TUMOR MARKERS Midiiielíi Knillkuvü, IVID L* b p iľľ'iiii bili bi Ľl u bk biin^íľy F u buky dí 1VJ b ill £in ö IVJíi^íiT/ii U_nl vbľúiy • substances which can be related to the presence or progress of a malignancy • antigens expressed on the tumor cells surfaces -cellular tumor markers • different substances (found in the blood or other body fluids) produced by the tumor cells (Tu-associated m.) or by an organism (induced m.) in the presence of tumor -humoral tumor markers • The ideal marker should brd both specific for a given type and localization m cancer and sensitive enough to iWíbťí 3IÍJílU íínilDľ^ ÍDľ bílľbj LÚíigllD^ Dľ íllíľUlg UTILIZATION OF TUMOR MARKERS Screening: calcitonin in families with MEN syndrome, AFP in patients with liver cirrhosis, PSA in men >50 years Dg and diff% dg in symptomatic individuals Clinical Staging Of cancer, is aided by quantitation of the marker, i. e. the serum level of the marker reflects the number of cancer cells present in the body Monitoring of the disease and estimation of tumor value Prognostic indicator of disease progression and patient survival Detection of cancer recurrence, permits early treatment or a change in therapy Monitoring of responses to therapy CLASSIFICATION OF TUMOR MARKERS • According to chemical structure • According to visceral specificity • According to function Chemical structure • ^l/koproteiiis J Ulil\UD^lobi\\ 111' j zuľbuhyúľuiba Visceral specificity • higlü calcitonin - medullary carcinoma of the thyroid PSA- ■ prostate cancer NSE ■ small cell lung cancer hCG - germ-cell tumors AFP - hepatocellular and germ-cell carcinoma J ÍIIDLÍbľí ;iie: CA 19-9 - pancreatic cancer CA 125 - ovarian cancer CA 15-3 - breast cancer ♦ low: CEA TPA Function üiizüpliitbixiiü iíixťigbiiu hu'ľlllUIlbu receptors Oucuíeížil žiuíigens • substances produced during fetal life • present in high concentrations in the sera of fetuses, decrease to low levels or disappear after the birth • reappear in patients with cancer • Their production demonstrates that certain genes are reactivated as a result of the malignant transformation of the cell. • examples: AFP, CEA, CAs, CYFRA 21-1, SCC, MCA, MSA, TATI • produced by the trophoblastic cells of the placenta in both pregnancy and pathological conditions and also by germinative tumors as a mark of malignant dedifferentiation • t levels show evidence of t malignancy and metastatic potency of the given tumor • examples: hCG> SP-1 sIüTlllÜhb u The production of hormones in cancer involves two separate routes: . the endocrine tissue that normally produces the given hormone can produce its excess amounts . ectopic syndrome - hormone produced by a distant nonendocrine tissue that normally does not produce this hormone for instance: ACTH normally produced by the pituitary gland ectopicaly produced by the lung small cells elevation of a hormone is not specific <— it may be produced by a variety of cancers examples: ACTH, ADH> PTH> calcitonin, STU, prolactin • present in much higher concentrations inside cells • released into circulation as the result of tumor necrosis or a change in the membrane permeability of the cancer cells —► • elevated enzyme levels may signal the presence of malignancy but usually are not specific enough to identify a cancer type or organ involvement • examples: NSE, TK, ALP, PSA, LD • produced either by tumor cells or by an organism in the presence of tumor • non-specific • monitoring • examples: ß2-microglobulin, ferritin, paraprotein R.eť.fi'r cellular markers used in hormone-producing tumors examples: estrogen and progesterone receptors Oihvľ i a moľ niííľkbľi. • tissues - produced substances, which we cannot class with the previously mentioned groups • examples: TPA, TPS, CgA, S-100B AFP (od -fetoprotein) • glycoprotein synthesized in large quantities by the fetal yolk sac and liver • one of the major proteins in the fetal circulation • in adults AFP /S f: pregnancy liver diseases • marker for hepatocellular and germ-cell carcinoma • cut off value < 13,0 lU/ml CEA (carcinoembryonic antigen) • family of related oncofetal cell-surface glykoproteins • nonspecific • |: liver cirrhosis, pulmonary emphysema, benign breast cysts disease, ulcerative colitis, rectal polyps lung, ovarial and breast carcinoma • marker for colorectal, pancreatic, gastric and bile ducts Ca • cut off value < 4,6 ug/ml Carbohydrate markers (CA - carbohydrate antigen) • high-molecular-weight mucins or blood group antigens on the tumor cell surface or secreted by the tumor cells • CA 15-3 • marker in monitoring of therapy and disease progression in metastatic breast cancer • cut off vaIue < 281U/ml • CA 125 • marker for ovarian and endometrial carcinomas • cut off value < 35 Ill/ml • CA 19-9 • marker for pancreatic and colorectal carcinoma • cut off value < 37 Ill/ml • CA 72-4 • marker for carcinomas of stomach, pancreas and ovary • cut off value £ 5 IU/ml SCC (squamous cell carcinoma antigen) • glycoprotein Ig receptor physiologically present in squamous epithelium cells • |: pregnancy lung dis., hepatic and renal failure • marker for pulmonary (NSCLC), orofacial, genital, and endometrial carcinoma » cut off value 11,5 jxg/1 CYFRA 21-1 (cytokeratin fragment) • cytokeratin fragment present in lung, uterine and GIT cells. Marker of degradation of malign tissues and necrosis. • f: cirrhosis, asthma, respiratory infections, renal failure • marker for cervical and pulmonary (NSLC) carcinoma • cut off value ^ 3^3 JJ^/I MCA (mucinous carcinoma antigen), MSA (mammar serum antigen) j j í breast Ca TATI (tumor associated trypsin inhibitor) ♦ |: GIT Ca and ovarian mucinous cystadenoCa hCG (human chorionic gonadotropin) • glycoprotein secreted by the syncytiotrophoblastic cells of placenta • consists of two subunits: a-subunit (common to several other hormones, e. g. FSH, LH or TSH) ß-subunit (unique to hCG) • ]: pregnant women hydatidiform mole • marker for tumors of placenta (trophoblastic tumors, particularly choriocarcinoma), and germ-cell tumors of the testis and ovary • cut off value < 2*00 IU/1 males, < 9*00 IU/1 females S P-1 (Schwangerschaftsprotein; ßrspecific pregnancy gfycoprotein) mixture of glycoproteins produced by the trophoblastic cells of placenta \\ pregnant women chorioCa, germinative Tu PSA (prostate-specific antigen) • glykoprotein protease (237 AA, Mr = 33 000) produced exlusively by the epitelial cells of the prostate gland, secreted into seminal fluid. In serum, it occurs as free fPSA and chymotrypsin or oc2-macroglobulin bonded. • t: benign prostatic hyperplasia BPH, prostate infammation, urological manipulations • marker for screening (men > 50y, urinating difficulties), dg and monitoring of course and treatment of prostate cancer • cutoff value <-U) jig/I Derived parameters * tPSAD (tPSA density): adjustment of BPH and PCa: 0,15 • tPSA-TZ (tPSA/transition zone ratio) • PSA V (tPSA velocity): healthy 0,04 ngA/y, BPH 0,07-0,27 Hgfl/y, PCa * 0,75 wg% • age specific tPSA levels: normal | 0,04 ng/l/y; cut off 40-49 y 2,5 or 1,5 jigfl, 50-59 y 3,5 or 2,5 ngfl, 60-69 y 4,5 ngfl, 70-79 y 6,5 or 7,5 jw^l • index fPSA/tPSA: j in CaP than BPH (cut off < 20%) • tPSADT (tPSA doubling tíme): adjustment of local reccurence x metastasis (shorter time) after radical prostatectomy NSE (neuron-specific enolase) • enolase - enzyme of glycolysis (2-phosphoglycerate —*■ phosphoenolpyruvate) • NSE - form of enolase found in neuronal and neuroendocrine tissues • t: lung and liver dis., renal failure • marker for small-cell lung cancer (SCLC), pheochromocytoma, neuroblastoma, medullary carcinoma of the thyroid, melanoma, and pancreatic endocrine tumors • cutoffvalue<15jxg/l TK (thymidine kinase) • enzyme of DNA synthesis (thymidine —> thymidine monophosphate) • t: psoriasis, sarcoidosis, kolagenosis, rheumatic dis., pernicious and megaloblastic anemia lung, breast, prostate, testicular or colorectal Ca • marker for hematologic malignancies monitoring • cutoffviiliie<5IU/l LD (lactate dehydrogenase) • enzyme of glycolysis (lactate <-► pyruvate) • non-specific • f: heart failure, lung and liver dis. etc. (isoenzymes) hematological and other malignances t izoenzvme LDs in liver metastases • marker for acute leukemia, non-hodgkin lymphoma, testikulär Ca and E wing Sa monitoring • ref. values: # 3,3 - 7,5 (Jkat/I, $3,3-6,3 jikat/1 ALP (alkaline phosphatase) • Zn2+ glycoprotein, in alkaline environment (pH= 8-10) it catalyses the hydrolysis of H3P04 monoesters and transphosphorylation • bone isoenzyme » |: osteoSa, bone metastases other bone affections; growth • liver isoenzyme • |: liver metastases other liver diseases • Regan isoenzyme (placental alike) • |: GIT and lung tumors • ref.values: adults 0,5-2,4 |ikat/k 1 month -15 years 1,0-4,8 |ikat/k newborns 0,6-53 |xkat/l Cathepsins • lyzosomal proteinases, participate in connective tissue and cell membranes degradation —► facilitate the tumor progression and origination of metastases • cathepsin B \ in breast, ovarial, colorectal, stomach and laryngeal Ca • cathepsin H f in breast lung, head and neck Ca, mainly in tumor progression and occurence of metastases • cathepsin D | in ad en ü Ca mammae Prolactin • peptide (198 AA) anterior pituitary hormone that stimulates and maintains the secretion of milk. Iť s secretion is stimulated by TRH and inhibited by dopamine. • f: prostatic and breast cancer • marker for prolactinoma • ret values males 80 - 390 mIU/1 females 70 - 520 mIU/1 ACTH (adrenocorticotropic hormone) • anterior pituitary hormone that stimulates the secretion of glucocortikoid hormones, Iť s secretion is stimulated by corticotropin-releasing hormone of hypothalamus. • f: ectopic formation: SCLC, Ca of pancreas, breast, GIT • marker for pituitary tumors • cut off value < 46*0 ng/i ADH (antidiuretic hormone, vasopressin) • peptide (9 AA) hormone synthesized in the supraoptic nuclei of the hypothalamus and transported via the hypophyseal tract to the posterior pituitary. Iť s binding and stimulation of insertion of aquaporines into distal and collecting tubules membranes increases the water reabsorption —► f blood pressure and [ excretion of urine • t: pneumonia, porfyria • marker for SCLC* adenocarcinoma of the lung *ssř • i et. value 2 - 8 ng/l PTH (parathyroid hormone) • peptide (84 AA) hormone of the parathyroid glands. Iťs release is stimulated by Ca++ /P [. PTH activates osteoclasts, t Ca++ renal resorption and t Ca++ intestinal absorption via stimulation of calcitriol renal production —► t Ca++ /P. • |: secondary and primary hyperparathyroidism • marker for parathyroideal tumors • ret values 10 - 65 ng/1, 1.6 - 6.9 pmol/l Calcitonin • polypeptide (32 AA) produced by the C cells of the thyroid • normally secreted in response to f Ca++ /P • inhibits the release of calcium from bone (inhibition of osteoclasts) • marker for medullary carcinoma of the thyroid • cut off value ^ 19 ng/1 Ferritin Fe3+ storage protein f: iron overload acute hepatitis and liver cells necrosis, inflammations (positive acute phase protein) marker for Hodgkin lymphoma and melanoma monitoring ref. values males 48 - 708 pmol/L females 20 - 640 pmol/1 ^microglobulin • part of the class 1 HLA, physiologically produced by B-lymphocytes and plasmocytes, helps Tc function • \: inflammations, chronic renal and liver dis. after chemo- and radiotherapy • marker for MM dg, CLL therapy • ret value 1 - 23 mg/l K, X light chains (paraproteins, Bence Jonesproteins) • the first described tumor markers produced by neoplastic plasma cells in monoclonal gammopathies. They are small enough (22 kD) to pass through the kidney into the urine —> prerenal „over-flow" proteinuria. • t: monoclonal gammopathy of uncertain significance (isolated finding of a Bence Jones protein without a clinical symptomatology) Waldenstrom macroglobulinemia, lymphomas and leukemias, osteogenic sarcoma, bone metastases • marker for multiple myeloma • ret values: FLC (free light chains)/S: k = 3.3-19.4 mg/1, X = 5.7-26.3 mg/1, index k/A, = 0.26-1.65; polyclonal FLCAJ = 1-10 mg/24_h; k/U = 1.25-5.5 mg/1, AAJ = 0.51-3.2 mg/1, index k/X = 0.82-3.0 TP A (tissue polypeptide antigen) • non-specific cytokeratins fragments produced by both normal and tumor cells • t levels seen in increased cell proliferation —► its estimation is useful for monitoring of the disease • t: liver dis., DM, rheumatoid dis. breast and GIT tumors • TP A/ U - marker for urinary bladder carcinoma • cut otT value < 85 IVI CgA (chromogranin A) • glycoprotein of the secretory vesicules of the neuroendocrine cells. Precursor to several functional peptides including vasostatin, pancreastatin, catestatin and parastatin. Regulates the storage and/or secretion of hormones and peptides inside the cell. • f: renal and hepatal dis., corticosteroids therapy neuroendocrine tumors • marker for carcinoid, pheochromocytoma, SCLC, MEN I, neuroendocrine tumors of GIT, particularly pancreas, children's neuroblastomas • ref. value < 35 U/l S-IOOB • Ca2+- binding protein of nervous system glial cells and melanoma cells. Participates on signal transmission, enzyme activity regulation and homeostasis —► stimulates neuronal growth and ] their survival. • f: brain injury Down and Alzheimer dis. malignant melanoma • marker for malignant melanoma monitoring • ref. value < 0>105 jjg/l ixföV7 b du e míiľk^ľ^ in b on s juötoiiiaea lig iĽUti JIIDíIÍÍD-TÍJI.^ • P1NP (N-terminal propeptide of type I collagen): monitoring of bone formation, highly specific for osteoblastic metastases formation. Is released into IC environment during collagen synthesis, than into the blood —> assesment /S. • b-CTX (ß-Cro$S Laps): bone resorption marker, monitoring of antiresorption therapy • re£ value < 0,704 \xg/l • ICTP (c-telopeptide of type I collagen): marker of bone resorption mediated by MMP9 (matrix metaloproteinase 9), activated in pathological conditions (physiological bone resorption is mediated by cathepsin K). Replaced by b-CTX. O'íilfí-T pSľSpbťlÍYb 'P'ľUgllDuťlZ ÍLU ti \)'ľblll£llYíi Illllľkíiľij • MMP-7 (matrüysin): metaloproteinase participating in EC matrix degradation, tumor invasion and progression, used in brasist Ca • SMR (mesomark, soluble mesothelin-related protein): marker for mesothelioma (no marker before now) • Heparanase: cleavage of heparane sulphate. | metastatic potenciál of tumor, I surgical survival; for example in pancreatic Ca» • RECAF (AFP receptor): allows transport of molecules into the fetal and malignant cells. Detectable in the tissues of breast, ovarian, lung, stomach, prostate, and cervical Ca, lymphoma, melanoma etc« • It K (human kallikreins): Ser proteases of hormone-dependent tissues, used in prostate and ovarian Ca; hK3 = PSA