TUMOR MARKERS

SOME LABORATORY ASPECTS OF

PREGNANCY
CEREBROSPINAL FLUID ANALYSIS

By
Dr. Amany Ragab
Lecturer of Clinical Pathology
Mansoura Faculty of Medicine
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 Tumor markers

• Tumor markers are macromolecules

mostly protein with carbohydrate or
lipid component whose appearance in
blood or body fluid is related to the
presence or progress of the neoplasm.

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• Cell (tissue) tumor markers
These include antigens located on cell
membranes such as cell markers for
leukemia, hormone receptors, genetic
intracellular components
• Humoral markers
Substances which are present in high
concentration in blood, urine, other
body fluid. They are synthesized and
excreted by tumor tissue.
• The ideal tumor markers should have the
following characters:
• Specificity for cancer:
Number of true –ve cases (low number of false
+ve cases)
• Tumor markers should produced only by the
tumor
• Should be absent or present in low
concentration in normal individuals
• Shows no elevation in benign diseases
• Sensitivity:
Number of true +ve cases (low number of false
–ve cases)
• Means that a very small growth of tumor
produces measurable amounts of markers
• The amount of the marker should
be correlated with the tumor load
• the assay for it should be
inexpensive, easy to do and
sensitive
• the half life of it should be short
enough so that when production 
the level  rapidly.

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Clinical application of tumor markers:
• Screening in general population
• Differential diagnosis in symptomatic
patients
• Clinical staging of cancer
• Estimating tumor volume
• prognostic indicator for disease
progression
• Monitoring the response to therapy
• Detecting the recurrence of cancer
tumor markers may be:
• Enzymes
• Hormones
• Oncofetal antigens
• Carbohydrate markers
• Blood group antigens
• Proliferation markers (mitotic index)
• Hormone receptor markers (estrogen &
progesterone receptors)
ENZYMES:

elevated levels can serve as tumor markers,

examples are:
• Alkaline phosphatase (ALP): primary or
secondary liver cancer, metastatic cancer
with bone or liver involvement, specially with
osteoblastic lesions.
• Lactate dehydrogenase (LDH): liver cancer,
non-Hodgkin’s lymphoma, acute leukemia,
non-Seminomatous germ-cell testicular
cancer, seminoma, neuroblastoma, etc ……
• Prostatic acid phosphatase (PAP):
prostatic cancer, osteogenic sarcoma,
multiple myeloma, and some benign
conditions such as benign prostatic
hyperplasia, osteoporosis and
hyperparathyroidism.
• Prostate-specific antigen (PSA): it is
extremely useful tumor marker to detect,
stage, and monitor treatment of prostate
cancer. Serum PSA rises also with age,
benign prostatic hypertrophy and lower
urinary tract infection
Hormones:
• production of hormones in cancer
involves either production of hormones
in excessive amounts by its original
gland or production at a distant site by
a non endocrine tissue (ectopic
syndrome), e.g production of ACTH by
the small cell carcinoma of the lung.

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• Calcitonin: medullary carcinoma of
the thyroid
Carcinoma of the lung
pancreas

prostate and
ovary
• B-HCG: Vesicular mole
choriocarcinoma,
Carcinoma of the liver,
lung.
• ACTH: Carcinoma of the lung,
colon, prostate and
ovary
• Prolactin: Pituitary tumors,
carcinoma of the lung
• Parathyroid hormone (PTH):
Parathyroid tumors, carcinoma
of the lung, kidney, liver and
breast.
• ADH: Carcinoma of the lung.
• Oncofetal antigens:
• are proteins produced during fetal life.
These proteins are present in high
concentration in the sera of fetuses
and decrease to low levels or disappear
after birth. These proteins reappear in
cancer patients. The production of
these proteins demonstrates that
certain genes are reactivated as a
result of malignant transformation of
cells.
Alpha-fetoprotein (AFP):
a marker for hepatocellular and germ-
cell carcinoma (non-seminoma) its
measurement can also used to
monitor treatment. Level in healthy
adults is less than 10 ug/L. [During
pregnancy, maternal AFP levels start
to show progressive increase]. Levels
can also be increased in non-
cancerous liver diseases such as
hepatitis and cirrhosis, but the
increase is mild.
• Carcinoembryonic antigen (CEA):
this is a marker for colorectal,
gastrointestinal, lung and breast
carcinoma. The upper limit in the
healthy population is about 3 ug/L
for non-smokers and 5 ug/L for
smokers.

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• Because of the false-positive and false-
negative results, CEA testing is better
used as an adjunct to clinical staging
and together with other markers. CEA
levels decline after successful therapy.
Rising values may indicate recurrence.
• Carbohydrate markers: These are
either antigens on the tumor cell
surface or secreted by the tumor cells.
They tend to be more specific than
enzymes or hormones and are
abbreviated as CA. Examples are CA
15-3, CA 549 (for breast and ovary), and
CA 125 (for ovary and endometrium).
• Blood group antigens: These include
CA 19-9 (colorectal and pancreatic
cancer) and CA 72-4 (cancer of GIT and
ovary).
 Some laboratory aspects of
pregnancy
The clinical laboratory has an important role in
diagnosis, management and evaluation of
pregnancy, both normal and abnormal.
• Diagnosis of pregnancy and ectopic
pregnancy:
The diagnosis of pregnancy is based on the
detection of hCG in serum about 10 days
after conception, with a marked and gradual
increase thereafter.
Typical intervals for serum hCG in
pregnancy
After fertilization (wk) IU/L

2----------------------------------------------------- • 5-100

3----------------------------------------------------- • 200-3000

4----------------------------------------------------- • 10 000-80 000

5-12------------------------------------------------- • 90 000-500 000

13-24----------------------------------------------- • 5000-80 000

26-38------------------------------------------------ • 3000-15 000

In ectopic pregnancy plasma Serial
measurement of hCG fails to rise at the
normal rate.

The use of serum progesterone together

with hCG is more predictive of outcome
than a single hCG measurement
Diagnosis of gestational
diabetes mellitus:

I- Screening

II- Diagnosis
I-Screening:
Performed between 24 and 28 wk of
gestation on all pregnant women not
identified as having glucose
intolerance
50 g oral glucose load is given without
regard to time of day or time of last
meal.
Venous plasma glucose is measured at 1
h.
If glucose is > or equal 140 mg/dl,
perform glucose tolerance test.
II-Diagnosis:
OGTT
Performed in the morning after a 8-14 h fast
The fasting venous plasma glucose is
measured
100 g glucose is given orally
the plasma glucose is measured orally for 3
hours
At least two values must exeed the following:
Fasting 105 mg/dl
1h 190 mg/dl
2h 165 mg/dl
3h 145 mg/dl
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Maternal serum screening for
fetal defects
• diagnosis of fetal abnormalities is advised
for pregnancies at risk because of either
advanced maternal age or family history.
• Maternal serum α-fetoprotein (AFP) is used
to screen for neural tube defects
(anencephaly and spina bifida) at 18-20 wk
gestation. If elevated levels are found on two
occasions, ultrasound and amniocentesis
may be indicated.
• Screening for the presence of a fetus with Down’s
syndrome can be performed by measurement of the
following analytes in maternal serum at 16 wk
gestation:
AFP: values are approximately 30% lower in mothers
having trisomy 21 or trisomy 18.
Chorionic gonadotropin: values are approximalety 2
times higher when fetal Down syndrome is present.
Unconjugated Estriol: values are approximately 0.7
time lower when fetal Down syndrome is present.
Values of these analytes (triple markers) should be
compared to median values reported for women of
matched age, body weight and gestational age in
weeks.
 Cerebrospinal fluid
It is the fluid that occupies the spaces of the
C.N.S, it circulates upward over the cerebral
hemispheres and downward over the spinal
cord and nerve roots.
Formation:-
70% by the ventricular choroid plexus and
30% by epindymal lining of the ventricles as
well as cerebral and arachinoid space. Its
normal adult volume is 100-200 ml. It
functions as an excretory vehicle, circulate
nutrients and lubricates CNS.
C.S.F. examination:-
C.S.F is obtained by lumbar puncture,
lateral cervical puncture or through
ventricular cannula or shunts under
aseptic conditions. Indications for
C.S.F examination are meningeal
infection, subarachinoid haemorrhage,
CNS malignancy and demylinating
diseases .
Appearance: Physical examination -
Normal C.S.F is:
• Clear
• Colourless
• Clot free. Clot formation may be due to
its traumatic tap, complete spinal
block (Froin`s syndrome) and
suppurative or T.B meningitis.

• Has the viscosity of water.

Turbidity in fresh CSF may be due to:
erythrocytes, leukocytes or bacteria.
Coloured CSF is due to oxy- hemoglobin,
bilirubin or drugs.
Bloody CSF sample may be due to:
• A traumatic tap (clear supernatant after
centrifugation)
• Hemorrhage (yellow supernatant, after
centrifugation;this is called xanthochromia).
Chemical examination:-

Total protein (normal range 20 – 40

mg/dl): -
• CSF proteins:
More than 80% of CSF protein content
originate from plasma by ultrafiltration
(forced diuresis) through walls of the
capillaries in meninges and choroid
plexuses.
The reminder 20% from intrathecal
synthesis.
Causes of  protein in CSF
I- Increase permeability of blood brain
barrier to plasma proteins:
• High intracranial pressure due to tumor
or hemorrhage.
• Inflammation: bacterial meningitis
• Obstruction of spinal cord by tumor
• The degree of permeability of blood
brain barrier can be evaluated by

measurement of albumin in CSF and

serum simultaneausly:
The CSF/ Serum albumin index is
calculated = albumin in
CSF(mg/dl)/Albumin in serum (g/dl)
• An index value < 9 is normal
• 9-14  slight impairment of the barrier
• 14-30  moderate impairment of the
barrier
• 30-100  severe impairment of the
barrier
• > 100  complete breakdown of the
barrier
II- increase intrathecal synthesis:
• Demyelinating disease of CNS;
multiple sclerosis, where
immunoglobulin production is
increased

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To identify the intrathecal production of
immunoglobulin one of the following
ratios are used
2. IgG (CSF) mg/dl / Alb |(CSF) mg/dl
Value > 0.27 indicates  synthesis of Ig
G
4. CSF IgG index= IgG CSF x Albumin
serum / IgG serum x Albumin CSF
Reference range for index: 0.3-0.77
Value >0.77 = increase synthesis in 90 %
of cases of multiple sclerosis
Glucose (normal CSF level 40-80 mg/dl):-
Increased level (relative to plasma glucose) is
an evidence of hyperglycemia 2-4 hour prior
to lumbar puncture. Decreased level of CSF
glucose < 40 mg/dl in fasting patients with
normal blood glucose may be due to
bacterial meningitis, T.B meningitis, fungal
meningitis, amaebic meningo-encephalitis
and subarachinoid hoemorrhge. In viral
meningitis CSF glucose is usually normal.
In Rhinorrhea : The fluid is tested for glucose,
if glucose is present the fluid is CSF.
Chloride :- (Normal 120 – 130 mmol/L,is
higher than plasma level).
Its level is low in pyogenic meningitis
and much lower in T.B meningitis.
Increased level of lactic acid occurs in
case of traumatic brain injury and
bacterial meningitis.

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Enzymes:
Lactic dehydrogenase (LDH): Increased in
bacterial meningitis, viral meningitis,
leukaemia, lymphoma, metastatic and
subarachinoid haemorrhage.
Creatine kinase (CK):-
Increased CK is sensitive but not specific for
CNS diseases as haemorrhage, thrombosis,
multiple sclerosis.
Aspartate amino transferases (AST):- Increased
in neurological disease with bad prognosis.
Microscopic examination:
• Without centrifugation of the sample for
total leucocytic counting (cells/ ml)
• With sample centrifugation for RBCS
counting / HPF from the precipitant.
• Stained smear by Leishman stain for
determination of the type of leucocyte
• Gram's stain for microbiological
examination. a
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