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HelpTest ID: PAVAL Paraneoplastic, Autoantibody Evaluation, Serum
Reporting Name
Paraneoplastic Autoantibody Eval, SUseful For
Serological evaluation of patients who present with a subacute neurological disorder of undetermined etiology, especially those with known risk factors for cancer
Directing a focused search for cancer
Investigating neurological symptoms that appear in the course of, or after, cancer therapy, and are not explainable by metastasis
Differentiating autoimmune neuropathies from neurotoxic effects of chemotherapy
Monitoring the immune response of seropositive patients in the course of cancer therapy
Detecting early evidence of cancer recurrence in previously seropositive patients
Clinical Information
Paraneoplastic autoimmune neurological disorders reflect a patient's humoral and cellular immune responses to cancer. The cancer may be new or recurrent, is usually limited in metastatic volume, and is often occult by standard imaging procedures. Autoantibodies specific for onconeural proteins found in the plasma membrane, cytoplasm, and nucleus of neurons, glia, or muscle are generated in this immune response and serve as serological markers of paraneoplastic autoimmunity. Cancers recognized in this context most commonly are small-cell lung carcinoma, thymoma, ovarian (or related mullerian) carcinoma, breast carcinoma, and Hodgkin lymphoma. Pertinent childhood neoplasms recognized thus far include neuroblastoma, thymoma, Hodgkin lymphoma, and chondroblastoma. An individual patient's autoantibody profile can predict a specific neoplasm with 90% certainty, but not the neurological syndrome.
Four classes of autoantibodies are recognized in this evaluation:
-Neuronal nuclear (ANNA-1, ANNA-2, ANNA-3)
-Anti-glial/neuronal nuclear (AGNA-1; also known as Sox1)
-Neuronal and muscle cytoplasmic (Purkinje cytoplasmic antibody [PCA]-1, PCA-2, PCA-Tr, collapsin response-mediator protein [CRMP]-5, amphiphysin, and striational)
-Plasma membrane cation channel, calcium channels, P/Q-type and N-type calcium channel, dendrotoxin-sensitive potassium channels, and neuronal (ganglionic) and muscle nicotinic acetylcholine receptors (AChR). These autoantibodies are potential effectors of neurological dysfunction.
Patients who are seropositive usually present with subacute neurological symptoms and signs such as encephalopathy, cerebellar ataxia, myelopathy, radiculopathy, plexopathy, or sensory, sensorimotor, or autoimmune neuropathy, with or without a neuromuscular transmission disorder: Lambert-Eaton syndrome, myasthenia gravis, or neuromuscular hyperexcitability. Initial signs may be subtle, but a subacute multifocal and progressive syndrome usually evolves. Sensorimotor neuropathy and cerebellar ataxia are common presentations, but the clinical picture in some patients is dominated by striking gastrointestinal dysmotility, limbic encephalopathy, basal ganglionitis, or cranial neuropathy (especially loss of vision, hearing, smell, or taste).
Cancer risk factors include past or family history of cancer, history of smoking, or social or environmental exposure to carcinogens. Early diagnosis and treatment of the neoplasm favor less neurological morbidity and offer the best hope for survival.
Interpretation
Antibodies directed at onconeural proteins shared by neurons, glia, muscle, and certain cancers are valuable serological markers of a patient's immune response to cancer. They are not found in healthy subjects, and are usually accompanied by subacute neurological symptoms and signs. Several autoantibodies have a syndromic association, but no autoantibody predicts a specific neurological syndrome. Conversely, a positive autoantibody profile has 80% to 90% predictive value for a specific cancer. It is not uncommon for more than one paraneoplastic autoantibody to be detected, each predictive of the same cancer.
Testing Algorithm
If immunofluorescence assay (IFA) patterns suggest antiglial nuclear antibody-1 (AGNA-1) antibody, then AGNA-1 immunoblot is performed at an additional charge.
If IFA patterns suggest amphiphysin antibody, then amphiphysin immunoblot is performed at an additional charge.
If IFA patterns suggest antineuronal nuclear antibodies (ANNA)-1 antibody, then ANNA-1 immunoblot is performed at an additional charge.
If IFA patterns suggest ANNA-2 antibody, then ANNA-2 immunoblot is performed at an additional charge.
If IFA patterns suggest Purkinje cytoplasmic antibody (PCA)-1 antibody, then PCA-1 immunoblot is performed at an additional charge.
If IFA patterns suggest PCA-Tr antibody, then PCA-Tr immunoblot is performed at an additional charge.
If IFA patterns suggest glutamic acid decarboxylase 65 (GAD65) antibody, then GAD65 antibody radioimmunoassay (RIA) is performed at an additional charge.
If IFA pattern suggest N-methyl-D-aspartate (NMDA)-receptor, then NMDA-receptor antibody cell-binding assay (CBA), and/or NMDA- receptor antibody titer is performed at an additional charge.
If IFA pattern suggest alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-receptor, then AMPA- receptor antibody CBA and/or AMPA- receptor antibody titer is performed at an additional charge.
If IFA pattern suggest gamma-aminobutyric acid B (GABA-B)-receptor, then GABA-B- receptor antibody CBA and/or GABA-B- receptor antibody titer is performed at an additional charge.
If IFA pattern suggest dipeptidyl-peptidase-like protein-6 antibody (DPPX), then DPPX antibody CBA and DPPX antibody titer is performed at an additional charge.
If IFA pattern suggest metabotropic glutamate receptor 1 (mGluR1), then mGluR1 antibody CBA and mGluR1 antibody titer is performed at an additional charge.
If voltage-gated potassium channels (VGKC) is above 0.00 nmol/L, then leucine-rich, glioma inactivated 1 (LGI1)-IgG CBA and contactin-associated protein-like 2 (CASPR2)-IgG are performed at an additional charge.
If collapsin response-mediator protein (CRMP) IFA is positive, then acetylcholine (muscle) receptor (AChR) binding antibody, CRMP-5-IgG Western blot, and ACh receptor (muscle) modulating antibody by fluorescence-activated cell sorting (FACS) will be performed at an additional charge.
CRMP-5-IgG Western blot is also performed by specific request for more sensitive detection of CRMP-5-IgG. Testing should be requested in cases of subacute basal ganglionic disorders (chorea, Parkinsonism), cranial neuropathies (especially loss of vision, taste, or smell) and myelopathies.
The following algorithms are available in Special Instructions:
Profile Information
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| PAINT | Interpretive Comments | No | Yes |
| GANG | AChR Ganglionic Neuronal Ab, S | No | Yes |
| AMPHS | Amphiphysin Ab, S | No | Yes |
| AGN1S | Anti-Glial Nuclear Ab, Type 1 | No | Yes |
| ANN1S | Anti-Neuronal Nuclear Ab, Type 1 | No | Yes |
| ANN2S | Anti-Neuronal Nuclear Ab, Type 2 | No | Yes |
| ANN3S | Anti-Neuronal Nuclear Ab, Type 3 | No | Yes |
| CRMS | CRMP-5-IgG, S | No | Yes |
| VGKC | Neuronal (V-G) K+ Channel Ab, S | No | Yes |
| CCPQ | P/Q-Type Calcium Channel Ab | No | Yes |
| PCABP | Purkinje Cell Cytoplasmic Ab Type 1 | No | Yes |
| PCAB2 | Purkinje Cell Cytoplasmic Ab Type 2 | No | Yes |
| PCATR | Purkinje Cell Cytoplasmic Ab Type Tr | No | Yes |
Reflex Tests
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| ARBI | ACh Receptor (Muscle) Binding Ab | Yes | No |
| AGNBS | AGNA-1 Immunoblot, S | No | No |
| AMPCS | AMPA-R Ab CBA, S | No | No |
| AMPIS | AMPA-R Ab IF Titer Assay, S | No | No |
| AMIBS | Amphiphysin Immunoblot, S | No | No |
| AN1BS | ANNA-1 Immunoblot, S | No | No |
| AN2BS | ANNA-2 Immunoblot, S | No | No |
| CS2CS | CASPR2-IgG CBA, S | No | No |
| CRMWS | CRMP-5-IgG Western Blot, S | Yes | No |
| DPPCS | DPPX Ab CBA, S | No | No |
| DPPIS | DPPX Ab IFA, S | No | No |
| DPPTS | DPPX Ab IFA Titer, S | No | No |
| GABCS | GABA-B-R Ab CBA, S | No | No |
| GABIS | GABA-B-R Ab IF Titer Assay, S | No | No |
| GD65S | GAD65 Ab Assay, S | Yes | No |
| LG1CS | LGI1-IgG CBA, S | No | No |
| GL1CS | mGluR1 Ab CBA, S | No | No |
| GL1IS | mGluR1 Ab IFA, S | No | No |
| GL1TS | mGluR1 Ab IFA Titer, S | No | No |
| NMDCS | NMDA-R Ab CBA, S | No | No |
| NMDIS | NMDA-R Ab IF Titer Assay, S | No | No |
| PC1BS | PCA-1 Immunoblot, S | No | No |
| PCTBS | PCA-Tr Immunoblot, S | No | No |
| ACMFS | AChR Modulating Flow Cytometry, S | No | No |
Special Instructions
Report Available
10 to 17 daysDay(s) Performed
AGN1S, AMPHS, AMPIS, ANN1S, ANN2S, ANN3S, CRMS, DPPIS, DPPTS, GABIS, GL1IS, GL1TS, NMDIS, PCAB2, PCABP, PCATR, ARBI,CCPQ, GANG, VGKC, GD65S:
Monday through Sunday
CRMWS, AGNBS, AMIBS, AN1BS, AN2BS, PC1BS, PCTBS:
Monday through Friday
ACMFS:
Monday, Wednesday, Saturday
AMPCS, CS2CS, DPPCS, GABCS, LG1CS, NMDCS:
Monday through Friday, Sunday
GL1CS:
Monday, Thursday
Clinical Reference
1. McKeon A, Pittock SJ: Paraneoplastic encephalomyelopathies: pathology and mechanisms. Acta Neuropathol. 2011;122:381-400
2. Horta ES, Lennon VA, Lachance DH, et al: Neural autoantibody clusters aid diagnosis of cancer. Clin Cancer Res. 2014;20:3862-3869
Method Name
AGN1S, AMPHS, AMPIS, ANN1S, ANN2S, ANN3S, CRMS, DPPIS, DPPTS, GABIS, GL1IS, GL1TS, NMDIS, PCAB2, PCABP, PCATR: Indirect Immunofluorescence Assay (IFA)
ARBI, CCPQ, GANG, GD65S, VGKC: Radioimmunoassay (RIA)
CRMWS: Western Blot (WB)
AGNBS, AMIBS, AN1BS, AN2BS, PC1BS, PCTBS: Immunoblot (IB)
AMPCS, CS2CS, DPPCS, GABCS, GL1CS, LG1CS, NMDCS: Cell-Binding Assay (CBA)
ACMFS: Flow Cytometry
Specimen Type
SerumNecessary Information
Provide the following information:
-Relevant clinical information
-Ordering Provider name, phone number, mailing address, and e-mail address
Specimen Required
Patient Preparation:
1. For optimal antibody detection, specimen collection is recommended prior to initiation of immunosuppressant medication or intravenous immunoglobulin (IVIg) treatment.
2. This test should not be requested in patients who have recently received radioisotopes, therapeutically or diagnostically, because of potential assay interference. The specific waiting period before specimen collection will depend on the isotope administered, the dose given, and the clearance rate in the individual patient. Specimens will be screened for radioactivity prior to analysis. Radioactive specimens received in the laboratory will be held 1 week and assayed if sufficiently decayed, or canceled if radioactivity remains.
3. Patient should have no general anesthetic or muscle-relaxant drugs in the previous 24 hours.
Container/Tube:
Preferred: Red top
Acceptable: Serum gel
Specimen Volume: 4 mL
Specimen Minimum Volume
2 mL
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Serum | Refrigerated (preferred) | 28 days | |
| Frozen | 28 days | ||
| Ambient | 72 hours |
Reference Values
|
Test ID |
Reporting name |
Methodology |
Reference value |
|
GANG |
AChR Ganglionic Neuronal Ab, S |
Radioimmunoassay (RIA) |
≤0.02 nmol/L |
|
AMPHS |
Amphiphysin Ab, S |
Immunofluorescence (IFA) |
<1:240 |
|
AGN1S |
Anti-Glial Nuclear Ab, Type 1 |
IFA |
<1:240 |
|
ANN1S |
Anti-Neuronal Nuclear Ab, Type 1 |
IFA |
<1:240 |
|
ANN2S |
Anti-Neuronal Nuclear Ab, Type 2 |
IFA |
<1:240 |
|
ANN3S |
Anti-Neuronal Nuclear Ab, Type 3 |
IFA |
<1:240 |
|
CRMS |
CRMP-5-IgG, S |
IFA |
<1:240 |
|
VGKC |
Neuronal (V-G) K+ Channel Ab, S |
RIA |
≤0.02 nmol/L |
|
|
|
|
|
|
CCPQ |
P/Q-Type Calcium Channel Ab |
RIA |
≤0.02 nmol/L |
|
PCABP |
Purkinje Cell Cytoplasmic Ab Type 1 |
IFA |
<1:240 |
|
PCAB2 |
Purkinje Cell Cytoplasmic Ab Type 2 |
IFA |
<1:240 |
|
PCATR |
Purkinje Cell Cytoplasmic Ab Type Tr |
IFA |
<1:240 |
|
|
|
|
|
Reflex Tests:
|
Test ID |
Reporting name |
Methodology |
Reference value |
|
ARBI |
ACh Receptor (Muscle) Binding Ab |
RIA |
≤0.02 nmol/L |
|
ACMFS |
Ach Receptor Modulating FACS, S |
Flow Cytometry |
Negative |
|
|
|
|
|
|
AGNBS |
AGNA-1 Immunoblot, S |
Immunoblot (IB) |
Negative |
|
AMPCS |
AMPA-R Ab CBA, S |
Cell-Binding Assay (CBA) |
Negative |
|
AMPIS |
AMPA-R Ab IF Titer Assay, S |
IFA |
<1:120 |
|
AMIBS |
Amphiphysin Immunoblot, S |
IB |
Negative |
|
AN1BS |
ANNA-1 Immunoblot, S |
IB |
Negative |
|
AN2BS |
ANNA-2 Immunoblot, S |
IB |
Negative |
|
CS2CS |
CASPR2-IgG CBA, S |
CBA |
Negative |
|
CRMWS |
CRMP-5-IgG Western Blot, S |
Western Blot |
Negative |
|
DPPCS |
DPPX Ab CBA, S |
CBA |
Negative |
|
DPPIS |
DPPX Ab IFA, S |
IFA |
Negative |
|
DPPTS |
DPPX Ab IFA Titer, S |
IFA |
<1:240 |
|
GABCS |
GABA-B-R Ab CBA, S |
CBA |
Negative |
|
GABIS |
GABA-B-R Ab IF Titer Assay, S |
IFA |
<1:120 |
|
GD65S |
GAD65 Ab Assay, S |
RIA |
≤0.02 nmol/L Reference values apply to all ages |
|
LG1CS |
LGI1-IgG CBA, S |
CBA |
Negative |
|
GL1CS |
mGluR1 Ab CBA, S |
CBA |
Negative |
|
GL1IS |
mGluR1 Ab IFA, S |
IFA |
Negative |
|
GL1TS |
mGluR1 Ab IFA Titer, S |
IFA |
<1:240 |
|
NMDCS |
NMDA-R Ab CBA, S |
CBA |
Negative |
|
NMDIS |
NMDA-R Ab IF Titer Assay, S |
IFA |
<1:120 |
|
PC1BS |
PCA-1 Immunoblot, S |
IB |
Negative |
|
PCTBS |
PCA-Tr Immunoblot, S |
IB |
Negative |
Neuron-restricted patterns of IgG staining that do not fulfill criteria for amphiphysin, ANNA-1, ANNA-2, ANNA-3, AGNA-1, PCA-1, PCA-2, PCA-Tr, or CRMP-5-IgG may be reported as "unclassified antineuronal IgG." Complex patterns that include non-neuronal elements may be reported as "uninterpretable."
Note: CRMP-5 titers lower than 1:240 are detectable by recombinant CRMP-5 Western blot analysis. CRMP-5 Western blot analysis will be done on request on stored serum (held 4 weeks). This supplemental testing is recommended in cases of chorea, vision loss, cranial neuropathy, and myelopathy. Call 800-533-1710 to request CRMP-5 Western blot.
Test Classification
This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.CPT Code Information
83519 x 3
86255 x 9
83519-ARBI (if appropriate)
86255 ACMFS (if appropriate)
84182-AGNBS (if appropriate)
86255-AMPCS (if appropriate)
86256-AMPIS (if appropriate)
84182-AMIBS (if appropriate)
84182-AN1BS (if appropriate)
84182-AN2BS (if appropriate)
86255-CS2CS (if appropriate)
84182-CRMWS (if appropriate)
86255-DPPCS (if appropriate)
86256-DPPTS (if appropriate)
86255-DPPIS (if appropriate)
86255-GABCS (if appropriate)
86256-GABIS (if appropriate)
86341-GD65S (if appropriate)
86255-LG1CS (if appropriate)
86255-GL1CS (if appropriate)
86256-GL1TS (if appropriate)
86255-GL1IS (if appropriate)
86255-NMDCS (if appropriate)
86256-NMDIS (if appropriate)
84182-PC1BS (if appropriate)
84182-PCTBS (if appropriate)
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| PAVAL | Paraneoplastic Autoantibody Eval, S | 43104-9 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 80776 | ANNA-2, S | 94343-1 |
| 83137 | ANNA-3, S | 94344-9 |
| 81185 | P/Q-Type Calcium Channel Ab | 94349-8 |
| 83077 | CRMP-5-IgG, S | 94815-8 |
| 84321 | AChR Ganglionic Neuronal Ab, S | 94694-7 |
| 29347 | Interpretive Comments | 57771-8 |
| 83138 | PCA-2, S | 94351-4 |
| 9477 | PCA-1, S | 94350-6 |
| 83076 | PCA-Tr, S | 94352-2 |
| 89165 | Neuronal (V-G) K+ Channel Ab, S | 94816-6 |
| 89080 | AGNA-1, S | 94341-5 |
| 81722 | Amphiphysin Ab, S | 94340-7 |
| 80150 | ANNA-1, S | 94342-3 |
| 36349 | Reflex Added | 77202-0 |
Forms
If not ordering electronically, complete, print, and send 1 of the following forms with the specimen:
-General Request (T239)
mml-bone-minerals