Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer

The pitfalls of CA19-9: routine testing and comparison of two automated immunoassays in a reference oncology center

We evaluated CA19-9 as a marker of various malignancies and compared the results of 2 commercial immunoassays. The Abbott ARCHITECT i2000 and Roche cobas 410 immunoassays were used on 500 consecutive samples to evaluate the frequency of positive results by cancer type and the correlation between assays. The patients were tested before or after surgery and/or during chemotherapy. The rate of results exceeding conventional thresholds was 92.3% in pancreatic cancer, 36.8% in gastric cancer, and ranged from 3.0% to 35.9% in other tumors. Agreement (90.6%) and correlation (R(2) = 0.865) between the 2 assays were good and the frequency of highly discordant results was low (6/500). In some cases, interference by heterophilic antibodies was demonstrated. The 2 methods were comparable in diagnostic accuracy and had good correlation but are not interchangeable. Patients should always be monitored for CA19-9 with the same method and it should be indicated in the report.

Surgical systems biology and personalized longitudinal phenotyping in critical care

Systems-wide molecular analysis of the metabolic, inflammatory and immune response to surgical trauma has yet to be translated into the operating room. Surgical patients are exposed to a large number of heterogeneous environmental insults that cannot only be quantified by genome-orientated 'omics platforms. Furthermore, surgery demands rapid or near real-time analysis. Systems-level metabolic phenotyping provides a novel 'global' perspective of an organism's metabolic response to surgical injury and, therefore, serves as an ideal platform for the development of personalized therapies in surgery. This article reviews current personalized approaches to healthcare in surgery and explores future directions for personalized surgical biomarker discovery and therapeutics. In particular, this article discusses our vision of 'personalized metabolic phenotyping' in surgery, and outlines next-generation technologies that will make this approach a reality.

Immunodiagnostic value of combined detection of autoantibodies to tumor-associated antigens as biomarkers in pancreatic cancer

Previous studies demonstrated that cancer sera contain antibodies, which react with a unique group of autologous cellular antigens called tumour-associated antigens (TAAs). This study determines whether a panel of TAAs would enhance antibody detection and be a useful approach in pancreatic cancer (PC) detection and diagnosis. The panel of TAAs was composed of six TAAs including p53, p16, p62, survivin, Koc and IMP1 full-length recombinant proteins. Enzyme-linked immunosorbent assay (ELISA) was used to detect antibodies against these six TAAs in 23 sera from patients with PC and also 23 sera from normal individuals. Antibody frequency to any individual TAA in PC was variable and ranged from 14.7% to 30.4%. With the successive addition of TAAs to a final total of six antigens, there was a stepwise increase in positive antibody reactions reaching a sensitivity of 60.9% and a specificity of 87.0% in PC. Positive and negative likelihood ratio were 4.685 and 0.449, respectively. Positive and negative predictive values were, respectively, 82.4% and 69.0%. Agreement rate and Kappa value were 73.9% and 0.478, respectively. The data from this study support our previous hypothesis that using a panel of appropriately selected TAAs can enhance autoantibody detection in immunodiagnosis of PC. In 15 PC sera with carbohydrate antigen 19-9 (CA19-9) negative, 6 (40%) were found to have anti-TAA (anti-tumour associated antigens) antibodies. When CA19-9 and anti-TAAs were used together as markers in PC detection, the diagnostic sensitivity could be raised from 60.9% to 69.6%. Anti-TAA and CA19-9 were independent markers, and the simultaneous use of these two markers could raise the sensitivity of PC detection.

Relationship between CA 19-9 levels and glucose regulation in a middle-aged and elderly Chinese population

OBJECTIVE

To investigate carbohydrate antigen (CA) 19-9 levels in subjects with different glucose regulation status and assess the relationship between CA 19-9 and glucose regulation status in a Chinese population aged 40 years and older.

METHODS

A total of 2792 participants aged 40 years or older with no history of diabetes were enrolled in the present study from the Songnan region, Shanghai, China. Each participant received a two-point (at 0 and 2 hours) 75-g oral glucose tolerance test and measurements of hemoglobin A1c (Hb(A1c)) and CA 19-9 were made.

RESULTS

The CA 19-9 levels increased gradually from normal glucose regulation to impaired glucose regulation to new-onset diabetic patients (8.81, 9.84, and 11.08 U/mL, respectively, P < 0.0001 for trend). In new-onset diabetic patients, the CA 19-9 levels were positively and significantly associated with fasting plasma glucose (r = 0.20, P < 0.0001), 2 h post-load plasma glucose (r = 0.17, P = 0.0007), and Hb(A1c) (r = 0.19, P = 0.0001). Meanwhile, patients with new-onset diabetes had 3.31-fold (OR, 4.31; 95% CI, 2.00-9.32) increased higher odds ratio of elevated CA 19-9 as compared with those with normal glucose regulation after adjustments for confounders.

CONCLUSIONS

The CA 19-9 levels were significantly higher in diabetic and patients with impaired glucose regulation compared with subjects with normal glucose regulation. Diabetic status was independently associated with elevated CA 19-9. These results imply that CA 19-9 might also relate to the endocrine function of the pancreas.

Serum HSP70: a novel biomarker for early detection of pancreatic cancer

OBJECTIVES

Heat shock protein 70 (HSP70) is overexpressed in human pancreatic cancer cell lines. To determine if serum HSP70 levels are elevated in patients with pancreatic cancer and can function as a biomarker for early detection of pancreatic cancer.

METHODS

Study subjects were divided into 3 groups: histologically proven pancreatic cancer (PC; n = 23), chronic pancreatitis (CP; n = 12), and matched normal control subjects (C; n = 10). Serum HSP70 levels were determined using a novel immunoelectrophoresis method developed and validated by the authors. Significance of difference between the groups was analyzed with analysis of variance (ANOVA). Receiver operating characteristic (ROC) curve analysis was performed to discriminate patients with pancreatic cancer from normal controls.

RESULTS

The mean ± SE serum HSP70 levels in the PC, CP, and C groups were 1.68 ± 0.083 ng/mL, 0.40 ± 0.057 ng/mL, and 0.04 ng/mL, respectively. Serum HSP70 levels in the PC group were significantly higher compared with either the CP or C groups (P < 0.01). The sensitivity and specificity of elevated serum HSP70 in the PC group was 74% and 90%, respectively.

CONCLUSIONS

Serum HSP70 levels are significantly increased in patients with pancreatic cancer and may be useful as an additional biomarker for the detection of pancreatic cancer.

Bioinformatic identification of proteins with tissue-specific expression for biomarker discovery

BACKGROUND

There is an important need for the identification of novel serological biomarkers for the early detection of cancer. Current biomarkers suffer from a lack of tissue specificity, rendering them vulnerable to non-disease-specific increases. The present study details a strategy to rapidly identify tissue-specific proteins using bioinformatics.

METHODS

Previous studies have focused on either gene or protein expression databases for the identification of candidates. We developed a strategy that mines six publicly available gene and protein databases for tissue-specific proteins, selects proteins likely to enter the circulation, and integrates proteomic datasets enriched for the cancer secretome to prioritize candidates for further verification and validation studies.

RESULTS

Using colon, lung, pancreatic and prostate cancer as case examples, we identified 48 candidate tissue-specific biomarkers, of which 14 have been previously studied as biomarkers of cancer or benign disease. Twenty-six candidate biomarkers for these four cancer types are proposed.

CONCLUSIONS

We present a novel strategy using bioinformatics to identify tissue-specific proteins that are potential cancer serum biomarkers. Investigation of the 26 candidates in disease states of the organs is warranted.

Comparing human pancreatic cell secretomes by in vitro aptamer selection identifies cyclophilin B as a candidate pancreatic cancer biomarker

Most cases of pancreatic cancer are not diagnosed until they are no longer curable with surgery. Therefore, it is critical to develop a sensitive, preferably noninvasive, method for detecting the disease at an earlier stage. In order to identify biomarkers for pancreatic cancer, we devised an in vitro positive/negative selection strategy to identify RNA ligands (aptamers) that could detect structural differences between the secretomes of pancreatic cancer and non-cancerous cells. Using this molecular recognition approach, we identified an aptamer (M9-5) that differentially bound conditioned media from cancerous and non-cancerous human pancreatic cell lines. This aptamer further discriminated between the sera of pancreatic cancer patients and healthy volunteers with high sensitivity and specificity. We utilized biochemical purification methods and mass-spectrometric analysis to identify the M9-5 target as cyclophilin B (CypB). This molecular recognition-based strategy simultaneously identified CypB as a serum biomarker and generated a new reagent to recognize it in body fluids. Moreover, this approach should be generalizable to other diseases and complementary to traditional approaches that focus on differences in expression level between samples. Finally, we suggest that the aptamer we identified has the potential to serve as a tool for the early detection of pancreatic cancer.

Diagnostic Role of Platelet Lymphocyte Ratio(PLR) in Pancreatic Head Masses

Masses in and around pancreas constitute an important clinical entity in gastrointestinal surgical practice. Most common being adenocarcinoma of head of pancreas followed by inflammatory masses due to chronic pancreatitis. Accurate diagnosis is of central importance as therapeutic strategies range from observation to complete surgical removal including total pancreatectomy.Several tumor markers are available which could help in prognostication and diagnosis of carcinoma pancreas. Carbohydrate antigen 19-9(CA 19-9) is traditionally accepted best marker available. The role of new tumor marker platelet lymphocyte ratio (PLR) has been defined recently in prognostication of carcinoma pancreas. Role of PLR in diagnosing and its efficacy after combining it with CA 19-9 is not known. The aim of study was to assess the demographics of histologically proven neoplastic and inflammatory pancreatic head masses in our department. To assess the role of CA19-9 and platelet lymphocyte ratio(PLR) in determining nature of pancreatic head mass. Data consisted of histologically proven 45 patients .23 having head mass due to chronic pancreatitis and 22 because of neoplastic lesions. Demographics in terms of age, sex, previous pain episodes, presence of jaundice, history of alcohol intake were compared in both groups. Also tumor markers CA 19-9 and PLR individually and in combination were compared in both groups. Cancer pancreas significantly (p < 0.001) occurred in older age group, was significantly associated with jaundice (p = 0.005) and weight loss (p < 0.001). Accuracy in diagnosis of cancer pancreas was similar with CA 19-9 and PLR (68.89 %), where as combining CA 19-9 with PLR showed increased sensitivity(81.82 %) and accuracy(71.11 %) in diagnosing cancer pancreas. Other combinations showed no advantage. PLR is at least as good as CA 19-9 as diagnostic marker to differentiate between malignant and inflammatory head mass of pancreas.

The prognostic and predictive value of serum CA19.9 in pancreatic cancer

Background

Current staging methods for pancreatic cancer (PC) are inadequate, and biomarkers to aid clinical decision making are lacking. Despite the availability of the serum marker carbohydrate antigen 19.9 (CA19.9) for over two decades, its precise role in the management of PC is yet to be defined, and as a consequence, it is not widely used.

Methods

We assessed the relationship between perioperative serum CA19.9 levels, survival and adjuvant chemotherapeutic responsiveness in a cohort of 260 patients who underwent operative resection for PC.

Results

By specifically assessing the subgroup of patients with detectable CA19.9, we identified potential utility at key clinical decision points. Low postoperative CA19.9 at 3 months (median survival 25.6 vs 14.8 months, P = 0.0052) and before adjuvant chemotherapy were independent prognostic factors. Patients with postoperative CA 19.9 levels >90 U/ml did not benefit from adjuvant chemotherapy (P = 0.7194) compared with those with a CA19.9 of ≤90 U/ml (median 26.0 vs 16.7 months, P = 0.0108). Normalization of CA19.9 within 6 months of resection was also an independent favorable prognostic factor (median 29.9 vs 14.8 months, P = 0.0004) and normal perioperative CA19.9 levels identified a good prognostic group, which was associated with a 5-year survival of 42%.

Conclusions

Perioperative serum CA19.9 measurements are informative in patients with detectable CA19.9 (defined by serum levels of >5 U/ml) and have potential clinical utility in predicting outcome and response to adjuvant chemotherapy. Future clinical trials should prioritize incorporation of CA19.9 measurement at key decision points to prospectively validate these findings and facilitate implementation.

New-onset diabetes in pancreatic cancer: a study in the primary care setting

BACKGROUND

Onset of diabetes mellitus (DM) is often first noted by primary care physicians. New-onset DM (duration <36 months before PaC diagnosis) can be a harbinger of pancreatic cancer (PaC). However, its clinical significance remains unclear.

METHODS

To determine the prevalence, onset, and delay in diagnosis of DM in PaC patients in the primary care setting, we retrospectively reviewed the records of consecutive patients followed in Mayo Clinic's primary care clinics (at least one visit in the preceding 2 years) from 1995 to 2009 who were eventually diagnosed with PaC. Onset of DM was the first date the fasting blood glucose was ≥126 mg/dl.

RESULTS

Of the 111 PaC patients (59 male, median age 74 years), 52 (47%) had DM of whom 30 (58%) had new-onset DM. Among the 30 with new-onset DM, 24 (80%) were asymptomatic (no cancer-specific symptoms), at DM onset. In these 24 patients, median duration of DM prior to PaC diagnosis was 6.5 (0.5-35) months, and median delay between onset and physician diagnosis of DM was 2.5 (0.25-14) months, which decreased from 8.8 (3.5-14) months in patients with DM onset between 1995 and 1999 to 0 (0-2) months, in patients with DM onset between 2004 and 2009. However, the proportion of patients with undiagnosed DM (~33%) remained unchanged.

CONCLUSIONS

Diabetes is very common (~50%) in PaC. In over a fifth of PaC, the onset of DM occurs when the cancer is asymptomatic, providing a potential window-of-opportunity to diagnose early PaC. However, nearly a third of new-onset DM in PaC remains undiagnosed.

Advances in biomarker research for pancreatic cancer

Pancreatic cancer (PC) is a leading cause of cancer related deaths in United States. The lack of early symptoms results in latestage detection and a high mortality rate. Currently, the only potentially curative approach for PC is surgical resection, which is often unsuccessful because the invasive and metastatic nature of the tumor masses makes their complete removal difficult. Consequently, patients suffer relapses from remaining cancer stem cells or drug resistance that eventually lead to death. To improve the survival rate, the early detection of PC is critical. Current biomarker research in PC indicates that a serum carbohydrate antigen, CA 19-9, is the only available biomarker with approximately 90% specificity to PC. However, the efficacy of CA 19-9 for assessing prognosis and monitoring patients with PC remains contentious. Thus, advances in technology and the detection of new biomarkers with high specificity to PC are needed to reduce the mortality rate of pancreatic cancer.

Requests for tumor marker tests in Turkey without indications and frequency of elevation in benign conditions

AIMS

To investigate the incidence of ordering tests for tumor markers which are used in cancer diagnosis, follow-up treatment and detection of recurrence, the rate of elevation in benign diseases and which clinics order them frequently.

MATERIALS AND METHOD

Data for the tumor markers carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), cancer antigen 125 (CA 125), cancer antigen 15-3 (CA 15-3) and alpha- fetoprotein (AFP) that were ordered by all the clinics in our Hospital between 2010 and 2011 were screened. When excluding repeated orders the results of 3,416 patients were available. It has been determined that in which benign diseases were the tumor markers frequently ordered and which of these conditions had high levels of them.

RESULTS

CA 19-9 was ordered for 1,858 patients 191 (10.3%) were malignant while 1667 (89.7%) were ordered in benign diseases. For CEA the total was 1,710, 226 (13.2%) malignant and 1484 (86.8%) benign, and for CA 125 1267, 111 (8.8%) malignant and 1156 (91.2%) benign. AFP was ordered for 1687 cases, 80 (4.7%) malignant but 1607 (95.3%) benign. CA 15-3 was ordered 1449 times, 174 (12%) for malignant and 1275 (88%) for benign diseases. In all cases, considerable proportions were positive.

CONCLUSIONS

It was shown that clinicians frequently order tumor markers for benign conditions. The findings of this study has shown that tumor markers are used widely without indications as cancer screening tests.

Enhanced discrimination of malignant from benign pancreatic disease by measuring the CA 19-9 antigen on specific protein carriers

The CA 19-9 assay detects a carbohydrate antigen on multiple protein carriers, some of which may be preferential carriers of the antigen in cancer. We tested the hypothesis that the measurement of the CA 19-9 antigen on individual proteins could improve performance over the standard CA 19-9 assay. We used antibody arrays to measure the levels of the CA 19-9 antigen on multiple proteins in serum or plasma samples from patients with pancreatic adenocarcinoma or pancreatitis. Sample sets from three different institutions were examined, comprising 531 individual samples. The measurement of the CA 19-9 antigen on any individual protein did not improve upon the performance of the standard CA 19-9 assay (82% sensitivity at 75% specificity for early-stage cancer), owing to diversity among patients in their CA 19-9 protein carriers. However, a subset of cancer patients with no elevation in the standard CA 19-9 assay showed elevations of the CA 19-9 antigen specifically on the proteins MUC5AC or MUC16 in all sample sets. By combining measurements of the standard CA 19-9 assay with detection of CA 19-9 on MUC5AC and MUC16, the sensitivity of cancer detection was improved relative to CA 19-9 alone in each sample set, achieving 67–80% sensitivity at 98% specificity. This finding demonstrates the value of measuring glycans on specific proteins for improving biomarker performance. Diagnostic tests with improved sensitivity for detecting pancreatic cancer could have important applications for improving the treatment and management of patients suffering from this disease.

CA 19-9 in pancreatic cancer: retrospective evaluation of patients with suspicion of pancreatic cancer

CA 19.9 serum levels were prospectively determined in 573 patients admitted to hospital for suspicion of pancreatic cancer. The final diagnosis was 77 patients with no malignancy, 389 patients with pancreatic cancer, 37 neuroendocrine pancreatic cancer, 28 cholangiocarcinomas, 4 gallbladder cancer, 27 ampullary carcinomas, and 11 periampullary carcinomas. CA 19.9 was determined using a commercial assay from Roche Diagnostics, and 37 U/ml was considered as the upper limit of normality. Abnormal CA 19.9 serum levels were found in 27%, 81.5%, 85.7%, 59.3%, 63.6%, and 18.9% of patients with benign diseases, pancreatic cancer, cholangiocarcinomas, and ampullary, periampullary, or neuroendocrine tumors. Significantly higher concentrations of CA 19.9 were found in patients with than in those without malignancy or with neuroendocrine tumors. CA 19.9 serum levels were higher in pancreatic cancer or cholangiocarcinoma than in other malignancies (p < 0.0001). CA 19.9 serum levels were also correlated with tumor stage, treatment (significantly lower concentrations in resectable tumors), and tumor location (the highest in those located in the body, the lowest in those in the tail or uncinate) and site of metastases (highest in liver metastases). A trend to higher CA 19.9 serum concentrations was found in patients with jaundice, but only with statistical significance in the early stages. Using 50 or 100 U/ml in patients with jaundice, CA 19.9 was useful as an aid in the diagnosis of pancreatic cancer (sensitivity 77.9%, specificity 95.9%) as well as tumor resectability in pancreatic cancer with different cutoffs according to tumor location and bilirubin serum levels with specificities ranging from 90% to 100%. CA 19.9 is the tumor marker of choice in pancreatic adenocarcinomas, with a clear relationship with tumor location, stage, and resectability.

A pilot study to explore circulating tumour cells in pancreatic cancer as a novel biomarker

Background:

Obtaining tissue for pancreatic carcinoma diagnosis and biomarker assessment to aid drug development is challenging. Circulating tumour cells (CTCs) may represent a potential biomarker to address these unmet needs. We compared prospectively the utility of two platforms for CTC enumeration and characterisation in pancreatic cancer patients in a pilot exploratory study.

Patients and methods:

Blood samples were obtained prospectively from 54 consenting patients and analysed by CellSearch and isolation by size of epithelial tumour cells (ISET). CellSearch exploits immunomagnetic capture of CTCs-expressing epithelial markers, whereas ISET is a marker independent, blood filtration device. Circulating tumour cell expression of epithelial and mesenchymal markers was assessed to explore any discrepancy in CTC number between the two platforms.

Results:

ISET detected CTCs in more patients than CellSearch (93% vs 40%) and in higher numbers (median CTCs/7.5 ml, 9 (range 0–240) vs 0 (range 0–144)). Heterogeneity observed for epithelial cell adhesion molecule, pan-cytokeratin (CK), E-Cadherin, Vimentin and CK 7 expression in CTCs may account for discrepancy in CTC number between platforms.

Conclusion:

ISET detects more CTCs than CellSearch and offers flexible CTC characterisation with potential to investigate CTC biology and develop biomarkers for pancreatic cancer patient management.

The predictive value of mean platelet volume in differential diagnosis of non-functional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas

OBJECTIVE

The aim of the present study is to evaluate in a retrospective manner the diagnostic value of mean platelet volume (MPV) in pancreatic adenocarcinomas and pancreatic neuroendocrine tumors (PNETs).

PATIENTS AND METHODS

A total of 92 patients, who were admitted for pancreatic adenocarcinoma (n=76) and PNET (n=16) between March 2007 and December 2009, were analyzed retrospectively for demographics and clinical information.

RESULTS

Thirty-nine patients (51.3%) had a resectable, whereas 37 patients (48.7%) had an unresectable pancreatic adenocarcinoma. Nine patients (56.3%) had a non-functional PNET, 6 patients (37.5%) had an insulinoma, and the remaining one patient had a gastrinoma. The mean age was 59.3±10.5 for pancreatic adenocarcinomas and 45.1±10.6 for PNETs. The mean age at diagnosis was significantly higher in patients with pancreatic adenocarcinomas than the patients with PNET (p<0.001). Preoperative mean hemoglobin levels were significantly lower in patients with pancreatic adenocarcinoma than those with PNET (12.4±1.8g/dl vs 13.7±2.2g/dl), (p<0.013). The preoperative median MPV levels were significantly lower in patients with PNET 7.8fL (7.2-9.4) than in patients with pancreatic adenocarcinomas 8.6fL (6.6-13.5), (p<0.014). In subgroup analysis, a significant difference in MPV levels was mainly caused by the difference between pancreatic adenocarcinomas and non-functional PNETs (p=0.017). The cut-off value of MPV level for detection of PNETs was calculated as≤7.8fL using ROC analysis [Sensitivity: 66.7%, specificity: 75.9%, AUC: 0.734 (0.587-0.880) p=0.022]. In logistic regression analysis, independent predictive factors for determining PNETs in the differential diagnosis of pancreatic adenocarcinomas were calculated as age (OR=0.068, 95% CI: 0.012-0.398), Ca 19-9 (OR=0.039, 95% CI: 0.006-0.263), MPV (OR=0.595, 95% CI: 0.243-1.458), and hemoglobin (OR=1.317, 95% CI: 0.831-2.086).

CONCLUSION

Age, Ca 19-9, MPV, and hemoglobin levels have diagnostic value for distinguishing PNETs from pancreatic adenocarcinomas.

Urine metabolic signature of pancreatic ductal adenocarcinoma by (1)h nuclear magnetic resonance: identification, mapping, and evolution

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis and is highly chemoresistant. Early detection is the only means to impact long-term survival, but screening methods are lacking. Given the complex and heterogeneous nature of pancreatic cancer, unbiased analytical methods such as metabolomics by nuclear magnetic resonance (NMR) spectroscopy show promise to identify disease-specific molecular fingerprints. NMR profiles constitute a fingerprint of the biofluid, reporting quantitatively on all detectable small biomolecules. NMR spectroscopy was applied to investigate the urine metabolome of PDAC patients (n = 33) and to detect altered metabolic profiles in comparison with healthy matched controls (n = 54). The spectral data were analyzed using multivariate statistical techniques. Statistically significant differences were found between urine metabolomic profiles of PDAC and control individuals (p < 10(-5)). Group discrimination was possible due to average concentration differences of several metabolite signals, pointing to a multimolecular signature of the disease. The robustness of the determined statistical model is confirmed by its predictive performance (sensitivity = 75.8%, specificity = 90.7%). Additionally, the method allowed for a neat separation between spectral profiles of individuals with intermediate and advanced pathologic staging, as well as for the discrimination of samples based on tumor localization. NMR spectroscopy analysis of urinary metabolic profiles proved successful in identifying a complex molecular signature of PDAC. Furthermore, results of a descriptive-level analysis show the possibility to follow disease evolution and to carry out tumor site mapping. Given the high reproducibility and the noninvasive nature of the analytical procedure, the described method bears potential to impact large-scale screening programs.

Mining the malignant ascites proteome for pancreatic cancer biomarkers

Pancreatic cancer (PC) is one of the most lethal malignancies and disease-specific biomarkers are desperately needed for better diagnosis, prognosis, monitoring treatment efficacy and for accelerating the development of novel targeted therapeutics. Being an advanced stage manifestation and a proximal fluid in contact with cancer tissues, the ascitic fluid presents itself as a promising rich source of biomarkers. Herein, we present a comprehensive proteomic analysis of pancreatic ascitic fluid. To fractionate the complex ascites proteome, we adopted a multi-dimensional chromatographic approach that included size-exclusion, ion-exchange and lectin-affinity chromatographic techniques. Our detailed proteomic analysis with high-resolution Orbitrap(®) mass spectrometer resulted in the identification of 816 proteins. We followed rigorous filtering criteria that consisted of PC-specific information obtained from three publicly available databases (Oncomine, Protein Atlas and Unigene) to segregate 20 putative biomarker candidates for future validation. Since these proteins are of membranous and extra-cellular origin, most are glycosylated, and many of them are over-expressed in cancer tissues, the probability of these proteins entering the peripheral blood circulation is high. Their validation as serological PC biomarkers in the future is highly warranted.

Integrated proteomic profiling of cell line conditioned media and pancreatic juice for the identification of pancreatic cancer biomarkers

Pancreatic cancer is one of the leading causes of cancer-related deaths, for which serological biomarkers are urgently needed. Most discovery-phase studies focus on the use of one biological source for analysis. The present study details the combined mining of pancreatic cancer-related cell line conditioned media and pancreatic juice for identification of putative diagnostic leads. Using strong cation exchange chromatography, followed by LC-MS/MS on an LTQ-Orbitrap mass spectrometer, we extensively characterized the proteomes of conditioned media from six pancreatic cancer cell lines (BxPc3, MIA-PaCa2, PANC1, CAPAN1, CFPAC1, and SU.86.86), the normal human pancreatic ductal epithelial cell line HPDE, and two pools of six pancreatic juice samples from ductal adenocarcinoma patients. All samples were analyzed in triplicate. Between 1261 and 2171 proteins were identified with two or more peptides in each of the cell lines, and an average of 521 proteins were identified in the pancreatic juice pools. In total, 3479 nonredundant proteins were identified with high confidence, of which ∼ 40% were extracellular or cell membrane-bound based on Genome Ontology classifications. Three strategies were employed for identification of candidate biomarkers: (1) examination of differential protein expression between the cancer and normal cell lines using label-free protein quantification, (2) integrative analysis, focusing on the overlap of proteins among the multiple biological fluids, and (3) tissue specificity analysis through mining of publically available databases. Preliminary verification of anterior gradient homolog 2, syncollin, olfactomedin-4, polymeric immunoglobulin receptor, and collagen alpha-1(VI) chain in plasma samples from pancreatic cancer patients and healthy controls using ELISA, showed a significant increase (p < 0.01) of these proteins in plasma from pancreatic cancer patients. The combination of these five proteins showed an improved area under the receiver operating characteristic curve to CA19.9 alone. Further validation of these proteins is warranted, as is the investigation of the remaining group of candidates.

-The advancement of biomarker-based diagnostic tools for ovarian, breast, and pancreatic cancer through the use of urine as an analytical biofluid

Despite considerable advancements, the development of effective cancer screening tools based on serum biomarker measurements has thus far failed to achieve a meaningful clinical impact. The incremental progress observed over the course of serum biomarker development suggests that further refinements based on novel approaches may yet result in a breakthrough. The use of urine as an analytical biofluid for biomarker development may represent such an approach. The unique characteristics of urine including a high level of stability, ease of sampling, and an inactive and low-complexity testing matrix offer several potential advantages over the use of serum. A number of recent reports have demonstrated the utility of urine in the identification of novel cancer biomarkers and also the improved performance of biomarkers previously evaluated in serum. In this review, advancements related to the use of urine biomarkers within the settings of ovarian, breast, and pancreatic cancer are presented and discussed. Findings regarding the identification of specific urine biomarkers for each disease are highlighted along with comparative analyses of urine and serum biomarkers as diagnostic tools.

Serum biomarker panels for the detection of pancreatic cancer

PURPOSE

Serum-biomarker based screening for pancreatic cancer could greatly improve survival in appropriately targeted high-risk populations.

EXPERIMENTAL DESIGN

Eighty-three circulating proteins were analyzed in sera of patients diagnosed with pancreatic ductal adenocarcinoma (PDAC, n = 333), benign pancreatic conditions (n = 144), and healthy control individuals (n = 227). Samples from each group were split randomly into training and blinded validation sets prior to analysis. A Metropolis algorithm with Monte Carlo simulation (MMC) was used to identify discriminatory biomarker panels in the training set. Identified panels were evaluated in the validation set and in patients diagnosed with colon (n = 33), lung (n = 62), and breast (n = 108) cancers.

RESULTS

Several robust profiles of protein alterations were present in sera of PDAC patients compared to the Healthy and Benign groups. In the training set (n = 160 PDAC, 74 Benign, 107 Healthy), the panel of CA 19-9, ICAM-1, and OPG discriminated PDAC patients from Healthy controls with a sensitivity/specificity (SN/SP) of 88/90%, while the panel of CA 19-9, CEA, and TIMP-1 discriminated PDAC patients from Benign subjects with an SN/SP of 76/90%. In an independent validation set (n = 173 PDAC, 70 Benign, 120 Healthy), the panel of CA 19-9, ICAM-1 and OPG demonstrated an SN/SP of 78/94% while the panel of CA19-9, CEA, and TIMP-1 demonstrated an SN/SP of 71/89%. The CA19-9, ICAM-1, OPG panel is selective for PDAC and does not recognize breast (SP = 100%), lung (SP = 97%), or colon (SP = 97%) cancer.

CONCLUSIONS

The PDAC-specific biomarker panels identified in this investigation warrant additional clinical validation to determine their role in screening targeted high-risk populations.

Identification of blood-protein carriers of the CA 19-9 antigen and characterization of prevalence in pancreatic diseases

The current best serum marker for pancreatic cancer, CA 19-9, detects a carbohydrate antigen on multiple protein carriers. Better knowledge of the protein carriers of the CA 19-9 antigen in various disease states may lead to improved diagnostic tests. To identify proteins that carry the CA 19-9 antigen, we immunoprecipitated the CA 19-9 antigen from pooled sera and identified the associated proteins using MS. Among the high-confidence identifications, we confirmed the presence of the CA 19-9 antigen on Apolipoprotein B-100 by antibody arrays and Western blot and on kininogen, ARVCF, and Apolipoprotein E by antibody arrays. We characterized the frequency and levels of the CA 19-9 antigen on the four proteins across various patient groups (pancreatic cancer, pancreatitis, and healthy controls) using antibody arrays. Nearly, 10-25% of the subjects showed elevations of the antigen on each protein, but the elevations were not associated with disease state or total CA 19-9 levels. These results contribute to our knowledge of the carrier proteins of an important functional glycan and the rate at which the glycan is displayed. This work also demonstrates a strategy for using the complementary methods of MS and antibody microarrays to identify protein carriers of glycans and assess the diagnostic value of measuring glycans on individual proteins.

The clinical utility and limitations of serum carbohydrate antigen (CA19-9) as a diagnostic tool for pancreatic cancer and cholangiocarcinoma

BACKGROUND

CA19-9 is a tumor marker for pancreatic cancer, cholangiocarcinoma, and other malignancies. However, its sensitivity and specificity is suboptimal in clinical practice, which we hypothesized limits its clinical utility.

AIMS

To evaluate the clinical utility and limitations of CA19-9 as a tumor marker.

METHODS

We performed a retrospective review of CA19-9 levels (U/ml) in 483 consecutive patients between 2006 and 2008 at two university hospitals. We abstracted clinical, radiographic, and pathological data and final diagnoses. Descriptive and non-parametric analyses were performed.

RESULTS

Patients presenting with jaundice had the highest CA19-9 (420) compared to other complaints (<20) (p<0.01). The indications with the highest CA19-9 had evidence of biliary obstruction (71), liver mass (54), and pancreatic head mass (27) compared to other indications (<15) (p<0.01). The diagnoses with the highest CA19-9 (p<0.01) were cholangiocarcinoma (476), pancreatic cancer (161), and choledocholithiasis (138). Using a receiver operator curve to evaluate CA19-9, the area under the curve was 0.7 when evaluating all patients for pancreatic cancer or cholangiocarcinoma or patients with pancreatic head mass for pancreatic cancer.

CONCLUSIONS

This study found that for pancreatic cancer and cholangiocarcinoma, CA19-9 had poor clinical utility as a tumor marker and did not change patient management. Elevations in CA19-9 were associated with biliary obstruction based on clinical history, laboratory data, and diagnoses.

Serum concentrations of CA 125, CA 15-3, CA 19-9 and CEA in normal pregnancy: a longitudinal study

PURPOSE

Although cancer diagnosed during pregnancy is rare, the coexistence of pregnancy and malignancy becomes more common in view of prolongation of reproductive age. Therefore, it is important that the specificity of a tumor marker be evaluated during pregnancy to avoid misinterpretation in the follow-up of a pregnant cancer patient. The present study aims to investigate the serum concentrations of CA-125, CA 15-3, CA 19-9 and CEA in healthy pregnant women through gestation.

METHODS

In this prospective study, we followed thirty healthy pregnant women. Blood samples were obtained during each trimester of pregnancy (10-12, 22-24 and 34-36 weeks). The maternal serum levels of CA-125, CA 15-3, CA 19-9 and CEA were measured using electrochemiluminescence immunoassay.

RESULTS

There was no difference between the first and second trimester serum levels of CA 125, CEA and CA 19-9. However, serum CA 125 levels in third trimester were found to be significantly elevated in pregnants compared to the second trimester (median values 19.6 vs. 15.6 IU/mL, p = 0,009). Similarly, the serum CEA levels in third trimester were significantly higher than those of second trimester (median values 1.1 vs. 0.7 ng/ml, p = 0.001). It is also found that CEA and CA 19-9 assay values were significantly elevated in the third trimester of pregnancy when compared with the first trimester of pregnancy (CEA median values 1.1 vs. 0.7 ng/ml, p = 0.02 and CA 19-9 median values 11.6 vs. 7.7 IU/mL, p = 0,02). Three trimester had statistically similar levels for serum CA 15-3 (median values 17.5, 19.7 and 18.3 U/mL, respectively). The four tumor markers assay values were found generally within the normal range.

CONCLUSIONS

These findings suggest that maternal serum levels of CA 125, CEA and CA 19-9 were increased during third trimester of pregnancy. However, these elevations were within the normal range. CA 15-3 is independent of gestation and reliable tumor markers in monitoring malignancy in pregnant patients.

Predictors of malignancy in pancreatic head mass: a prospective study

Introduction

The objective of the study was to identify the predictive factors for malignancy in pancreatic head mass as a primary outcome and assess the value of CA 19-9 as a diagnostic tool for malignancy as a secondary outcome.

Methods

A prospective study of patients presented with pancreatic head mass was conducted in a tertiary care referral hospital, Manipal, India from May 2006 to November 2008. The study population was divided into malignant and benign groups based on the final histopathology report. A univariate and multivariate analysis of potential predictive factors for malignancy were conducted.

Results

A total of 102 patients with pancreatic head mass were included in the study after fulfilling the inclusion/exclusion criteria. 78 were malignant and 24 were benign. There was significant weight loss (p<0.001) and high mean bilirubin levels (p=0.002) in the malignant group. Mean CA 19-9 was significantly higher in the malignant group (290.7 vs. 30.3 U/ml; p<0.001). Sensitivity and specificity of CA 19-9 for detecting malignancy in pancreatic head mass at a cut off of 35U/ml was 86% and 79% respectively. CA 19-9 positivity rate was higher with increasing cut off values of 100, 200 and 300U/ml but such high levels occurred in fewer patients. All the non-jaundiced patients (100%) with raised CA 19-9 levels were found to be malignant compared to 86% malignancy in jaundiced patients. In multivariate analysis, a combination of weight loss>10% of body weight and bilirubin>3 mg/dl and CA 19-9>35U/ml had specificity and positive predictive value of 100% for predicting malignancy in pancreatic head mass.

Conclusion

The presence of weight loss and jaundice and raised CA 19-9 levels together in a patient with pancreatic head mass can be predictive of malignancy. A very high CA 19-9 level can be an indicator of malignancy in a pancreatic head mass. A raised CA 19-9 level may be more predictive of malignancy in non-jaundiced patients than in jaundiced patients.

An unusual case of autoimmune pancreatitis presenting as pancreatic mass and obstructive jaundice: a case report and review of the literature

Background

Autoimmune pancreatitis is a rare chronic inflammatory pancreatic disease that is increasingly being diagnosed worldwide. As a result of overlap in clinical and radiological features, it is often misdiagnosed as pancreatic cancer. We report the case of a patient with autoimmune pancreatitis that was initially misdiagnosed as pancreatic cancer.

Case presentation

A 31-year-old Caucasian man presented to our hospital with epigastric pain, jaundice and weight loss. His CA 19-9 level was elevated, and computed tomography and endoscopic ultrasound revealed a pancreatic head mass abutting the portal vein. Endoscopic retrograde cholangiopancreaticography showed narrowing of the biliary duct and poor visualization of the pancreatic duct. Fine-needle aspiration biopsy revealed atypical ductal epithelial cells, which raised clinical suspicion of adenocarcinoma. Because of the patient's unusual age for the onset of pancreatic cancer and the acuity of his symptoms, he was referred to a tertiary care center for further evaluation. His immunoglobulin G4 antibody level was 365 mg/dL, and repeat computed tomography showed features typical of autoimmune pancreatitis. The patient's symptoms resolved with corticosteroid therapy.

Conclusion

Autoimmune pancreatitis is a rare disease with an excellent response to corticosteroid therapy. Its unique histological appearance and response to corticosteroid therapy can reduce unnecessary surgical procedures. A thorough evaluation by a multidisciplinary team is important in rendering the diagnosis of autoimmune pancreatitis.

Secretome-based identification of ULBP2 as a novel serum marker for pancreatic cancer detection

Background

To discover novel markers for improving the efficacy of pancreatic cancer (PC) diagnosis, the secretome of two PC cell lines (BxPC-3 and MIA PaCa-2) was profiled. UL16 binding protein 2 (ULBP2), one of the proteins identified in the PC cell secretome, was selected for evaluation as a biomarker for PC detection because its mRNA level was also found to be significantly elevated in PC tissues.

Methods

ULBP2 expression in PC tissues from 67 patients was studied by immunohistochemistry. ULBP2 serum levels in 154 PC patients and 142 healthy controls were measured by bead-based immunoassay, and the efficacy of serum ULBP2 for PC detection was compared with the widely used serological PC marker carbohydrate antigen 19-9 (CA 19-9).

Results

Immunohistochemical analyses revealed an elevated expression of ULPB2 in PC tissues compared with adjacent non-cancerous tissues. Meanwhile, the serum levels of ULBP2 among all PC patients (n = 154) and in early-stage cancer patients were significantly higher than those in healthy controls (p<0.0001). The combination of ULBP2 and CA 19-9 outperformed each marker alone in distinguishing PC patients from healthy individuals. Importantly, an analysis of the area under receiver operating characteristic curves showed that ULBP2 was superior to CA 19-9 in discriminating patients with early-stage PC from healthy controls.

Conclusions

Collectively, our results indicate that ULBP2 may represent a novel and useful serum biomarker for pancreatic cancer primary screening.

Y-box protein-1/p18 fragment identifies malignancies in patients with chronic liver disease

Background

Immunohistochemical detection of cold shock proteins is predictive for deleterious outcome in various malignant diseases. We recently described active secretion of a family member, denoted Y-box (YB) protein-1. We tested the clinical and diagnostic value of YB-1 protein fragment p18 (YB-1/p18) detection in blood for malignant diseases.

Methods

We used a novel monoclonal anti-YB-1 antibody to detect YB-1/p18 by immunoblotting in plasma samples of healthy volunteers (n = 33), patients with non-cancerous, mostly inflammatory diseases (n = 60), hepatocellular carcinoma (HCC; n = 25) and advanced solid tumors (n = 20). YB-1/p18 was then tested in 111 patients with chronic liver diseases, alongside established tumor markers and various diagnostic measures, during evaluation for potential liver transplantation.

Results

We developed a novel immunoblot to detect the 18 kD fragment of secreted YB-1 in human plasma (YB-1/p18) that contains the cold-shock domains (CSD) 1-3 of the full-length protein. YB-1/p18 was detected in 11/25 HCC and 16/20 advanced carcinomas compared to 0/33 healthy volunteers and 10/60 patients with non-cancerous diseases. In 111 patients with chronic liver disease, YB-1/p18 was detected in 20 samples. Its occurrence was not associated with advanced Child stages of liver cirrhosis or liver function. In this cohort, YB-1/p18 was not a good marker for HCC, but proved most powerful in detecting malignancies other than HCC (60% positive) with a lower rate of false-positive results compared to established tumor markers. Alpha-fetoprotein (AFP) was most sensitive in detecting HCC, but simultaneous assessment of AFP, CA19-9 and YB-1/p18 improved overall identification of HCC patients.

Conclusions

Plasma YB-1/p18 can identify patients with malignancies, independent of acute inflammation, renal impairment or liver dysfunction. The detection of YB-1/p18 in human plasma may have potential as a tumor marker for screening of high-risk populations, e.g. before organ transplantation, and should therefore be evaluated in larger prospective studies.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Serum CA 19-9 as a Biomarker for Pancreatic Cancer-A Comprehensive Review

Pancreatic cancer is an aggressive tumor with a dismal prognosis, biomarkers that can detect tumor in its early stages when it may be amenable to curative resection may improve prognosis. At present, serum CA 19-9 is the only validated tumor marker in widespread clinical use, but precise knowledge of its role in pancreatic cancer diagnosis, staging, determining resectability, response to chemotherapy and prognosis remains limited. A comprehensive search was performed using PubMed with keywords "pancreatic cancer" "tumor markers" "CA 19-9" "diagnosis" "screening" "prognosis" "resectability" and "recurrence". All English language articles pertaining to the role of CA 19-9 in pancreatic cancer were critically analyzed to determine its utility as a biomarker for pancreatic cancer. Serum CA 19-9 is the most extensively studied and clinically useful biomarker for pancreatic cancer. Unfortunately, CA 19-9 serum level evaluation in pancreatic cancer patients is limited by poor sensitivity, false negative results in Lewis negative phenotype (5-10%) and increased false positivity in the presence of obstructive jaundice (10-60%). Serum CA 19-9 level has no role in screening asymptomatic populations, and has a sensitivity and specificity of 79-81% and 82-90% respectively for the diagnosis of pancreatic cancer in symptomatic patients. Pre-operative CA 19-9 serum level provide useful prognostic information as patients with normal CA 19-9 serum levels (<37 U/ml) have a prolonged median survival (32-36 months) compared to patients with elevated CA 19-9 serum levels (>37 U/ml) (12-15 months). A CA 19-9 serum level of <100 U/ml implies likely resectable disease whereas levels >100 U/ml may suggest unresectablity or metastatic disease. Normalization or a decrease in post-operative CA 19-9 serum levels by ≥20-50% from baseline following surgical resection or chemotherapy is associated with prolonged survival compared to failure of CA 19-9 serum levels to normalize or an increase. Carbohydrate antigen (CA 19-9) is the most extensively studied and validated serum biomarker for the diagnosis of pancreatic cancer in symptomatic patients. The CA 19-9 serum level can provide important information with regards to prognosis, overall survival, and response to chemotherapy as well as predict post-operative recurrence. Non-specific expression in several benign and malignant diseases, false negative results in Lewis negative genotype and an increased false positive results in the presence of obstructive jaundice severely limit the universal applicability of serum CA 19-9 levels in pancreatic cancer management.

CA 19-9 level in patients with type 2 diabetes mellitus and its relation to the metabolic control and microvascular complications

INTRODUCTION

The aim of this study is to compare CA 19-9 levels in patients with type 2 diabetes mellitus (DM) and healthy control group. The relation of CA 19-9 levels to metabolic control and microvascular complications in patients with diabetes was also investigated.

METHODS

Three hundred forty patients with type 2 DM and age-, sex- and body mass index-matched 214 healthy controls group were included in the study. HbA₁(c), duration of DM and microvascular complications of DM were reviewed. CA 19-9 levels (normal range, 0-35 U/mL) were measured in all participants.

RESULTS

Median CA 19-9 level was significantly higher in patients with diabetes compared with control group [19.5 U/mL (0-214.8 U/mL) versus 7.4 U/mL (0.4-47.0 U/mL)] (P < 0.001). Prevalence of high CA 19-9 levels in patients with diabetes was 31.2%, and CA 19-9 level was positively correlated with age, duration of diabetes, HbA₁(c) and number of complications. Effects of duration of diabetes, HbA₁(c) and diabetic nephropathy were still continuing in multiple linear regression analysis. Using regression coefficients of all variables in multiple regression analysis, this study tried to determine a new cutoff value for CA 19-9 level in patients with diabetes. The cutoff value at 97th percentile was 57.14 U/mL.

CONCLUSIONS

High CA 19-9 value in patients with diabetes may indicate the need for a careful evaluation of blood glucose regulation and investigation of complications. Defining a new cutoff value in these patients would prevent unnecessary laboratory or imaging procedures.

Clinical value of serum neopterin, tissue polypeptide-specific antigen and CA19-9 levels in differential diagnosis between pancreatic cancer and chronic pancreatitis

BACKGROUND

Neopterin and tissue polypeptide-specific antigen (TPS) have been suggested to be useful in differential diagnosis between pancreatic adenocarcinoma (PA) and chronic pancreatitis (CP). The aim of our study was to compare the clinical usefulness of CA19-9, neopterin and TPS serum levels in patients with PA and CP.

METHODS

The study included 85 patients with PA, 72 with CP and 50 healthy controls. The serum concentrations of neopterin, TPS and CA19-9 were measured (DRG International, USA). The associations of the analyzed markers and clinical data at diagnosis have been evaluated.

RESULTS

Serum levels of neopterin, TPS and CA19-9 were higher in PA patients compared to CP (p < 0.001). TPS and CA19-9 levels were also elevated in patients with CP compared to the control group (p < 0.001). In contrast, there was no difference between neopterin serum levels in CP patients and the control group (p > 0.05). Neopterin showed the best sensitivity and specificity (91.8 and 87.5%) in PA diagnosis compared to CA19-9 (respectively 83.5 and 75%) and TPS (75.3 and 65.3%).

CONCLUSION

Our results indicate that neopterin may be potentially useful in differential diagnosis between PA and CP. Assessment of TPS probably adds no significant information to that obtained with CA19-9 and neopterin. and IAP.

Serum biomarkers for improved diagnostic of pancreatic cancer: a current overview

PURPOSE

Complete resection constitutes the only curative approach in pancreatic cancer but is possible only in a minority of patients due to advanced stages upon diagnosis. Consequently, early detection is crucial for curative treatment. Clinical routine still lacks efficient, non-invasive screening assays, and 80-90% of pancreatic carcinomas are detected at unresectable stages. A wide range of serum proteins have been in the focus of intensive search for biomarkers specific for pancreatic cancer. This article will give an overview on serum biomarkers with screening potential for pancreatic malignancy.

DESIGN AND METHODS

PUBMED database was searched for articles, and 43 manuscripts were selected that provided data regarding biomarkers used, type of assay, study population, sample cohort quality and diagnostic performance.

RESULTS

Superior values for diagnostic performance were shown for MIC-1, PAM4, OPN, HSP27, TPS, TSGF, and CAM17.1 as individual markers. Panels of biomarkers comprised CA 19-9, MCSF, CEA, SAA, Haptoglobin, TSGF, CA 242, and HSP27. Individually or in concerted form, sensitivity and specificity ranged from 77 to 100% and 84-100%, respectively.

CONCLUSIONS

While the above named markers show high screening potential for pancreatic cancer, standardized validation studies using multiplex assays are required to pave the way for clinical routine application.

CA 19-9 level as indicator of early distant metastasis and therapeutic selection in resected pancreatic cancer

PURPOSE

In patients with pancreatic cancer treated with curative resection, we evaluated the effect of clinicopathologic parameters on early distant metastasis within 6 months (DM6m) to identify patients who might benefit from surgery.

METHODS AND MATERIALS

The study involved 84 patients with pancreatic cancer who had undergone curative resection between August 2001 and April 2009. The parameters of gender, age, tumor size, histologic differentiation, T classification, N classification, pre- and postoperative carbohydrate antigen (CA) 19-9 level, resection margin, and adjuvant chemoradiotherapy were analyzed to identify the risk factors associated with DM6m.

RESULTS

Of the 84 patients, locoregional recurrence developed in 35 (41.7%) and distant metastasis in 58 (69%). Of the 58 patients with distant metastasis, DM6m had developed in 27 (46.6%). Multivariate analysis showed that preoperative CA 19-9 level was significantly associated with DM6m (p<.05). Of all 84 patients, DM6m was observed in 9.1%, 50%, and 80% of those with a preoperative CA 19-9 level of ≤100 U/mL, 101-400 U/mL, and >400 U/mL, respectively (p<.001).

CONCLUSIONS

The preoperative CA 19-9 level might be a useful predictor of DM6m and to identify those who would benefit from surgical resection.

Identification of a novel type of CA19-9 carrier in human bile and sera of cancer patients: an implication of the involvement in nonsecretory exocytosis

Carbohydrate antigen 19-9 (CA19-9) is a well-known tumor marker for pancreatic cancer. Although the CA19-9 level is measured using anti-sialyl Lewis A antibodies, it remains unknown which molecules carry CA19-9 other than mucins. Here we report the identification and characterization of a novel type of CA19-9 carrier, BGM (bile globular membrane), which is thought to exist in normal bile and to be secreted into sera of patients with pancreatic cancer. We purified the BGM from bile juice using a β-casein column because surface plasmon resonance analysis could detect such carrier vesicles binding to β-casein in sera of patients with pancreatic cancer. We identified characteristic molecules for BGM such as AHNAK (desmoykoin) and a novel golgin family member, CABIN (CAsein Binding domain integral protein with golgIN motif) by mass spectrometry analysis. BGM was detected in the sera of patients with pancreatic cancer as well as athymic mice with transplanted pancreatic cancer cells. Down regulation of CABIN inhibited the secretion of CA19-9 on BGM in pancreatic cancer cell lines. We measured and visualized BGM in sera of patients with cancer. Thus, BGM might be another CA19-9 carrier (glyco-lipids on membrane vesicles) other than mucins and could be applied to the diagnosis of pancreatic cancer.

Standardized peptidome profiling of human serum for the detection of pancreatic cancer

OBJECTIVE

To establish new biomarkers for accurate diagnosis of pancreatic cancer (PC) using a standardized serum peptidome profiling and compare the results with those from the tumor marker, CA 19-9.

METHODS

Serum samples from 102 patients (55 with chronic pancreatitis and 47 with PC) and 56 healthy controls were collected and analyzed following a protocol that was rigorously designed to prevent preanalytical variation. Serum peptides were extracted using immobilized copper ion chromatography on a robotic platform. Mass spectra were acquired by matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry on an Autoflex II spectrometer (Bruker Daltonics, Bremen, Germany). Statistical analysis was performed using the Clinprotools 2.2 software (Bruker Daltonics) and the SPSS 15.0 software (SPSS Inc, Chicago, Ill).

RESULTS

Standardized peptidome profiling showed a median coefficient of variation of 11.6% calculated using all the extracted peptides and negligible influence of sex and age on peptidome profiles. The diagnostic sensitivity was 89.9%, and the diagnostic specificity was 92.7%, using 2 serum features and CA 19-9 serum concentration. Healthy controls were differentiated from patients with PC and chronic pancreatitis, with the use of 3 features of the peptidome (diagnostic sensitivity, 98.2%; diagnostic specificity, 97.1%).

CONCLUSIONS

Standardized serum peptidome profiling could be a useful tool to improve biochemical diagnosis of PC in combination with the classic tumor marker, CA 19-9.

Detection of pancreatic adenocarcinoma using circulating fragments of fibrinogen

BACKGROUND

There is an urgent need for biomarkers to detect pancreatic cancer in the early, potentially curable, stages.

METHODS

We have used SELDI profiling to analyze serum from 75 patients with pancreatic cancer and 61 patients with nonmalignant pancreaticobiliary diseases.

RESULTS

A peak in the SELDI spectra corresponding to a 53 residue fragment of the α-chain of fibrinogen is remarkably elevated in approximately 50% of the cancer patients. In addition, fibrinogen degradation products were measured using the DR-70 assay. The areas under the receiver operating characteristic curves for the SELDI-detected fibrinogen fragment, DR-70 and CA19-9 were 0.65, 0.75 and 0.86, respectively. Class prediction models using combinations of these markers did not increase the area under the receiver operating characteristic curve compared with CA19-9. The novel fibrinogen fragment was not elevated to the same extent in other malignancies but was elevated in some patients with benign pancreatic disease.

CONCLUSION

Both the SELDI-detected fragment of fibrinogen and DR-70 are significantly elevated in the serum of pancreatic cancer patients. However, they do not seem to improve pancreatic cancer detection over CA19-9 alone.

Pilot study of blood biomarker candidates for detection of pancreatic cancer

OBJECTIVES

Biomarkers that detect pancreatic cancer at earlier stages could improve the outcome of this deadly disease.

METHODS

We investigated a dozen biomarker candidates for their potential as pancreatic cancer blood biomarkers using enzyme-linked immunosorbent assays.

RESULTS

Among them, the macrophage migration inhibitory factor and osteopontin blood tests were nearly perfect in distinguishing pancreatic cancer cases from healthy controls (100% and 95% sensitivity, respectively, at 100% specificity). Five biomarker candidates were then tested on an expanded set of diseased controls, which included sera from patients with pancreatitis. The sensitivity dropped significantly for all 5 candidate markers.

CONCLUSIONS

Our results suggest that biomarker candidates could fail in various steps of biomarker development. Earlier knowledge of candidate biomarker flaws could lead to strategies to overcome the flaw or alternatively lead to earlier termination of biomarkers that are prone to failure in the later phases of validation testing.

Discovery of serum biomarkers for pancreatic adenocarcinoma using proteomic analysis

Background and aims:

The serum/plasma proteome was explored for biomarkers to improve the diagnostic ability of CA19-9 in pancreatic adenocarcinoma (PC).

Methods:

A Training Set of serum samples from 20 resectable and 18 stage IV PC patients, 54 disease controls (DCs) and 68 healthy volunteers (HVs) were analysed by surface-enhanced laser desorption and ionisation time-of-flight mass spectrometry (SELDI-TOF MS). The resulting protein panel was validated on 40 resectable PC, 21 DC and 19 HV plasma samples (Validation-1 Set) and further by ELISA on 33 resectable PC, 28 DC and 18 HV serum samples (Validation-2 Set). Diagnostic panels were derived using binary logistic regression incorporating internal cross-validation followed by receiver operating characteristic (ROC) analysis.

Results:

A seven-protein panel from the training set PC vs DC and from PC vs HV samples gave the ROC area under the curve (AUC) of 0.90 and 0.90 compared with 0.87 and 0.91 for CA19-9. The AUC was greater (0.97 and 0.99, P<0.05) when CA19-9 was added to the panels and confirmed on the validation-1 samples. A simplified panel of apolipoprotein C-I (ApoC-I), apolipoprotein A-II (ApoA-II) and CA19-9 was tested on the validation-2 set by ELISA, in which the ROC AUC was greater than that of CA19-9 alone for PC vs DC (0.90 vs 0.84) and for PC vs HV (0.96 vs 0.90).

Conclusions:

A simplified diagnostic panel of CA19-9, ApoC-I and ApoA-II improves the diagnostic ability of CA19-9 alone and may have clinical utility.

[A case of cholangiocarcinoma suspected by continuous elevation of CA 19-9 after surgery of xanthogranulomatous cholecystitis]

Xanthogranulomatous cholecystitis (XGC) is an unusual and destructive inflammatory process that is characterized by thickening of the gallbladder (GB) wall with a tendency to adhere to neighboring organs. XGC is often mistaken for GB carcinoma, and the frequency of the coexistence of these two lesions is approximately 10%. Therefore, in case of severe XGC, there is chance of either overlooking the carcinoma or other significant lesions. CA 19-9 is commonly measured in the serum of patients with hepatobiliary malignancies. Although CA 19-9 can be elevated in benign conditions such as cholestasis, pancreatitis, tuberculosis, thyroid disease etc., malignancy should be considered at first in setting of its significant and persistent elevation. We report a case of a 62-year-old man who showed continuously rising level of CA19-9 over 2000 U/mL after cholecystectomy for xanthogranulomatous cholecystitis and finally was diagnosed as cholangiocarcinoma by short-term follow up.

Serum tumor markers in pancreatic cancer-recent discoveries

The low prevalence of pancreatic cancer remains an obstacle to the development of effective screening tools in an asymptomatic population. However, development of effective serologic markers still offers the potential for improvement of diagnostic capabilities, especially for subpopulations of patients with high risk for pancreatic cancer. The accurate identification of patients with pancreatic cancer and the exclusion of disease in those with benign disorders remain important goals. While clinical experience largely dismissed many candidate markers as useful markers of pancreatic cancer, CA19-9 continues to show promise. The present review highlights the development and the properties of different tumor markers in pancreatic cancer and their impact on the diagnostic and treatment of this aggressive disease.

Postoperative chemoradiotherapy for extrahepatic bile duct cancer

PURPOSE

To evaluate the effect of postoperative concurrent chemoradiotherapy using three-dimensional conformal radiotherapy and to identify the prognostic factors that influence survival in patients with extrahepatic bile duct cancer.

METHODS AND MATERIALS

We retrospectively analyzed the data from 101 patients with extrahepatic bile duct cancer who had undergone postoperative concurrent chemoradiotherapy using three-dimensional conformal radiotherapy. Of the 101 patients, 52 (51%) had undergone complete resection (R0 resection) and 49 (49%) had microscopic or macroscopic residual tumors (R1 or R2 resection). The median radiation dose was 50 Gy. Also, 85 patients (84%) underwent concurrent chemotherapy with 5-fluorouracil.

RESULTS

The median follow-up period was 47 months for the surviving patients. The 5-year overall survival rate was 34% for all patients. A comparison between patients with R0 and R1 resection indicated no significant difference in the 5-year overall survival (44% vs. 33%, p=.2779), progression-free survival (35% vs. 22%, p=.3107), or locoregional progression-free survival (75% vs. 63%, p=.2784) rates. An analysis of the first failure site in the 89 patients with R0 or R1 resection indicated isolated locoregional recurrence in 7 patients. Elevated postoperative carbohydrate antigen 19-9 level was an independent prognostic factor for overall survival (p=.001) and progression-free survival (p=.033). A total of 3 patients developed Grade 3 or greater late toxicity.

CONCLUSION

Adjuvant concurrent chemoradiotherapy using three-dimensional conformal radiotherapy appears to improve locoregional control and survival in extrahepatic bile duct cancer patients with R1 resection. The postoperative carbohydrate antigen 19-9 level might be a useful prognostic marker to select patients for more intensified adjuvant therapy.

Serum CA19-9 alterations during preoperative gemcitabine-based chemoradiation therapy for resectable invasive ductal carcinoma of the pancreas as an indicator for therapeutic selection and survival

OBJECTIVE

To evaluate serum CA19-9 alterations during preoperative gemcitabine-based chemoradiation therapy (CRT) for resectable pancreatic cancer (PC) in the earlier identification of patients who are likely to benefit from subsequent resection.

SUMMARY BACKGROUND DATA

One of the advantages of the preoperative CRT strategy for patients with advanced PC is that undetectable systemic disease may be revealed during preoperative CRT, thus avoiding unnecessary surgery. Serum CA19-9 has been evaluated as a predictive indicator of the treatment efficacy and outcome in various clinical settings.

METHODS

We retrospectively reviewed 64 consecutive patients with resectable PC (at diagnosis) who received preoperative CRT at our hospital between 2002 and 2008. Patients were divided into 2 groups (efficacy grouping) to evaluate the efficacy of preoperative CRT according to the clinical course. Group A included patients who were unable to receive the subsequent resection due to the development of unresectable factors during preoperative CRT and those who received the subsequent resection but developed recurrent disease within 6 months after surgery; group B included patients who received the subsequent resection and survived without recurrences for more than 6 months after surgery. We developed a new classification utilizing pretreatment CA19-9 and proportional alteration of CA19-9 2 months after the initiation of treatment. The categories were defined as: I (increased), MD (modestly decreased), and SD (substantially decreased). Clinicopathological variables and CA19-9 alteration status were correlated with the efficacy grouping and overall survival.

RESULTS

All of the category I patients were included in group A, 93.5% of the category SD patients in group B, and approximately half of the category MD patients in group A. CA19-9 alteration status was a single independent variable associated with efficacy grouping and overall patient survival, with the 1-year survival rate of category I patients, and the 4-year survival rate of category MD and SD patients being 22.2%, 34.1%, and 58.9%, respectively.

CONCLUSIONS

CA19-9 alteration status is useful in identifying those who will benefit from the preoperative CRT and subsequent resection and those who will not; it was a significant predictor for patient prognosis in the setting of the preoperative CRT strategy for resectable PC.