Download Common pitfall in Oncology(1)

Common pitfall in Oncology
Luangyot Thongthieang, MD
MEDICAL ONCOLOGY UNIT
INTERNAL MEDICINE, KHONKAEN HOSPITAL
Common pitfall in Oncology
Common pitfall in Oncology
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
Clear-cut
Early relapse detection
Assess treatment response
 Predict prognosis and outcome
 Diagnose cases suspected of having
cancer
 Cancer screen for early cancer
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)
Common pitfall in Oncology(1)
Common pitfall in Oncology(1)
Common pitfall in Oncology(1)
Common pitfall in Oncology(1)
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
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: 24 - 36 hours
RAISED  HCG 100 % - Choriocarcinoma
60% - Embryonal carcinoma
55% - Teratocarcinoma
25% - Yolk Cell Tumour
7%
- Seminomas
BIOLOGY
Tumor
Marker
HCG
AFP
LDH
PLAP
seminoma
+
0
+
+/-
+/-
+
+
+/-
seninoma
nonseminoma
Prognosis, Tumor response, Tumor recurrence
Clinical use of AFP and hCG
Screening
• Men
Diagnostic
Prognostic
• Midline mass
- mediastinum
- retroperitoneum
Clinical use of AFP and hCG
Screening
Diagnostic
• High level poor
prognosis
• Staging
Prognostic
• High tumor burden
Clinical use of AFP and hCG
Monitoring
Treatment response
Follow up
Tumor recurrence
Common pitfall in oncology(2)
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
Clinical use of PSA
Non malignancy
Malignancy
 Prostate cancer
 Prostatitis
 BPH
 Urinary tract infection
Prostate cancer small cell type
PSA normal
Clinical use of PSA
Average risk
Screening
Diagnostic
•
Men
•
Age > 50 years
•
DRE, PSA
High risk
•
Afarican, american
•
Prognostic
Father, brother
: CA prostate
• Age 40 – 45 years
•
DRE, PSA
Clinical use of PSA
Screening
• Men
Diagnostic
Prognostic
• Osteoblastic
• PSA high level
• High level poor
prognosis
Clinical use of PSA
Monitoring
Treatment response
Follow up
Tumor recurrence
Common pitfall in oncology(3)
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
Screening
Diagnostic
Average risk
High risk
• Family history of BRCA mutation
• Pelvic ultrasound and CA125
Prognostic
Clinical use of CA125
Screening
Diagnostic
Adjunct > definitive
Prognostic
High level : poor prognosis
Clinical use of CA125
Monitoring
Treatment response
Follow up
Tumor recurrence
Common pitfall in oncology(4)
Male 54 year
Jaundice, abdominal pain
History non cooking meal
No history of cancer
Common pitfall in oncology(4)
Tumor marker
 Male 54 year
 CA19-9
 Jaundice, abdominal pain
 Carbohydrate antigen
 History non cooking meal
 No history of cancer
Clinical use of CA19-9






Non malignancy
Normal variation
Liver abscess
Chronic lung disease
Colitis
Pancreatic disease
Biliary tract disease
Malignancy








Colon
Cholangiocarcinoma
Bladder
Gastric
Pancreatic
Lungs
Liver
Ovary
Clinical use of CA19-9
Screening
Diagnostic
Prognostic
High level : poor prognosis
Clinical use of CA19-9
Monitoring
Treatment response
CA19-9 with clinical
correlation
Follow up
Tumor recurrence
Common pitfall in oncology(5)
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
 Pregnancy woman
- fetal screening
- fetus problem
- placenta problem
Liver disease
Malignancy
 Testicular cancer
 Hepatocellular carcinoma
 Other tumor
- neuroblastoma
- hepatoblastoma
Clinical use of AFP
Screening
Diagnostic
Average risk
High risk
• chronic hepatitis B/C infection
• cirrhosis from any cause
Prognostic
•Ultrasound + AFP
•Every 6 months
Clinical use of AFP
Screening
Diagnostic
Adjunct > definitive
Prognostic
High level : poor prognosis
Clinical use of AFP
Monitoring
Treatment response
Follow up
Tumor recurrence
Common pitfall in oncology(6)
Female 57 year
Anemia , irondeficiency anemia
No bowel habit change
Stool occult blood : positive
Common pitfall in oncology(6)
Tumor marker
 CEA
 Carcinoembryonic antigen
Clinical use of CEA








Non malignancy
Normal variation
Smoker
Liver disease
Colitis
Pancreatic disease
Biliary tract disease
Hypothyroid
Chronic lung disease
Malignancy










Colorectal
Cholangiocarcinoma
Bladder
Gastric
Pancreatic
Lungs
Liver
Ovary
Thyroid
Breast
Clinical use of CEA
Screening
Diagnostic
Prognostic
High level : poor prognosis
Clinical use of CEA
Monitoring
Treatment response
Follow up
Tumor recurrence
Common pitfall in Oncology(7)
Common pitfall in Oncology(7)
Current Consensus on the Roles of
Selected Markers in Cancer Screening
Tumor
marker
ASCO
ACB
EGTM
ESMO
AUA
colorectal
CEA
N
-
N
N
NA
Breast
CEA,CA153
N
-
N
N
-
Ovarian
CA125
-
-
N
N
NA
prostate
PSA
N
Y
Y
NA
Y
*** EGTM : European group of Tumor marker
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
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