Biliary Concentration of Carbohydrate Antigen 19-9 and Cancer Antigen 125, Iron Metabolism Markers, and PIVKA-II Activity in Pancreatobiliary Tumors

Gene Variants That Affect Levels of Circulating Tumor Markers Increase Identification of Patients With Pancreatic Cancer

Ultrasensitive Detection of KRAS2 Mutations in Bile and Serum from Patients with Biliary Tract Carcinoma Using LigAmp Technology

To the Editor We present the rare occurrence of a concurrent pancreatic neuroendocrine tumor (pNET) and pancreatic ductal adenocarcinoma (PDAC) in a patient with multiple endocrine neoplasia 1 (MEN1) syndrome. It is important for clinicians to consider the possibility of PDAC in patients with MEN1 because aggressive early surgical intervention provides the only chance of cure. Multiple endocrine neoplasia 1 is characterized by parathyroid adenomas, pNETs, and anterior pituitary tumors.1 Multiple endocrine neoplasia 1–associated pNETs are usually slowly progressive and associated with low malignant potential. In the context of MEN1, pancreatic NET size correlates with prognosis and the presence of metastases,2 and lesions of more than 2 cm are associated with greater genetic instability and malignant behaviour.3 The European Neuroendocrine Tumour Society recommendations for management of pancreatic lesions in a patient with MEN1 state that early diagnosis and surgical excision of MEN1-related pNET improve survival, preventing or delaying the development of distant metastases.4 It is mandatory to operate on MEN1-related nonfunctioning pancreatic tumors with metastases, size of more than 2 cm, or yearly increased size of more than 0.5 cm. Management of pNETs of less than 2 cm is controversial, current recommendation being intensive surveillance to avoid repeated intervention where lesions are typically multiple and behave in an indolent fashion.

Screening for Early Pancreatic Neoplasia in High-Risk Individuals: A Prospective Controlled Study

Objective To investigate the diagnostic values of ultrasonography combined with serum cancer antigen 125 (CA125), serum carbohydrate antigen 199 (CA199), serum carcinoembryonic antigen (CEA) in ovarian malignant tumors. Methods From November 2015 to December 2017, 140 patients with ovarian cancer admitted to the hospital were selected as subjects, and ultrasound examination was carried out with IU22 ultrasound diagnostic instrument. The patients were divided into 92 cases of benign ovarian tumors and 48 cases of malignant ovarian tumors through pathological diagnosis. The serum CA125, CA199 and CEA of all patients were detected by automatic biochemical analyzer, and receiver operating characteristic (ROC) curve was used to analyze the diagnostic value of four combined detection in ovarian malignancies. Results The coincidence rate of ultrasound diagnosis in ovarian benign tumor patients was significantly higher than that in ovarian cancer patients (P<0.05). The levels of serum CA125, CA199 and CEA in benign ovarian tumors were significantly lower than those in malignant ovarian tumors (P<0.05), and the levels of serum CA125, CA199 and CEA in patients with stage Ⅰ to Ⅱ were significantly lower than those in stage Ⅲ to Ⅳ (P<0.05). The area of serum CA125, CA199 and CEA under the ROC curve was 0.788, 0.750 and 0.708, respectively. The boundary points of diagnosis were 50.61 U/ml, 36.47 U/ml and 4.32 ng/ml, respectively. The area under the combined diagnosis curve of the serum CA125, CA199 and CEA was 0.832. The sensitivity, specificity and accuracy of the combined detection were higher than that of single index detection and serum combined detection. Conclusions Ultrasound combined with serum CA125, CA199 and CEA levels detection can improve the sensitivity, specificity and accuracy of diagnosis of ovarian benign and malignant tumors, which has certain clinical value. Key words: Ultrasonography; CA125; CA199; Carcinoembryonic antigen; Ovarian neoplasms

Changes to the glycan structures of proteins secreted by cancer cells are known to be functionally important and to have potential diagnostic value. However, an exploration of the population variation and prevalence of glycan alterations on specific proteins has been lacking because of limitations in conventional glycobiology methods. Here we report the use of a previously developed antibody-lectin sandwich array method to characterize both the protein and glycan levels of specific mucins and carcinoembryonic antigen-related proteins captured from the sera of pancreatic cancer patients (n = 23) and control subjects (n = 23). The MUC16 protein was frequently elevated in the cancer patients (65% of the patients) but showed no glycan alterations, whereas the MUC1 and MUC5AC proteins were less frequently elevated (30 and 35%, respectively) and showed highly prevalent (up to 65%) and distinct glycan alterations. The most frequent glycan elevations involved the Thomsen-Friedenreich antigen, fucose, and Lewis antigens. An unexpected increase in the exposure of alpha-linked mannose also was observed on MUC1 and MUC5ac, indicating possible N-glycan modifications. Because glycan alterations occurred independently from the protein levels, improved identification of the cancer samples was achieved using glycan measurements on specific proteins relative to using the core protein measurements. The most significant elevation was the cancer antigen 19-9 on MUC1, occurring in 19 of 23 (87%) of the cancer patients and one of 23 (4%) of the control subjects. This work gives insight into the prevalence and protein carriers of glycan alterations in pancreatic cancer and points to the potential of using glycan measurements on specific proteins for highly effective biomarkers.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is the fourth most common cause of cancer death in the Western world. Early diagnosis of PDAC is difficult, and no biomarkers in blood can identify patients with pancreatic cancer at an early stage. Serum cancer antigen 19-9 (CA19-9) remains the gold standard serum marker for patients with PDAC; however, inadequate sensitivity and specificity limit the use of CA19-9 in the early diagnosis of PDAC. Therefore, the discovery of biomarkers derived from blood that facilitate the distinction of PDAC would greatly affect patient management. Exosomes are extracellular lipid microvesicles, secreted by nearly all cells in body fluids such as peripheral blood. The exosome-associated RNA is called exosomal shuttle RNA that includes microRNAs and messenger RNAs (mRNAs). Methods: The aims of the present study are to assess if the mRNA that we found in the intracellular exosomes of PDAC cells is secreted from PDAC cells, and it is useful as a serum diagnostic marker for differentiating PDAC from individuals without pancreatic disorders compared with CA19-9. 20 PDAC patients (stage III: n = 5, stage IVa: n = 7 and stage IVb: n = 8 according to the classification of pancreatic carcinoma of the Japan Pancreas Society) and 30 control individuals without pancreatic diseases were analyzed in a retrospective cohort study. Circulating exosomes were isolated from serum, and then the mRNA localizing in exosomes was measured by real-time quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Results: We confirmed that the mRNA was localized in secreted exosomes from cultured PDAC cells: a moderately differentiated PDAC cell line (S2-013) by the use of condition media real-time RT-PCR. Furthermore, the retrospective clinical study showed that the area under the curve (AUC) of reciever operating characteristic curves (ROC curves) was 0.805 (95%CI 0.691-0.9199) for this RNA and 0.8 (95%CI 0.675-0.926) for CA19-9. If the mRNA was combined with serum CA19-9, the AUC increased (0.921 [95%CI 0.851-0.991]). Conclusions: Our data suggest that measuring the level of this exosome-associated mRNA has the potential to improve detection of PDAC. Further research is necessary to understand whether this mRNA has clinical implications for early detection of PDAC (stage I and II) and how much this information adds to serum CA19-9. Citation Format: Keisuke Taniuchi. A tumor-associated mRNA localizing in circulating exosomes as a novel serological marker for pancreatic cancer: the retrospective clinical study. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 423A.

Serum tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA125) have been useful in the management of gastrointestinal and gynecological cancers; however, there is limited information regarding their utility in patients with appendiceal adenocarcinoma. To assess the association of serum tumor markers (CEA, CA19-9, and CA125) with clinical outcomes and pathologic and molecular features in patients with appendiceal adenocarcinoma. This is a retrospective cohort study at a single tertiary care comprehensive cancer center. The median (IQR) follow-up time was 52 (21-101) months. Software was used to query the MD Anderson internal patient database to identify patients with a diagnosis of appendiceal adenocarcinoma and at least 1 tumor marker measured at MD Anderson between March 2016 and May 2023. Data were analyzed from January to December 2023. Association of serum tumor markers with survival in patients with appendiceal adenocarcinoma. Cox proportional hazards regression analyses were also performed to assess associations between clinical factors (serum tumor marker levels, demographics, and patient and disease characteristics) and patient outcomes (overall survival). A total of 1338 patients with appendiceal adenocarcinoma were included, with a median (range) age at diagnosis of 56.5 (22.3-89.6) years. The majority of the patients had metastatic disease (1080 patients [80.7%]). CEA was elevated in 742 of the patients tested (56%), while CA19-9 and CA125 were elevated in 381 patients (34%) and 312 patients (27%), respectively. Individually, elevation of CEA, CA19-9, or CA125 were associated with worse 5-year survival; elevated vs normal was 81% vs 95% for CEA (hazard ratio [HR], 4.0; 95% CI, 2.9-5.6), 84% vs 92% for CA19-9 (HR, 2.2; 95% CI, 1.4-3.4), and 69% vs 93% for CA125 (HR, 4.6; 95% CI, 2.7-7.8) (P < .001 for all). Quantitative evaluation of tumor markers was associated with outcomes. Patients with highly elevated (top 10th percentile) CEA, CA19-9, or CA125 had markedly worse survival, with 5-year survival rates of 59% for CEA (HR, 9.8; 95% CI, 5.3-18.0), 64% for CA19-9 (HR, 6.0; 95% CI, 3.0-11.7), and 57% for CA125 (HR, 7.6; 95% CI, 3.5-16.5) (P < .001 for all). Although metastatic tumors had higher levels of all tumor markers, when restricting survival analysis to 1080 patients with metastatic disease, elevated CEA, CA19-9, or CA125 were all still associated worse survival (HR for CEA, 3.4; 95% CI, 2.5-4.8; P < .001; HR for CA19-9, 1.8; 95% CI, 1.2-2.7; P = .002; and HR for CA125, 3.9; 95% CI, 2.4-6.4; P < .001). Interestingly, tumor grade was not associated with CEA or CA19-9 level, while CA-125 was slightly higher in high-grade tumors relative to low-grade tumors (mean value, 18.3 vs 15.0; difference, 3.3; 95% CI, 0.9-3.7; P < .001). Multivariable analysis identified an incremental increase in the risk of death with an increase in the number of elevated tumor markers, with an 11-fold increased risk of death in patients with all 3 tumor markers elevated relative to those with none elevated. Somatic mutations in KRAS and GNAS were associated with significantly higher levels of CEA and CA19-9. In this retrospective study of serum tumor markers in patients with appendiceal adenocarcinoma, CEA, CA19-9, and CA125 were associated with overall survival in appendiceal adenocarcinoma. Given their value, all 3 biomarkers should be included in the initial workup of patients with a diagnosis of appendiceal adenocarcinoma.

Will Detection of MicroRNA Biomarkers in Blood Improve the Diagnosis and Survival of Patients With Pancreatic Cancer?

Endoscopic Ultrasound–Guided Fine-Needle Aspiration of Ascites

Objective Anemia of chronic disease is a frequent consequence in rheumatoid arthritis and is associated with major clinical and patient outcomes. The present cross-sectional study explored the role of hepcidin (HEP) in anemia of chronic disease in rheumatoid arthritis by studying its relationships with markers of anemia, iron metabolism, inflammation, and erythropoiesis. Methods Blood samples from anemic ( n = 43) and nonanemic ( n = 43) rheumatoid arthritis patients were analyzed for markers of anemia (hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cells distribution width, and reticulocyte hemoglobin), iron metabolism (iron, total iron binding capacity, ferritin, transferrin saturation, soluble transferrin receptor), inflammation (erythrocyte sedimentation rate, C-reactive protein, and interleukin 6), and erythropoiesis (erythropoietin and HEP). Correlation analysis was used to identify relationships between HEP and all other variables. Principal component analysis was used to identify common underlying dimensions representing linear combinations of all variables. Results HEP had statistically significant mostly moderate-to-large correlations with markers of anemia (0.30–0.70, all p < 0.01), small correlation with markers of iron metabolism and markers of inflammation ( r = 0.20–0.40, all p < 0.01), and moderate correlations with markers of erythropoiesis. Principal component analysis revealed two underlying components (factors) capturing approximately 50% of total variability. Factor 1 comprised mainly of markers of anemia, iron metabolism, and erythropoiesis and was related to “erythrocyte health status,” while factor 2 comprised mainly markers of inflammation and iron metabolism and was related to “acute phase reactants.” HEP was the only variable demonstrating substantial loadings on both factors. Conclusions HEP is related to markers of anemia, iron metabolism, inflammation, and erythropoiesis. In addition, when all variables are “reduced” to a minimum number of two “latent” factors, HEP is loaded on both, thus underlying its pivotal role in the complex interaction of the erythropoietic response in inflammation-induced anemia and/or functional iron deficiency.

Pancreatic Cancer: Novel Approaches to Diagnosis and Therapy

Disorders of iron metabolism has been implicated in cardiovascular disease. However, the association of serum iron stores and coronary artery disease (CAD) remains inconsistent. Here, we investigated the associations of serum iron metabolism with the incidence of CAD, the severity of coronary artery stenosis, metabolic biomarkers, and the risk of major adverse cardiovascular event (MACE). A total of 643 CAD patients and 643 healthy controls were enrolled to assess the associations of serum iron status with the presence of CAD, the severity of CAD, and the risk of MACE. Serum iron metabolism and other metabolic markers were measured in all subjects. All statistical analyses were analyzed using SPSS22.0 software and STATA statistical package. Serum level of iron metabolism markers, including serum iron, unsaturated transferrin iron binding capacity (UIBC), Total iron binding capacity (TIBC) levels, in CAD groups was significantly lower than the control group (P < 0.001). UIBC and TIBC were negatively correlated with ferritin in both sexes. Each unit increase of serum iron and TIBC were found to have a protective role for CAD in women (iron: OR 0.794, 95% CI (0.647–0.973), TIBC: OR 0.891, 95% CI (0.795–0.999), P < 0.05). However, high ferritin level was significant associated the CAD incident in both sexes (OR 1.029, 95% CI (1.002–1.058) in men, OR 1.013, 95% CI (1.0–1.025) in women, P < 0.05). Serum iron metabolism markers exhibited no significant association with the severity of CAD. Increased serum level of iron and TIBC levels were found to have a protective role for CAD in women, but not in men. Elevated serum ferritin is independently and positively associated with CAD in men and women.

Objective To investigate the clinical value of serum carbohydrate antigen 19-9 (CA19-9) in the differential diagnosis of benign and malignant biliary system diseases. Methods Clinical data of 167 patients with biliary system diseases in Department of General Surgery, the First Hospital of Lanzhou University from January 2008 to March 2011 were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. The patients were divided into benign biliary system diseases group (benign diseases group, n=85) and cholangiocarcinoma group (malignant diseases group, n=82). Blood alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), total bilirubin (TB), direct bilirubin (DB), total protein (TP), albumin (ALB) and CA19-9, cancer antigen (CA) 125, carcino-embryonic antigen (CEA), alpha fetoprotein (AFP) were detected after admission to hospital. The indexes of two groups were expressed in M (Q25,Q75), and were compared by Wilcoxon rank sum test. The correlation study was analyzed using Spearman rank correlation analysis. The sensitivity and specificity of serum CA19-9 in diagnosis of cholangiocarcinoma was analyzed using receiver operating characteristic (ROC) curve. Results The median level of serum CA19-9 in malignant diseases group was significantly higher than that in benign diseases group [318(41,733) μg/L vs. 43 (15,139) μg/L ; Z=3.736; P<0.05]. Serum CA19-9 in benign diseases group was positively correlated with GGT, ALP, TB, DB and CA125 (r=0.318, 0.335, 0.282, 0.355, 0.387; P<0.05), while was negatively correlated with TP and ALB (r=-0.300,-0.437; P<0.05). CA19-9 in malignant diseases group was positively correlated with ALP, TB, DB and CA125 (r=0.340, 0.394, 0.385, 0.480; P<0.05), while was negatively correlated with ALB (r=-0.389, P<0.05). For all the patients or the jaundice patients, the best positive reference values of CA19-9 in diagnosis of cholangiocarcinoma were both 309 μg/L and the diagnostic sensitivity and specificity were 0.51 and 0.89 in all the patients, 0.57 and 0.85 in the jaundice patients respectively. Conclusions The best reference value of CA19-9 in the differential diagnosis of benign or malignant biliary system diseases is 309 μg/L. The diagnostic specificity of serum CA19-9 for cholangiocarcinoma is comparatively high but the sensitivity is moderate. Key words: Biliary system disease; Cholangiocarcinoma; Diagnosis; Serum; Carbohydrate antigen 19-9

In the screening of early pancreatic cancer and bile duct cancer, the first issue was 'what are the types of abnormality in laboratory data and symptoms in case of early pancreatic cancer and bile duct cancer?' Early cancer in the pancreaticobiliary region has almost no symptoms, however epigastralgia without abnormality in the gastrointestinal (GI) tract is a sign of early stage pancreaticobiliary cancer. Sudden onset and aggravation of diabetes mellitus is an important change in the case of pancreatic cancer. Extracorporeal ultrasonography is a very useful procedure of checking up changes of pancreatic and biliary lesions. As the role of endoscopy in screening, endoscopic ultrasonography (EUS) is the most effective means of cancer detection of the pancreas, and endoscopic retrograde cholangiopancreatography (ERCP) is most useful of diagnosis tool for abnormalities of the common bile duct. Endoscopic retrograde cholangiopancreatography is an important modality as the procedure of sampling of diagnostic materials. Endoscopic ultrasonography-fine needle aspiration (EUS-FNA) has the role of histological diagnosis of pancreatic mass lesion also. Especially, in the case of pancreas cancer without evidence of cancer by pancreatic juice cytology and brushing cytology, EUS-FNA is essential. Intra ductal ultrasonography (IUDS) and perotral cholangioscopy (POCS) are useful for determination of mucosal extent in extrahepatic bile duct cancer. Further improvements of endoscopical technology, endoscopic procedures are expected to be more useful modalities in detection and diagnosis of early pancreatic and bile duct cancers.