRC Colorectal
patients with ≥3 CTC/7.5 ml of peripheral blood were associated with
shorter PFS and OS, i.e. poor prognosis tumor
Breast cancer
patients with ≥5 CTC/7.5 ml of peripheral blood are associated with
shorter PFS and OS, i.e. poor prognosis Prostate≥5 CTC/7.5 ml of
peripheral blood is associated with poor prognosis

27. EGFR
BladderOverexpression of EGFR is associated
with high grade and high stage
NSCLC High gene copy number of EGFR in
NSCLC patients is associated with poor
prognosis
NSCLC EGFR mutation in NSCLC patients is
associated with better prognosis in untreated
patients
RectalOverexpression of EGFR in rectal cancers
is also associated with poor prognosis
ER BreastPatients with ER-positive breast

28.  MSI status CRC
High frequency MSI colorectal tumors are associated with better
prognosis and show improved relapse-free survival
 K-ras NSCLC
K-ras mutation is associated with poor prognosis in NSCLC patients
 Oncotype DX BreastA 21-gene multiplex test used for
prognosis to determine 10-year disease recurrence for ER-
positive, lymph node negative breast cancers using a
continuous variable algorithm and assigning a tripartite
recurrence score

29.  VEGF RCC
Overexpression of VEGF is associated with
poor prognosis in clear cell renal carcinoma
patients
 Her2/neuBreast Patients with Her2/neu-
positive breast tumors are more aggressive
and have a worse prognosis compared to
Her2/neu-negative tumors

30. Metabolic Biomarkers
 Bio-energetic index of cell has been suggested for
classification and prognosis of cancer, besides predicting the
response to therapy.
 Positron emission tomography allows non invasive and
quantitative analysis of various biologic process.
 It uses a glucose analogue [2-deoxy-D-glucose] labelled with
positron emitter Fluorine 18.
 FDG that is partially metabolized and trapped as its
phosphate [2-DG-6-P] in the tumor tissue, thus, localizing the
tumor

31.  Extent of increase in glucose utilization measured by FDG-PET
has been co-related with degree of malignancy in some tumors.
 Studying cancer through metabolomics could reveal new
biomarkers for cancer that could be useful for its future
prognosis ,diagnosis & therapy.