Common pitfall in Oncology Luangyot Thongthieang, MD MEDICAL ONCOLOGY UNIT INTERNAL MEDICINE, KHONKAEN HOSPITAL

Common pitfall in Oncology

Serum tumor marker Express by both malignancy and normal tissue and shed in to circulation Can detectable in healthy subject Produce and release in large amount by the tumor than by the normal tissue

Serum tumor marker Most are glycoprotein or protein Function - hormone : HCG - enzyme : LDH, PSA - adhesion molecule : CEA - transport protein : AFP - unknown : CA19-9, CA125

Clinical Use of Serum Tumor Markers Monitor clinical courses  Early relapse detection  Assess treatment response Predict prognosis and outcome Diagnose cases suspected of having cancer Cancer screen for early cancer Clear-cut Controversial

Tumor marker for cancer screening Tumor marker not sensitive for early cancer Tumor marker can detect in early stage and late stage cancer patient False positive and false negative

Common pitfall in Oncology(1) Male 32 year No underlying disease Progressive dypnea No history of cancer

Common pitfall in Oncology(1)

Tissue diagnosis Diagnosis - tissue diagnosis - serum tumor marker Serum tumor marker Onco fetal substance - AFP : Trophoblastic Cells - B-HCG : syncytiotrophoblast Cellular substance - LDH - PLAP Common pitfall in Oncology(1) Prognosis, Tumor response, Tumor recurrence

AFP (Alpha-fetoprotein) NORMAL VALUE: Below 16 ngm / ml HALF LIFE OF AFP : 5 and 7 days Raised AFP : Pure embryonal carcinoma Teratocarcinoma Yolk sac Tumor Combined tumors, AFP not raised in : pure choriocarcinoma : pure seminoma

Human Chorionic Gonadotropin Has  and  polypeptide chain NORMAL VALUE: < 1 ng / ml HALF LIFE of HCG: hours RAISED  HCG % - Choriocarcinoma 60% - Embryonal carcinoma 55% - Teratocarcinoma 25% - Yolk Cell Tumour 7% - Seminomas

BIOLOGY seninoma Prognosis, Tumor response, Tumor recurrence Tumor Marker HCGAFPLDHPLAP seminoma +0++/- nonseminoma +/-++

Clinical use of AFP and hCG Diagnostic Screening Prognostic Men Midline mass - mediastinum - retroperitoneum

Clinical use of AFP and hCG Diagnostic Screening Prognostic High level poor prognosis Staging High tumor burden

Clinical use of AFP and hCG Follow up Monitoring Treatment response Tumor recurrence

Male 62 year Chronic low back pain Constitutional symptom Common pitfall in oncology(2)

Serum tumor marker PSA (prostate specific antigen) Produce from prostate gland Common pitfall in oncology(2)

Clinical use of PSA Non malignancy Prostatitis BPH Urinary tract infection Malignancy Prostate cancer Prostate cancer small cell type PSA normal

Clinical use of PSA Diagnostic Screening Prognostic Average risk Men Age > 50 years DRE, PSA High risk Afarican, american Father, brother : CA prostate Age 40 – 45 years DRE, PSA

Clinical use of PSA Diagnostic Screening Prognostic Men Osteoblastic PSA high level High level poor prognosis

Clinical use of PSA Follow up Monitoring Treatment response Tumor recurrence

Female 54 year Abdominal discomfort No underlying disease No history of cancer Common pitfall in oncology(3)

Tumor marker CA125 Cancer antigen 125

Clinical use of CA125 Non malignancy Menstrual Pregnancy Endometriosis Ovarian cyst PID Peritonitis Cirrhosis Pericarditis Malignancy Ovary Uterine Peritoneum cancer Cervix Gastric Pancreatic Lungs Liver > 50% Early stage ovarian CA fails to produce CA 125

Clinical use of CA125 Diagnostic Screening Prognostic Average risk High risk Family history of BRCA mutation Pelvic ultrasound and CA125

Clinical use of CA125 Diagnostic Screening Prognostic Adjunct > definitive High level : poor prognosis

Clinical use of CA125 Follow up Monitoring Treatment response Tumor recurrence

Male 54 year Jaundice, abdominal pain History non cooking meal No history of cancer Common pitfall in oncology(4)

Male 54 year Jaundice, abdominal pain History non cooking meal No history of cancer Tumor marker CA19-9 Carbohydrate antigen Common pitfall in oncology(4)

Clinical use of CA19-9 Non malignancyMalignancy Colon Cholangiocarcinoma Bladder Gastric Pancreatic Lungs Liver Ovary Normal variation Liver abscess Chronic lung disease Colitis Pancreatic disease Biliary tract disease

Clinical use of CA19-9 Diagnostic Screening Prognostic High level : poor prognosis

Clinical use of CA19-9 Follow up Monitoring Treatment response Tumor recurrence CA19-9 with clinical correlation

Male 43 year Jaundice, abdominal pain Alcoholic cirrhosis Chronic hepatitis B infection Common pitfall in oncology(5)

Tumor marker AFP Human protein encode by AFP gene

Clinical use of AFP Non malignancy - fetal screening - fetus problem - placenta problem Liver disease Malignancy Testicular cancer Hepatocellular carcinoma Other tumor - neuroblastoma - hepatoblastoma Pregnancy woman

Clinical use of AFP Diagnostic Screening Prognostic Average risk High risk chronic hepatitis B/C infection cirrhosis from any cause Ultrasound + AFP Every 6 months

Clinical use of AFP Diagnostic Screening Prognostic Adjunct > definitive High level : poor prognosis

Clinical use of AFP Follow up Monitoring Treatment response Tumor recurrence

Female 57 year Anemia, irondeficiency anemia No bowel habit change Stool occult blood : positive Common pitfall in oncology(6)

Tumor marker CEA Carcinoembryonic antigen Common pitfall in oncology(6)

Clinical use of CEA Non malignancyMalignancy Colorectal Cholangiocarcinoma Bladder Gastric Pancreatic Lungs Liver Ovary Thyroid Breast Normal variation Smoker Liver disease Colitis Pancreatic disease Biliary tract disease Hypothyroid Chronic lung disease

Clinical use of CEA Diagnostic Screening Prognostic High level : poor prognosis

Clinical use of CEA Follow up Monitoring Treatment response Tumor recurrence

Common pitfall in Oncology(7)

Current Consensus on the Roles of Selected Markers in Cancer Screening *** EGTM : European group of Tumor marker Tumor marker ASCOACBEGTMESMOAUA colorectalCEAN-NNNA BreastCEA,CA153N-NN- OvarianCA125--NNNA prostatePSANYYNAY

Common pitfall in oncology Tumor markers have very specific indications Most important use of tumor markers is in known cases of cancer patients to assess for response to ongoing treatment in patients with active cancer monitor for relapse/ recurrence after completion of treatment (colon CA, testicular CA, prostate CA)

Common pitfall in oncology Tumor marker not use for screening in average risk person. Not use only tumor marker for diagnosis tumor. A normal tumor marker does not exclude malignancy - High false negative rate in early cancers A high tumor marker does not always indicate cancer - High false positive rate in general population

Common pitfall in oncology Question and Answer