Although the presence of specific morphological criteria enables neoplastic cells to be easily identified and distinguished from normal cell populations in many histological specimens, it is not always possible to distinguish dysplastic or neoplastic cells from cells showing reactive or degenerative changes in cytological preparations. The identification of atypical cells may be particularly difficult in cytological specimens where few neoplastic cells are present amongst a diffuse background of normal or reactive cells. In particular, the use of morphological criteria is often insufficient for the accurate detection of neoplastic cells from early carcinomas or preinvasive dysplastic lesions in cytological specimens, as a result of the small numbers of neoplastic cells present. It has been advocated that differences in the expression of specific biological markers between normal and neoplastic cells may be useful in the early detection of common carcinomas and in the monitoring of treatment and detection of recurrence
1.1.5.1 Tumour markers
Tumour markers are biological substances that are produced by neoplastic cells. They may be secreted into the blood, making them detectable as serum markers, or may remain localised in tumour cells allowing their identification in histological or cytological specimens of the tumour. The first tumour markers were described in colorectal carcinomas over 30 years ago (Gold et a l, 1965). Since then, several different tumour markers have been identified and are in current use (Table 1.2).
All these markers show clinical limitations in terms of their sensitivity and specificity and are not routinely used for the screening of asymptomatic populations. As most of these markers are also produced by normal cells, albeit at lower levels than that found in neoplastic cells, there is considerable overlap between the expression of these markers in normal tissues and preinvasive lesions or early carcinomas. Indeed, some tumour markers, such as prostate specific antigen (PSA), cannot reliably distinguish benign from malignant disease (Aziz et a l, 1993). Their clinical use is thus restricted to symptomatic patients with suspected malignancy or for the identification of tumour recurrence after surgical excision.
Table 1.2 Sum m ary of biological tum our m arkers (Ramies, 1996)
M arker Carcinom a Comments
Carcinoembryonic antigen (CEA) Colon, lung Diagnostic and treatment monitoring
Alpha fetoprotein (AFP) Ovary, testis Diagnostic
Acid phosphatase (AP) Prostate Diagnostic and treatment monitoring
Human chorionic gonadotrophin (HCG) Placenta, testis Diagnostic and treatment monitoring
Oestrogen receptor (ER) Breast Prognostic
Prostate specific antigen (PSA) Prostate Diagnostic and treatment monitoring
CA125 Breast, ovary Diagnostic and treatment monitoring
CA 19.9 Colon, ovary Diagnostic and treatment monitoring
CA 15.3 Breast Diagnostic and treatment monitoring
1) Markers fo r colorectal carcinoma
Colorectal carcinoma is the second most common cause of malignancy in both men and women. Although early (stage I) tumours have a 5-year survival rate of 90%, symptoms usually present late and the colorectal carcinoma is often diagnosed when it has extended beyond the muscle wall of the bowel. Carcinoembryonic antigen (CEA) is detectable both in the serum of patients with colorectal carcinoma, and in the histological sections of these tumours. However, the finding that CEA is also detectable in normal colon, as well as other types o f tumour, makes it of little value for the screening or early diagnosis of colorectal carcinoma. The clinical use of CEA is therefore restricted to the detection of tumour recurrence in those patients with a previously resected colorectal carcinoma. In order to diagnose recurrence of a colorectal carcinoma, two consecutive elevations of serum CEA must be detected and this results in a sensitivity of 84% and specificity of 100% (Ballesta et al., 1995). Similarly, whilst serum protease inhibitor (PI) is elevated in the initial stages of most colorectal carcinomas, its high false-positive and false-negative rate have limited its clinical use to the detection of tumour recurrence (Pamies, 1996).
More recently, the use of mucin histochemical markers has been proposed as a potential screening test for the identification o f early colorectal carcinomas (Shamsuddin et al., 1994). It has been found that the characteristics of mucins in the rectum are altered by malignant transformation, with increased production of the disaccharide GAINac and galactose oxidase. The levels of other tumour-related mucins, including CAM26, CAM29, CA 15.3 and CA 549, are also altered in the presence of colorectal carcinoma and may be useful for detection of tumour recurrence and monitoring o f treatment (Yedema et al., 1991). However, no biochemical marker is presently advocated for the early detection of colorectal carcinoma, as part o f a noninvasive, population-based screening test in asymptomatic individuals.
2) Markers fo r prostatic carcinoma
Prostatic carcinoma occurs in men over the age of 40, and shows a rising annual incidence. The American Cancer Society has advocated that routine digital rectal examination and serum prostate specific antigen (PSA) measurements should be performed annually as a screening measure for the detection of early prostatic carcinomas (American Cancer Society, 1992). Although PSA has shown 90% sensitivity for the detection of prostatic carcinoma, its specificity (60%) is not sufficient to allow its use as a sole agent in mass screening. In particular, a case of benign prostatic hypertrophy can result in the same level of serum PSA as an early prostatic carcinoma (Littrup et a l, 1992). The use of age-related serum PSA cutoff values has been suggested as a way of increasing the sensitivity in young men and the specificity in older men, but at the expense of the positive predictive value of the test (Brawer et al., 1993). The level of serum prostatic acid phosphatase (PAP) whilst not a useful marker of prostatic carcinoma on its own, may be used to improve the sensitivity of PSA. At present, PSA is most useful for monitoring of treatment and detection of recurrence in prostatic carcinoma, and its use in the detection of early carcinomas must be interpreted with caution.
3) Markers fo r breast carcinoma
Breast cancer is the most frequent type of carcinoma in women and accounts for 4% of all deaths in Western Europe and North America (Meden et a l, 1995). Current screening procedures include breast self-examination, clinical examination and mammography, with the mortality rate in women who participate in screening programmes being 50% lower than for women who have not been screened (Shapiro et a l, 1985). Efforts are currently being made to identify tumour markers that can be used for early diagnosis and patient follow-up. The tumour markers CA 15.3 and CA 549 have good sensitivity and specificity for metastatic breast carcinoma but low sensitivity for localised disease, making them suitable markers for tumour recurrence rather than for the early detection o f breast carcinomas. Mucins, including M26, M29 and mucin-like carcinoma associated antigen (MCA), are also useful for the
detection of tumour recurrence. In contrast, MUC 1 is expressed predominantly in normal breast epithelium and its expression is altered in histological sections of breast carcinoma.
Most recently, the finding that overexpression of the c-erbB2 protein occurs in up to 25% of invasive ductal breast carcinomas and correlates with poor prognostic outcome has resulted in the use of this marker for the identification of breast carcinoma in fine needle aspirates (FNA) of the breast. Wu et al. have reported that an enzyme immunoassay for elevated c-erbB2 protein ( p i85) can be used successfully to detect breast carcinomas in FNAs of the breast (Wu et a l, 2000).
4) Markers fo r ovarian carcinoma
As ovarian carcinoma is often silent until the late stages of the disease, it has a low overall survival rate and research is currently focussed on identifying biological markers that may enable the early detection of this carcinoma. The tumour markers examined include serum mucin antigens, CA 125, CA 19.9 and c-erbB2 protein ( p i85). These have been found to have either low sensitivity or low specificity for ovarian carcinoma and their use for the screening of asymptomatic individuals has not been advocated (Pamies, 1996). In particular, whilst increased CA 125 levels are found in 90% of women with metastatic ovarian cancer, they occur in only 50% of women with disease confined to the ovary, making this a poor screening test for early disease. The use of CA 125 is limited to monitoring response to treatment and identification o f tumour recurrence (Pamies, 1996).