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• Clinical use of paraneoplastic antibodies
  Albert Grueger
  Published on: 13 April 2016
• Re: Clinical use of paraneoplastic antibodies
  Jeremy H Rees
  Published on: 13 April 2016

• Published on: 13 April 2016

  Clinical use of paraneoplastic antibodies

  • Albert Grueger, Consultant Neurologist

  Dear Editor

  How useful is antibody testing for paraneoplastic disease in a patient without known tumour?

  Dr Rees proposes to search for paraneuroplastic antibodies in patients with possible paraneoplastic syndromes. At the same time he points out that the incidence of specific disabling neurological paraneoplastic syndromes is very low. No information on the sensitivity and specifity of an antibody scre...

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  Dear Editor

  How useful is antibody testing for paraneoplastic disease in a patient without known tumour?

  Dr Rees proposes to search for paraneuroplastic antibodies in patients with possible paraneoplastic syndromes. At the same time he points out that the incidence of specific disabling neurological paraneoplastic syndromes is very low. No information on the sensitivity and specifity of an antibody screening is given. One might speculate that - for example - in the comparatively large population of patients with polyneuropathies without obvious cause positive antibody tests without underlying tumour could outnumber true positive findings. In the study on Anti-Hu positive Encephalomyelitis cited by Dr Rees,[1] 17% of the patients never developed a tumour. I find it difficult to label them paraneoplastic. Anyway, the treatment of a patient with or without antibodies will probably not be modified until the underlying tumour is found.

  In conclusion, I fail to understand the benefit of the test for the management of individual patients: in a patient with a possibly paraneoplastic neurological syndrome the tumour must be searched anyway. Negative antibodies will not exclude the presence of an identifiable tumour nor will positive antibodies prove it. My personal experience is that negative antibody screenings may lead to false reassurance and thus sometimes delay the diagnosis of an underlying malignancy. As emphasized during the PSA discussion, false positive results may also be harmful.

  Reference

  1. Graus F, Keime-Guibert F, Rene R, et al. Anti-Hu-associated paraneoplastic encephalomyelitis: analysis of 200 patients. Brain 2001;124:1138–48.

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Re: Clinical use of paraneoplastic antibodies

  • Jeremy H Rees, Neurologist

  Dear Editor

  Dr Grueger raises an interesting and relevant management point about the usefulness or not of testing patients with suspected paraneoplastic neurological disease for the presence of anti-neuronal antibodies.

  I do not agree however that this test has no benefit. These antibodies are highly specific for an underlying tumour e.g. anti-Hu for small cell lung cancer and anti-Yo for breast and gy...

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  Dear Editor

  Dr Grueger raises an interesting and relevant management point about the usefulness or not of testing patients with suspected paraneoplastic neurological disease for the presence of anti-neuronal antibodies.

  I do not agree however that this test has no benefit. These antibodies are highly specific for an underlying tumour e.g. anti-Hu for small cell lung cancer and anti-Yo for breast and gynaecological malignancy. Every test has false positives and false negatives but the majority of patients with positive anti-neuronal antibodies will have an underlying and potentially treatable cancer. For example in the classic paper by Peterson et al, 52 out of 55 patients with cerebellar degeneration and anti-Yo antibodies had an underlying malignancy.

  Furthermore in 34 of these 52 patients the neurological syndrome predated the diagnosis of cancer. It may be that Dr Grueger has the facilities to do body scans on all his patients with suspected paraneoplastic disease but this is not the case in all centres and a low index of suspicion would not normally be sufficient to justify a large dose of radiation.

  I agree that a negative test may be falsely reassuring but a positive test is highly informative and, even where no tumour is found, allows a useful discussion with the patient about diagnosis and prognosis.

  Reference

  (1). Peterson K, Rosenblum MK, Kotanides H, Posner JB. Paraneoplastic cerebellar degeneration. I. A clinical analysis of 55 anti- Yo antibody-positive patients. Neurology. 1992 Oct;42(10):1931-7.

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  Conflict of Interest:
  None declared.

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