CA19-9 is a commonly performed tumour marker in pancreatico -biliary malignancy,but the levels keeps varying ? depending on the severity of obstruction causing cholangitis.In these circumstances if the levels are high does it mean it is a disseminated malignancy or it is probably due to cholangitis !
Dear collegae,
it is not very sensitive, see also the manuscript "Toepassing van tumormarkers in de dagelijkse praktijk" by Keuren et al (unfortunately in dutch, but there will be plenty of similar manuscripots in English.
1) Approximately 7-10% of the population is not able to produce lewis antigen. Ca19.9 is related to lewis antigen and therefore cannot be produced by these people, despite the presence of pancreas carcinoma.
2) Sensitivity and specificity are so low, that it cannot be used as a screeningstool in otherwise healthy people. In case of a positive CT scan, the presence of an evalated C19.9 can support the diagnosis of a malignancy. however, also in low-grade chronic pancreatitis serum levels can be elavated.
(see Goonetilleke KS, Siriwardena AK. Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer. Eur J Surg Oncol. 2007;33:266-70.
Katz MH, Savides TJ, Moossa AR, Bouvet M. An evidence-based approach to the diagnosis and staging of pancreatic cancer. Pancreatology. 2005;5:576-90.).
The marker can be used to follow the effectivity of chemotherapy and therefore help in precizing the prognosis/survival
(Ni XG, Bai XF, Mao YL, Shao YF, Wu JX, Shan Y, et al. The clinical value of serum CEA, CA19-9, and CA242 in the diagnosis and prognosis of pancreatic cancer. Eur J Surg Oncol. 2005;31:164-9.
Boeck S, Stieber P, Holdenrieder S, Wilkowski R, Heinemann V. Prognostic and therapeutic significance of carbohydrate antigen 19-9 as tumor marker in patients with pancreatic cancer. Oncology. 2006;70:255-64.)
therefore, the use of this marker seems quite limited.
Yours sincerely
Jeroen heemskerk
We do not use the CA-19-9 (syalylated Lewis A) due to its low sensibility. The mechanism of elevation of the CA-19-9 in the patients with a pancreatic cancer (or a gallbladder's one, etc.) is not clear to the best of knowledge, whether it is a direct tumorogen, or indirect one. Judging on published data, this antigen can be taken into account for the remote follow-up of the CA-19-9-positive cancers' patients operated upon radically for detection of recurrency.
Thanks to Dr.Heemskerk for the profound review of literature. I'll try to find the references provided above.
Diagnostic accuracy is about 85%. In one study, our group found that age >55 and presence of jaundice together had a higher association with cancer diagnosis in patients undergoing pancreatic resection. You can see false positives in patients with obstructive jaundice and false negatives in patients who are Lewis A negative (nonproducers).
There is a nice paper about the value of CA19-9:
http://www.ncbi.nlm.nih.gov/pubmed/23187839
As it noted, it has utility as a prognostic marker and as a marker of disease recurrence. Prognostic marker especially in perisurgiical situations. If its level is preoperatively high, or it is not dropping to the normal range postoperatively it shows poorer prognosis. CA19-9 could also be used in the postoperative follow up as a screening tool in a population affected by this disease and to follow and monitor the effectivity of palliative chemotherapy of pancreatic cancer.
On the ather hand, it is not recommended as a primary screening tool to detect pancreatic cancer earlier.
It is also noteworthy that CA19-9 level could be elevated in case of different diseases of bile tract, but in these cases the level of CA19-9 is usually just slightly elevated not reaching hundreds or thousands and there is also a fluctuation in the level depending from the activity of the underlying disease. If the tumor causes the CA19-9 elevation, there is a stable and constant growing pattern during the time.
Dr.Muscarella and Dr.Torday,
Thank you for the exellent posts. However, tt is clear about the Lewis A negative patients: if there has not been this antigen from one's birth, so it will never appear in the form of CA19-9 either in cancer or health.
Will you speak your opinion(s) about a putative mechanism(s) of the CA-19-9 elevation in obstructive jaundice and in case of the pancreatic cancer without the obstructive jaundice (for example, the body or/and the tail), please? Does not any sort of the pancreatic adenocarcinoma produce this antigen, don't it? And is its level depended on the tumor mass?
Sincerely,
See the following paper on pancreatic cancer biomarkers.
http://annonc.oxfordjournals.org/content/21/3/441.long
The mechanism for CA 19-9 elevation in patients with obstructive jaundice is unclear, but we know this is the case from numerous studies. Many pancreatic cancer experts would not even use CA 19-9 at all in jauniced patients until a stent was placed and the liver functions normalized. Serum CA 19-9 levels will be elevated in 85% of patients with pancreatic cancer. The value often correlates with tumor burder, but this is not always the case. In our study, CA 19-9 greater than 150 was always associated with a pancreatic cancer diagnosis in patients undergong pancreatic resection.
So, basically, it seems to be that there is a threshold for CA19-9 for pancreatic cancer, even in patients having jaundice... ?
There are several paper correlating the value of Ca19.9 with prognosis. Unfortunately the problem is that not all PC are associated with elevated Ca 19.9.
Ca 19.9 is recently considered also a prognostic index of response to neb-adjuvant treatment
And never forget the rule, that if a marker is not useful for a patient, do not use it. But if it is useful, use it.
It means that if a pancreatic cancer is not producing CA19-9, do not use this marker for follow up. But if it is proven (e.g. by preoperative CA19-9 determination) you should use it for monitoring.
If the level of CA19-9 started to increase, it is good question why? but in 95% of the cases the answer is more than easy: tumor progression.
CA 19‑9 assay values can assist in the differential diagnosis and monitoring
of patients with pancreatic carcinoma (sensitivity 70‑87 %). There is no
correlation between tumor mass and the CA 19‑9 assay values. However,
patients with CA 19‑9 serum levels above 10000 U/mL almost always have
distal metastasis.
The determination of CA 19‑9 cannot be used for the early detection of
pancreatic carcinoma. As the mucin is excreted exclusively via the liver, even slight cholestasis can lead to clearly elevated CA 19‑9 serum levels in some cases. Elevated CA 19‑9 values are also found with a number of benign and inflammatory diseases of the gastrointestinal tract and the liver, as well as in cystic fibrosis
Oncology rule: Go for the money (i.e. tissue diagnosis). Oncologists will refuse to see a patient for management unless the tissue diagnosis is available.
A DICTUM USED BY ONCOLOGISTS IS "NO TISSUE, NO ISSUE".
Diagnosis of most of the malignancies depends on the tissue diagnosis very high alpha-fetoprotein (AFP) in a cirrhotic patient or very high prostate specific antigen in a patient with enlarged prostate.
Diagnosis of most of the malignancies depends on the tissue diagnosis very high alpha-fetoprotein (AFP) in a cirrhotic patient or very high prostate specific antigen in a patient with enlarged prostate.
The role of cancer biomarkers e.g. CA 19-9 is if it is raised in a patient with a confirmed pancreatic malignancy by tissue diagnosis, is to serve as a baseline to follow up the patient after surgery or chemotherapy. Further rise or fall in the CA 19-9 will respectively indicate recurrence or disease free period.
Please have a look on the links below to these articles on tumor markers in general and the CA 19-9 in particular.
1. Article Practice Guidelines for Tumor Marker Use in the Clinic
2. Article CA 19-9 in pancreatic cancer: Retrospective evaluation of pa...
3. Article CA 19-9: Handle with care
- Badges
- Science method