2012-TTD-Antalya 1

Bio-markers in pleural effusions

Dr. Öner DikensoyDepartment of Pulmonary Diseases

Gaziantep UniversityGaziantep-Turkey

dikensoy@yahoo.com

I have no conflict of interest related to content of this

presentation

Plan

• Definition of biomarker • Epidemiology of pleural effusions• Widely used pleural biomarkers• New biomarkers• Future bio-markers• Final summary

What is a biomarker?

• Biomarker is a term often used to refer to a protein measured in body fluids that reflects the severity or presence of some disease state.

Wikipedia-Medicine-2011

Definition of ideal biomarker

• Easy and standardized method• Cheap• Widely available• Reproducible cut-off values• High sensitivity and specifity

Potential benefits of bio-markers

• Separation of transudate and exudate• Separation of malignant and bening• Disease specific diagnosis• Prediction of drainage need in PPE• Monitorization of treatment• Identification of High risk subjects

EpidemiologyCHF 500,000 (%36)PNEUMONIA 300,000 (%22)MALIGNANT EFFUSION200,000 (%14)PULMONARY EMBOLI 150,000 (%11)UNDIAGNOSED (?VIRAL) 100,000 POST-CABG 50,000CHIROSSIS-ASCITES 50,000GASTROINTESTINAL 25,000CONNECTIVE TD 6,000TUBERCULOSIS 3,000

Light RW.Pleural Diseases 4th ed.2001

%83

%17

1.384.000 cases/yr

Common causes of pleural effusions

• CHF (>90% OF ALL TRANS)• MALIGNANT EFFUSION • PNEUMONIA• TUBERCULOSIS• PULMONARY EMBOLI

85%

Biomarkers for most common pleural effusions?

• CHF

• PNEUMONIA

• MALIGNANT EFF

• PULMONARY EMBOLI

• TUBERCULOSIS

Natriuretic peptides

Ph, LDH, Glucose

Tm markers, mesothelinosteopontin

??

ADA, Gama-IF

Recomended to use in clinical practice for diagnostic purpose

• Adenosine deaminase• BNP, NT-proBNP• Mesothelin

***All needs to be used in conjunction with clinical and other lab data

Not recomended to use in clinical practice

• Classical tumor markers (CEA, CA 125, CA 15–3 and CYFRA 21–1, etc.)

Porcel JM, et al. Chest 2004;126:1757

Biomarkers for Tuberculosis:Adenosine deaminase (ADA)

• Predominantly T-lymphocyte enzyme• adenosine/deoxyadenosine inosine/deoxyinosine

• The method is easy/inexpensive

• High in HIV patients with very low CD4

• Widely accepted cut-off : 35 U/L (35-47)

• Molecular forms: ADA1 and ADA2 1. Porcel JM. Lung 2009; 187: 263–702. Liang QL, Shi HZ,Wang K et al. Respir.Med.2008; 102: 744–54.3. Baba K, Hoosen AA, Langeland N et al. PLoS One 2008; 3:e2788.4. Perez-Rodriguez E, Castro DJ. Curr.Opin.Pulm.Dis. 2000; 6: 259–66.

Where can we measure ADA?

• All kind of effusions (peritonitis, pericarditis, menengitis, pus)1

• New studies suggest: sputum2, blood3

1. Koc I, Arslan E, Isik F, Dikensoy Ö. IJCRI 2011;2(3):5-8. 2. Dimakou K, etal. Int J Tuberc Lung Dis 2009; 13:744–748. 3. Erer B, et al. Rheumatol Int 2009; 29:651–654. 

ADA1 or ADA2 ?

• ADA1 is found in all cells (mostly lympho and monocytes)

• ADA2 is found only in monocytes, macrophages

• ADA2 is more prevalent in TB pleural fluid

• ADA1 / total ADA < 0.42 (slightly increases sensitivity/ specificity)

Current Opinion in Pulmonary Medicine. 16(4):367-375, 2010.

•Separation of ADA is not necessary

Is ADA an ideal biomarker?

• A recent meta-analysis of 63 studies• 2796 patients with TB pleuritis • 5297 with non-TB effusion • the sensitivity/specificity: 92% / 90% • The positive likelihood ratio: 9.03, • The negative likelihood: 0.10,

Liang QL, Shi HZ,Wang K et al. Respir.Med.2008; 102: 744–54.

Is ADA an ideal biomarker?

There are two major concerns: • False negative:

– ADA levels might be low in the early stage of TB pleurisy

• False positive: – Parapneumonic, empyema, malignant, rheumatoid

effusions might have ADA levels>40 IU  – Elevated ADA level might be expected:

• 1/2 - 2/3 of empyemas • 1/10 - 1/3 of PPEs. 

Valdés L, etal. Eur J Intern Med 2003; 14:77–88 Dikensoy O, et al. Respirology 2008; 13:473–474.Porcel JM. Lung 2009; 187:263–270.  

The predictive value of ADA depends local prevalence of the TB:

• Low prevalence (5%) :PPV of high ADA 41%. • High prevalence (85%) PPV of high ADA 99%The opposite relation refers to negative

predictive value (NPV):• Low prevalence (5%): NPV of low ADA 99.6%, • High prevalence (85%) NPV of low ADA 86% 

Does high and low ADA mean the same in every country?

Greco S, Girardi E, Masciangelo R, et al. Int J Tuberc Lung Dis 2003; 7:777–786

These means that: •High TB prevalence setting: •high ADA means TB very likely•Low TB prevalence setting: •Low ADA means TB very unlikely 

Biomarkers for Tuberculosis:Gama-interferon (IF)

• It is a cytokine released by activated CD4 (+) T lymphocytes

• It increases the mycobactericidal activity of macrophages.

ADA vs. Gama-IF

Greco S, et al. IJTLD 2003:7:777

Summary: •It is impossible to establish a cut-off value•Higher the level higher the possibility•ADA is simpler and less expensive than Gama-IF•Always add clinic+laboratory together

Biomarkers for CHF: Cardiac Natriuretic Peptides

• They are secreted by the cardiomyocytes in

response to stretch and elevated pressure

• They are diuretic, natriuretic, hypotensive

• Both serum and pleural levels are increased in

CHF

Porcel JM. COPM 2011,17:215–219

Natriuretic Peptide Family

1. A-type natriuretic peptides (ANP, proANP, NT-proANP, and mid-regional-proANP),

2. B-type natriuretic peptides (BNP, NT-proBNP, and pro-BNP),

3. C-type natriureticpeptides (CNP and NT-proCNP),

4. Urodilatin (an isoform of ANP), 5. Dendroaspis natriuretic peptide (DNP)

Taub PR, et al. Congest Heart Fail 2010; 16 (Suppl 1):S19–S24.

BNP and NT-proBNP

• They are the most widely studied NPs• Automated assays are readily available • Both appear equally accurate and clinically

useful when measured in the blood • NT-proBNP has theoretical advantages

due to its stability and longer half-life.

Porcel JM. COPM 2011,17:215–219

• serum BNP < 100 pg/ml • NT-proBNP < 300 pg/ml

• serum BNP > 500 pg/ml • NT-proBNP >450-1800 pg/ml*

• (*cut off points depends on and increasing with the patient’s age)

HF unlikely

HF likely

What are the Cut-off levels?

Mohammed AA, Januzzi JL Jr. Heart Fail Clin 2009; 5:489–500.

Do we need pleural NPs ?

• NT-proBNP > 1500 pg/mL the accuracy of identifying PEs due to HF was 89% for serum and 90% for pleura

• The AUC for the diagnosis of PEs due to HF – 0.931, (95% CI: 0.871-0.991) for pleura and– 0.919, (95% CI: 0.855-0.984) for serum NT-

proBNP. 

Porcel JM, Chorda J, Cao G, et al. Respirology 2007; 12:654–659.

It looks like there is no need to measure pleural NPs

Are they useful in misclassified effusions?

• Light’s criteria misclassify the 25% of transudates as exudate

• Pleural NT-proBNP>1300 pg/ml labeled 27 of 31 (87%)

• Protein gradient labeled 16 of 30 (53%), • Albumin gradient labeled 11 of 14 (79%)

Porcel JM, Vives M, Cao G, et al. Am J Med 2004; 116:417–420..Porcel JM, Chorda J, Cao G, et al. Respirology 2007; 12:654–659. Porcel JM, Martı´nez-Alonso M, Cao G, et al. Chest 2009; 136:671–677

Summary

• Natriuretic peptides are most useful in intermediate probability of heart failure

• Higher the value higher the probability• Values < cut-off exclude CHF• Best in misclassified effusions• Serum levels seems enough to establish a

diagnosis of pleural effusion due to CHF

Biomarkers for Mesothelioma• A universally fatal malignancy and its

incidence is rising exponentially in Western Europe

• Asbestos is still widely used in developing countries,

• Cytologic differentiation of MM from normal or reactive mesothelial cells is very difficult.

• A reliable biomarker would be very helpful

Soluble mesothelin related peptides (SMRPs)

• Mesothelin: – a differentiation antigen present in mesothelial

cells • Soluble Mesothelin:

– a soluble protein in serum captured using antibodies targeting mesothelin

• SMRPs released into the circulation from malignant cells that overexpress mesothelin

Hassan R, Bera T, Pastan I.Clin Cancer Res 2004; 10:3937–3942.Maeda M, Hino O. Pathol Int 2006; 56:649–654.

• The sensitivity and specificity of SMRPs: – 77%-76% in a multicenter study from

France– 67%-98% in a Western Australian

cohort of 234 patients• The diagnostic accuracy of pleural fluid

SMRP was as good as serum SMRP

Is SMRP an ideal biomarker?

Scherpereel A, et al. Am J Respir Crit Care Med 2006; 173:1155Creaney J, et al.Thorax. 2007 ;62:569-76.

• False positive: high in ovarian, pancreatic lung CAs and non-Hodgkin’s lymphoma

• False negative: in sarcomatoid MM

Is SMRP an ideal biomarker?

Scherpereel A, et al. Am J Respir Crit Care Med 2006; 173:1155Creaney J, et al.Thorax. 2007 ;62:569-76.

Can we use SMRPs in populations exposed to asbestosis?

• 40 subjects exposed to asbestosis• 7 had elevated serum SMRPs levels• 3 of 7 developed MPM in 5 years• 1 of 7 developed lung CA• 33 of 40 followed for 8 yrs without any

problem

Robinson BWS, et al. Lancet 2003; 362:1612–1616

At present: 1-There is no effective cure2- No data to support that early detection alter outcome

• Serum osteopontin, have little value in distinguishing mesothelioma from metastatic pleural carcinomas or benign asbestos pleural diseases.

Biomarkers for Mesothelioma:Osteopontin

Scherpereel A, Lee YCG. Curr Opin Pulm Med 2007;13:339–343

Can we use mesothelioma markers for disease monitoring?

• Serum SMRP levels are higher in subjects with larger tumor load

• Serum SMRP levels decreased ovarian CA patients underwent tumor debulking surgery

Robinson BWS, et al. Lancet 2003; 362:1612–1616Hassan R, etal. Clin Can Res 2006;12:447

Summary

• SMRP seems to have the best sensitivity and specifity to diagnose mesothelioma

• High in ovarian, pancreatic and lung CA• Low in sarcomatoid type• Not recomended for screening• There is a hope for disease monitoring• SMRP can be used to support diagnosis

New biomarkers:Ischemia Modified Albumin (IMA):– IMA is a relatively new biomarker

advocated in the early diagnosis of cardiac ischemia

– We hypothesized that IMA should be higher in the pleural effusion of subjects with CHF

Dikensoy O, et al. Respir Med. 2011;105:1712-7.

New biomarkers:Ischemia Modified Albumin (IMA):

Dikensoy O, et al. Respir Med. 2011;105:1712-7.

New biomarkers:Ischemia Modified Albumin (IMA):

• Higher in transudates especially due to CHF

Dikensoy O, et al. Respir Med. 2011;105:1712-7.

•It looks promising•There is need to conduct new studies

Future Biyo-markers

• Proteomics• FISH • PCR• Elektronic Nose• Nano-mekanic cell analysis

Final Summary

• There is no perfect biomarker yet• There are many ongoing studies• At present biomarkers look useful when

they are used in conjunction with clinical and laboratory data