1. TUMOR MARKER’S Prof. Adi Koesoema Aman. Prof. Ratna Akbari Ganie. Departement of Clinical Pathology University of Sumatera Utara / RSUP. H.Adam Malik Medan.

2. PENGERTIAN SECARA UMUM : Penanda tumor serologik merupakan produk yang berasal dari tumor, yang kadarnya dalam darah merupakan pencerminan masa tumor yang ada dalam tubuh. Dulunya dianggap ada harapan produk tersebut sensitip dan spesifik sehinga dapat digunakan sebagai test kanker tipe tumor tertentu.

3. PENGERTIAN PENANDA TUMOR PENGERTIAN LAMA : Berbagai substansi yang diekskresikan oleh sel kanker kedalam cairan tubuh / diproduksi oleh sel jinak sebagai respons terhadap keganasan “Tumor marker”

4. PENGERTIAN BARU PENANDA TUMOR PENGERTIAN LAMA PLUS Berbagai molekul termasuk onkogen & anti onkogen serta produknya yang diekspresikan oleh sel kanker BIOMARKER KEGANASAN Dapat diukur kualitatif & kuantitatif

5. PENANDATUMORPENANDATUMOR SELULER : perubahan yang tampak/ diidentifikasi di tingkat seluler SEROLOGIK : produk sel ganas produk sel sebagai respons terhadap keganasan MOLEKULER (Biomarker) perubahan yang diidentifikasi di tingkat molekuler

6. ONKOGENESIS DAN PENANDA TUMOR Growth promoting oncogenes Tumor suppressor genes DNA repair gene Gangguan kontrol genetik Mutasi Inaktivasi Mutasi Amplifikasi Apoptosis Defek

7. What are Tumor Markers ？ Biological substances synthesized and released by cancer cells or produced by the host in response to the presence of tumor Biological substances synthesized and released by cancer cells or produced by the host in response to the presence of tumor Detected in a solid tumor, in circulating tumor cells in peripheral blood, in lymph nodes, in bone marrow, or in other body fluid (urine, stool, ascites) Detected in a solid tumor, in circulating tumor cells in peripheral blood, in lymph nodes, in bone marrow, or in other body fluid (urine, stool, ascites)

8. PENGGUNAAN PENANDA TUMOR. Skrening dan Deteksi Awal. Skrening dan Deteksi Awal. Differential Diagnosis. Differential Diagnosis. Menentukan Prognosis. Menentukan Prognosis. Meramal Residif. Meramal Residif. Menganalisa Respons Terapi. Menganalisa Respons Terapi.

9. Klasifikasi Penanda Tumor. Protein Onkofetal. Protein Onkofetal. - Carcino Embrionik Antigen ( CEA ). - Alfa feto Protein ( AFP ). Hormon. Hormon. - HCG,HPL, ACTH, ADH, Parathormon. Enzim. Enzim. - PAP, LDH, NSE. Immunoglobulin. Immunoglobulin. Antigen terassosiasi tumor Antigen terassosiasi tumor - CA 19-9, CA 125, PSA.

15. Potential Uses of Tumor Markers Population Screening Population Screening Diagnosis Diagnosis Establishing prognosis, staging Establishing prognosis, staging Postoperatory evaluation ： access the radicality of the surgery Postoperatory evaluation ： access the radicality of the surgery Monitor treatment response Monitor treatment response Surveillance for recurrence Surveillance for recurrence Targets for therapeutic intervention Targets for therapeutic intervention

16. Statistical Considerations Sensitivity ： cancer (+), abnormal test Sensitivity ： cancer (+), abnormal test Specificity ： cancer (-), normal test Specificity ： cancer (-), normal test Positive predictive value ： abnormal test, cancer (+) Positive predictive value ： abnormal test, cancer (+) Negative predictive value ： normal test, cancer (-) Negative predictive value ： normal test, cancer (-) Prevalence ： affect PPV, ∴ every marker has failed as a screening test in ASYMPTOMATIC persons, because the PREVALENCE of cancer is low among ASYMPTOMATIC persons Prevalence ： affect PPV, ∴ every marker has failed as a screening test in ASYMPTOMATIC persons, because the PREVALENCE of cancer is low among ASYMPTOMATIC persons

17. Tumor Specific Proteins Expressed only in tumor cells Expressed only in tumor cells Example: an oncogene is translocated and fused to an active promoter of another gene → fusion proteins → constant active production → development of malignant clone Example: an oncogene is translocated and fused to an active promoter of another gene → fusion proteins → constant active production → development of malignant clone Philadelphia chromosome in CML, t(9;22) (q34;q11) bcr/abl translocation Philadelphia chromosome in CML, t(9;22) (q34;q11) bcr/abl translocation T(8;21) acute non-lymphocytic leukemia, t(15;17) APL T(8;21) acute non-lymphocytic leukemia, t(15;17) APL Hematological malignancies Hematological malignancies

18. Non-Specific Proteins or Markers Related to Malignant Cells Oncofetal proteins ： expressed by cells as they de-differentiate and take on embryonic characteristics Oncofetal proteins ： expressed by cells as they de-differentiate and take on embryonic characteristics α-FP ： HCC, testicular, ovarian cancer α-FP ： HCC, testicular, ovarian cancer CEA ： many GI tumors CEA ： many GI tumors

19. Cell Specific Proteins Overexpressed in Malignant Cells Proteins expressed normally by differentiated cells, but are expressed at higher rates in the corresponding tumor cells Proteins expressed normally by differentiated cells, but are expressed at higher rates in the corresponding tumor cells PSA ： prostate cancer PSA ： prostate cancer

20. Colorectal Cancer Carcinoembryonic antigen (CEA) Carcinoembryonic antigen (CEA) fetal glycoprotein found on cell surfaces, produced by fetal GI tract, liver, and pancreas fetal glycoprotein found on cell surfaces, produced by fetal GI tract, liver, and pancreas Normal serum and tissue fluid value ： <3.0 ng/ml Normal serum and tissue fluid value ： <3.0 ng/ml Circulating half-life ： weeks Circulating half-life ： weeks Detect early relapse of colorectal cancer and prognostic indicator Detect early relapse of colorectal cancer and prognostic indicator Normal pretherapy CEA ： lower metastasis incidence Normal pretherapy CEA ： lower metastasis incidence High initial CEA ： higher metastasis incidence High initial CEA ： higher metastasis incidence In 2/3 of patients an elevated CEA may be the 1 st indication of relapse In 2/3 of patients an elevated CEA may be the 1 st indication of relapse

21. CEA fibrocystic breast disease Found also in 30~50% of breast cancer, small cell lung cancer, mucinous cystadenocarcinoma of ovary, adenocarcinoma of cervix fibrocystic breast disease Found also in 30~50% of breast cancer, small cell lung cancer, mucinous cystadenocarcinoma of ovary, adenocarcinoma of cervix Elevation (<10 ng/ml) in smokers, COPD, inflammatory or peptic bowel disease, liver inflammation or cirrhosis, renal failure, Elevation (<10 ng/ml) in smokers, COPD, inflammatory or peptic bowel disease, liver inflammation or cirrhosis, renal failure,

22. Alpha-Fetoprotein in HCC Glycoprotein, found in fetal liver, yolk sac, GI tract, biochemically related to albumin in adults Glycoprotein, found in fetal liver, yolk sac, GI tract, biochemically related to albumin in adults half-life ： 4~6 days half-life ： 4~6 days Normal serum levels ： Normal serum levels ： 12~15th gestational week30~40 ng/ml At birth30 ng/ml >1 years old (adult)<20 ng

23. Increased in 70% HCC, elevated in hepatoblastoma, 20~70% germ cell tumors (yolk sac tumors, embryonal cell carcinoma) of testis and ovary, except dysgerminoma Increased in 70% HCC, elevated in hepatoblastoma, 20~70% germ cell tumors (yolk sac tumors, embryonal cell carcinoma) of testis and ovary, except dysgerminoma For Hbs Ag (+) chronic hepatitis/cirrhosis screening, further improved by using US For Hbs Ag (+) chronic hepatitis/cirrhosis screening, further improved by using US The absolute AFP level correlates with tumor bulk The absolute AFP level correlates with tumor bulk CSF ： plasma ratio of AFP > 1:40 → suggest CNS involvement CSF ： plasma ratio of AFP > 1:40 → suggest CNS involvement Benign ： conditions that cause hepatic parenchymal inflammation, hepatic necrosis and hepatic regeneration, ex. hepatitis, pregnancy, primary biliary cirrhosis, extrahepatic biliary obstruction Benign ： conditions that cause hepatic parenchymal inflammation, hepatic necrosis and hepatic regeneration, ex. hepatitis, pregnancy, primary biliary cirrhosis, extrahepatic biliary obstruction

24. Germ Cell Tumors Human chorionic gonodotropin (βHCG) Human chorionic gonodotropin (βHCG) Glycoprotein synthesized by syncythiotrophoblastic cells of normal placenta, never in males! Glycoprotein synthesized by syncythiotrophoblastic cells of normal placenta, never in males! Serum and urine HCG ↑ in early gestation and peak in the first trimester (60~90 days) Serum and urine HCG ↑ in early gestation and peak in the first trimester (60~90 days) T ½: 1.25 days, ~30 hours T ½: 1.25 days, ~30 hours Elevated in ： gestational trophoblastic disease ( a progressive rise in after 90 days of gestation → highly suggestive), choriocarcinoma Elevated in ： gestational trophoblastic disease ( a progressive rise in after 90 days of gestation → highly suggestive), choriocarcinoma

25. Germ Cell Tumors Detection Detection Monitor treatment response (ex. C/T) ： production of BHCG ceases on commencement of tx, rising or persistently elevated levels are diagnostic of resistance to C/T Monitor treatment response (ex. C/T) ： production of BHCG ceases on commencement of tx, rising or persistently elevated levels are diagnostic of resistance to C/T evaluate radicality of the surgery: ex. In testicular cancer, the presence of β-HCG after orchiectomy → residual cancer and needs further treatment evaluate radicality of the surgery: ex. In testicular cancer, the presence of β-HCG after orchiectomy → residual cancer and needs further treatment Monitor relapse (reliable indicator of CR) Monitor relapse (reliable indicator of CR)

26. Breast Cancer CA15-3 ： monitor treatment and to detect recurrence CA15-3 ： monitor treatment and to detect recurrence Normal ： < 31 U/ml Normal ： < 31 U/ml ↑ in 20% with localized breast cancer, ~80% with metastatic disease, esp. if with bone involvment ↑ in 20% with localized breast cancer, ~80% with metastatic disease, esp. if with bone involvment Specificity of 86%, sensitivity of 30% Specificity of 86%, sensitivity of 30% Also increased in gastric, pancreatic, cervical lung cancer Also increased in gastric, pancreatic, cervical lung cancer

27. Breast Cancer Estrogen receptor (ER) ： 2 isoforms ： ERa + ERb 2 isoforms ： ERa + ERb ERa → better prognosis, predictor of relapse ERa → better prognosis, predictor of relapse useful when deciding on adjuvant hormone treatment useful when deciding on adjuvant hormone treatment Not guarantee response, fails in 30~40% of patients to endocrine treatment Not guarantee response, fails in 30~40% of patients to endocrine treatment As diagnostic marker when it is a primary unknown tumor As diagnostic marker when it is a primary unknown tumor ERb → distinct biological roles and ligand binding specificity, good prognostic factor, correlate with low grade and (-) axillary LN status ERb → distinct biological roles and ligand binding specificity, good prognostic factor, correlate with low grade and (-) axillary LN status

28. HER-2/neu oncogene (using monoclonal antibody) ： overexpression related to poor prognosis in breast cancer HER-2/neu oncogene (using monoclonal antibody) ： overexpression related to poor prognosis in breast cancer Oncogene c-erbB-2 gene ： overexpressed in 30% of breast cancers, correlation between c-erbB- 2 gene positivity, positive axillary node status, reduced time to relapse and reduced overall survival Oncogene c-erbB-2 gene ： overexpressed in 30% of breast cancers, correlation between c-erbB- 2 gene positivity, positive axillary node status, reduced time to relapse and reduced overall survival BRCA1 gene on chromosome 17q ： familial breast-ovarian cancer syndrome, and breast cancer in early-onset breast cancer families → high risk screening BRCA1 gene on chromosome 17q ： familial breast-ovarian cancer syndrome, and breast cancer in early-onset breast cancer families → high risk screening

29. Cervical Sqamous Cell Carcinoma Squamous cell carcinoma antigen (SCC) Squamous cell carcinoma antigen (SCC) Normal value: <2 ng/ml Normal value: <2 ng/ml Not sensitive enough for screening early – stage carcinoma Not sensitive enough for screening early – stage carcinoma Prognosis, monitor Prognosis, monitor

30. Ovarian Cancer CA-125 ： CA-125 ： Cell surface glycoprotein, present during embryonic development of coelomic epithelium and is present in adult structures derived from it Cell surface glycoprotein, present during embryonic development of coelomic epithelium and is present in adult structures derived from it Normal ： <35 U/ml, t ½ ： 4~5 days Normal ： <35 U/ml, t ½ ： 4~5 days For followup, an increase may predict recurrent disease, may precede clinical recurrence by months For followup, an increase may predict recurrent disease, may precede clinical recurrence by months >80% of epithelial ovarian cancer, cell types ： serous > endometriod, clear cell > mucinous >80% of epithelial ovarian cancer, cell types ： serous > endometriod, clear cell > mucinous Correlate with tumor bulk Correlate with tumor bulk

31. Low specificity and poor sensitivity in detecting small-volume disease Low specificity and poor sensitivity in detecting small-volume disease Also found in carcinoma of pancreas, colon, gallbladder, stomach, kidney, breast, and lung Also found in carcinoma of pancreas, colon, gallbladder, stomach, kidney, breast, and lung Endometriosis is the most common alternative diagnosis, elevated levels also found in PID, 1 st trimester Endometriosis is the most common alternative diagnosis, elevated levels also found in PID, 1 st trimester CA 19-9 CA 19-9 A mucin, normal ： <37 U/ml, does not increase during pregnancy A mucin, normal ： <37 U/ml, does not increase during pregnancy Monitor of a subpopulation of patients that did not express CA 125, ex. Mucinous (76%) > serous (27%) Monitor of a subpopulation of patients that did not express CA 125, ex. Mucinous (76%) > serous (27%)

32. Pancreatic Cancer CA 19-9 ： CA 19-9 ： mucin, normal ： <37 mucin, normal ： <37 infrequently elevated in patients with other mucin-secreting cancer (colorectal, gastric cancer) infrequently elevated in patients with other mucin-secreting cancer (colorectal, gastric cancer) Diagnosis, monitor, detect relapse, 70% specificity and 90% sensitivity Diagnosis, monitor, detect relapse, 70% specificity and 90% sensitivity Mild ↑ in pancreatitis and early stage of pancreatic cancer, ∴ not for diagnosing early-stage pancreatic caner Mild ↑ in pancreatitis and early stage of pancreatic cancer, ∴ not for diagnosing early-stage pancreatic caner

33. Prostate Cancer PSA ： PSA ： Tissue specific antigen, produced by prostatic alveolar and ductal epithelial cells, a serine protease, t 1/2 ： 2~3 days Tissue specific antigen, produced by prostatic alveolar and ductal epithelial cells, a serine protease, t 1/2 ： 2~3 days AgeSerum PSA (ng/ml) 40~500~2.5 50~600~3.5 60~700~4.5 70~800~6.5

34. Relapse Relapse Reflect response to treatment and correspond to tumor volume and androgen level Reflect response to treatment and correspond to tumor volume and androgen level As a predictor of surgical failure ： by using RT- PCR for PSA to detect circulating prostate cancer cells in the bloodstream As a predictor of surgical failure ： by using RT- PCR for PSA to detect circulating prostate cancer cells in the bloodstream PSA is expected to be undetectable >30 days after the radical prostatectomy, persistent elevated level indicate residual disease PSA is expected to be undetectable >30 days after the radical prostatectomy, persistent elevated level indicate residual disease

35. Free PSA ： PSA that is not bound to the plasma antiproteases α1-antichymotrypsin and α2-macroglobulin Free PSA ： PSA that is not bound to the plasma antiproteases α1-antichymotrypsin and α2-macroglobulin An ↑ in ratio of free/total PSA is associated with increased probability of prostate cancer An ↑ in ratio of free/total PSA is associated with increased probability of prostate cancer 97% specific for this disease, 96% sensitivity in detecting disease 97% specific for this disease, 96% sensitivity in detecting disease For population screening and diagnosis ： an increase of 0.75 ng/ml per year in any given patient has high sensitivity and specificity for prostate cancer vs BPH, especially when combined with DRE and TRUS For population screening and diagnosis ： an increase of 0.75 ng/ml per year in any given patient has high sensitivity and specificity for prostate cancer vs BPH, especially when combined with DRE and TRUS

36. Melanoma Tyrosinase Tyrosinase Use RT-PCR to detect hematogenous spread of melanoma cells from a solid tumor in peripheral blood Use RT-PCR to detect hematogenous spread of melanoma cells from a solid tumor in peripheral blood S100B protein S100B protein For confirmation of amelanotic malignant melanoma in immunohistology For confirmation of amelanotic malignant melanoma in immunohistology ↑ in 70% with stage IV metastasized melanoma ↑ in 70% with stage IV metastasized melanoma MIA (melanoma inhibitory activity) MIA (melanoma inhibitory activity) Preoperation: 59% at stage III, 89% at stage IV Preoperation: 59% at stage III, 89% at stage IV

37. Thyroid Cancer Thyroglobulin ： Thyroglobulin ： Tissue-specific, glycoprotein produced by thyroid follicular cells Tissue-specific, glycoprotein produced by thyroid follicular cells normal: <60 ug/L normal: <60 ug/L Also increased in breast or lung cancer Also increased in breast or lung cancer Thyrocalcitonin ： Thyrocalcitonin ： Produced by thyroid C cells and medullary thyroid cancer Produced by thyroid C cells and medullary thyroid cancer normal: <100 ng/L or <29 p mole/L normal: <100 ng/L or <29 p mole/L Effective in screen patients with 1 st degree relatives affected by medullary thyroid cancer and multiple endocrine neoplasia type 2 Effective in screen patients with 1 st degree relatives affected by medullary thyroid cancer and multiple endocrine neoplasia type 2

38. Multiple Myeloma Β2-microglobulin ： Β2-microglobulin ： Normal: 0.7~2.0 (serum), 20~600 (urine) Normal: 0.7~2.0 (serum), 20~600 (urine) Correlates with tumor burden, prognosis, response to therapy Correlates with tumor burden, prognosis, response to therapy Increase with poor renal function Increase with poor renal function

39. Lymphoma Burkitt’s type lymphoma and leukemia ： Burkitt’s type lymphoma and leukemia ： T (8;14) ： due to juxtaposition and activation of the c-myc gene T (8;14) ： due to juxtaposition and activation of the c-myc gene CD 25 ： most sensitive serum marker for tumor burden CD 25 ： most sensitive serum marker for tumor burden CD 44 ： high concentration indicates poor prognosis CD 44 ： high concentration indicates poor prognosis Lactate dehydrogenase (LDH) ： Lactate dehydrogenase (LDH) ： normal: 100~250 IU/L normal: 100~250 IU/L high-grade lymphomas, blood levels correlate closely with disease activity and response to therapy high-grade lymphomas, blood levels correlate closely with disease activity and response to therapy

40. Neuroendocrine Tumors Neuron-specific enolase (NSE) Neuron-specific enolase (NSE) A neuronal isoenzyme of the cytoplasmic enzyme enolase, in neuroendocrine cells A neuronal isoenzyme of the cytoplasmic enzyme enolase, in neuroendocrine cells As a prognostic factor in neuroblastoma As a prognostic factor in neuroblastoma Occur in neuroendocrine tumors: medullary carcinoma of the thyroid, pheochromocytoma, carcinoid tumors; immature teratoma, 65~85% with small cell carcinoma of lung, ~38% with non-small-cell lung cancer, and melanoma Occur in neuroendocrine tumors: medullary carcinoma of the thyroid, pheochromocytoma, carcinoid tumors; immature teratoma, 65~85% with small cell carcinoma of lung, ~38% with non-small-cell lung cancer, and melanoma Correlate with stage and bulk of disease Correlate with stage and bulk of disease N-myc oncogene in neuroblastoma ： N-myc copy number is associated with stage and prognosis N-myc oncogene in neuroblastoma ： N-myc copy number is associated with stage and prognosis

44. Conclusion Screening ： most tumor markers fail, because Screening ： most tumor markers fail, because 1. Low prevalence of malignancy in asymptomatic persons 1. Low prevalence of malignancy in asymptomatic persons 2. Not elevated in patients with small-volume (early) cancer 2. Not elevated in patients with small-volume (early) cancer Diagnosis ： most markers have low specificity, only for high risk groups (αFP, β-HCG, PSA, thyrocalcitonin) Diagnosis ： most markers have low specificity, only for high risk groups (αFP, β-HCG, PSA, thyrocalcitonin) Prognosis ： markers correlate with tumor burden Prognosis ： markers correlate with tumor burden Monitor treatment response ： most markers’ level alone cannot be used to define CR (except: β-HCG in trophoblastic malignancy) Monitor treatment response ： most markers’ level alone cannot be used to define CR (except: β-HCG in trophoblastic malignancy) Early detection of recurrence Early detection of recurrence