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HelpTest Code PAC1 Paraneoplastic, Autoantibody Evaluation, Spinal Fluid
Reporting Name
Paraneoplas Autoantibody Eval,CSFUseful For
Aids in the diagnosis of paraneoplastic neurological autoimmune disorders related to carcinoma of lung, breast, ovary, thymoma, or Hodgkin lymphoma in spinal fluid specimens
Performing Laboratory
Mayo Clinic Laboratories in Rochester
Specimen Type
CSFAdditional Testing Requirements
In patients with a history of tobacco use or other lung cancer risk, or if thymoma is suspected, PAVAL / Paraneoplastic Autoantibody Evaluation, Serum is also recommended.
Necessary Information
Provide the following information:
-Relevant clinical information
-Ordering provider name, phone number, mailing address, and e-mail address
Specimen Required
Container/Tube: Sterile vial
Specimen Volume: 4 mL
Specimen Minimum Volume
2 mL
Testing Algorithm
If indirect immunofluorescence assay (IFA) pattern suggests AGNA-1 antibody, then AGNA-1 immunoblot is performed at an additional charge.
If IFA pattern suggests ANNA-1 antibody, then ANNA-1 immunoblot is performed at an additional charge.
If IFA pattern suggests ANNA-2 antibody, then ANNA-2 immunoblot is performed at an additional charge.
If IFA pattern suggests PCA-1 antibody, then PCA-1 immunoblot is performed at an additional charge.
If IFA pattern suggests PCA-Tr antibody, then PCA-Tr immunoblot is performed at an additional charge.
If IFA patterns suggest CRMP-5-IgG, then CRMP-5-IgG Western blot is performed at an additional charge.
If IFA patterns suggest GAD65 antibody, then GAD65 antibody radioimmunoassay (RIA) is performed at an additional charge.
If IFA patterns suggest neuronal voltage-gated potassium channel-complex (VGKC) autoantibody, then VGKC-complex antibody RIA is performed at an additional charge.
If VGKC-complex antibody RIA is greater than 0.00 nmol/L, then LGI1-IgG cell-binding assay (CBA) and CASPR2-IgG CBA are performed at an additional charge.
If IFA patterns suggest amphiphysin antibody, then amphiphysin immunoblot is performed at an additional charge.
If IFA pattern suggests NMDA-Receptor, then NMDA-Receptor antibody CBA and/or NMDA-Receptor titer is performed at an additional charge.
If IFA pattern suggests AMPA-Receptor, then AMPA-Receptor antibody CBA and/or AMPA-Receptor titer is performed at an additional charge.
If IFA pattern suggests GABA-B-Receptor, then GABA-B-Receptor antibody CBA and/or GABA-B-Receptor titer is performed at an additional charge.
If IFA pattern suggests DPPX, then DPPX antibody CBA and DPPX titer is performed at an additional charge.
If IFA pattern suggests mGluR1, then mGluR1 antibody CBA and mGluR1 titer is performed at an additional charge.
The following algorithms are available in Special Instructions.
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| CSF | Refrigerated (preferred) | 28 days | |
| Frozen | 28 days | ||
| Ambient | 72 hours |
Special Instructions
Reference Values
|
Test ID |
Reporting name |
Methodology |
Reference value |
|
AMPHC |
Amphiphysin Ab, CSF |
Indirect immunofluorescence (IFA) |
<1:2 |
|
AGN1C |
Anti-Glial Nuclear Ab, Type 1 |
IFA |
<1:2 |
|
ANN1C |
Anti-Neuronal Nuclear Ab, Type 1 |
IFA |
<1:2 |
|
ANN2C |
Anti-Neuronal Nuclear Ab, Type 2 |
IFA |
<1:2 |
|
ANN3C |
Anti-Neuronal Nuclear Ab, Type 3 |
IFA |
<1:2 |
|
CRMC |
CRMP-5-IgG, CSF |
IFA |
<1:2 |
|
PCTRC |
Purkinje Cell Cytoplasmc Ab Type Tr |
IFA |
<1:2 |
|
PCA1C |
Purkinje Cell Cytoplasmic Ab Type 1 |
IFA |
<1:2 |
|
PCA2C |
Purkinje Cell Cytoplasmic Ab Type 2 |
IFA |
<1:2 |
Reflex Information:
|
Test ID |
Reporting name |
Methodology |
Reference value |
|
AGNBC |
AGNA-1 Immunoblot, CSF |
Immunoblot (IB) |
Negative |
|
AMPCC |
AMPA-R Ab CBA, CSF |
Cell-binding assay (CBA) |
Negative |
|
AMPIC |
AMPA-R Ab IF Titer Assay, CSF |
IFA |
<1:2 |
|
AMIBC |
Amphiphysin Immunoblot, CSF |
IB |
Negative |
|
AN1BC |
ANNA-1 Immunoblot, CSF |
IB |
Negative |
|
AN2BC |
ANNA-2 Immunoblot, CSF |
IB |
Negative |
|
CRMWC |
CRMP-5-IgG Western Blot, CSF |
Western blot (WB) |
Negative |
|
CS2CC |
CASPR2-IgG CBA, CSF |
CBA |
Negative |
|
DPPCC |
DPPX Ab CBA, CSF |
CBA |
Negative |
|
DPPIC |
DPPX Ab IFA, CSF |
IFA |
Negative |
|
DPPTC |
DPPX Ab IFA Titer, CSF |
IFA |
<1:2 |
|
GABCC |
GABA-B-R Ab CBA, CSF |
CBA |
Negative |
|
GABIC |
GABA-B-R Ab IF Titer Assay, CSF |
IFA |
<1:2 |
|
GD65C |
GAD65 Ab Assay, CSF |
Radioimmunoassay (RIA) |
≤0.02 nmol/L |
|
LG1CC |
LGI1-IgG CBA, CSF |
CBA |
Negative |
|
GL1CC |
mGluR1 Ab CBA, CSF |
CBA |
Negative |
|
GL1IC |
mGluR1 Ab IFA, CSF |
IFA |
Negative |
|
GL1TC |
mGluR1 Ab IFA Titer, CSF |
IFA |
<1:2 |
|
NMDCC |
NMDA-R Ab CBA, CSF |
CBA |
Negative |
|
NMDIC |
NMDA-R Ab IF Titer Assay, CSF |
IFA |
<1:2 |
|
PC1BC |
PCA-1 Immunoblot, CSF |
IB |
Negative |
|
PCTBC |
PCA-Tr Immunoblot, CSF |
IB |
Negative |
|
VGKCC |
VGKC-complex Ab IPA, CSF |
RIA |
≤0.02 nmol/L |
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: Titers lower than 1:2 are detectable by recombinant CRMP-5 Western blot analysis. CRMP-5 Western blot analysis will be done on request on stored spinal fluid (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.
Day(s) and Time(s) Performed
AGN1C, AMPHC, AMPIC, ANN1C, ANN2C, ANN3C, CRMC, PCTRC, PCA1C, PCA2C, DPPTC, DPPIC, GABIC, GL1TC, GL1IC, NMDIC:
Monday through Friday; 5 a.m., 7 a.m., 5 p.m.
Saturday, Sunday; 6 a.m.
AGNBC, AMIBC, AN1BC, AN2BC, PC1BC, PCTBC:
Monday through Friday; 6 p.m.
AMPCC, CS2CC, DPPCC, GABCC, LG1CC, NMDCC:
Monday through Friday; 10 p.m.
Sunday; 3 p.m.
CRMWC:
Monday through Thursday; 8 a.m.
GL1CC:
Monday and Thursday; 6 p.m.
GD65C:
Monday through Friday; 5 a.m., 2 p.m.
Saturday, Sunday; 7 a.m.
VGKCC:
Monday through Friday; 11 a.m., 6 p.m.
Saturday, Sunday; 6 a.m.
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 U.S. Food and Drug Administration.CPT Code Information
86255 x 9
84182-AGNBC (if appropriate)
86255-AMPCC (if appropriate)
86256-AMPIC (if appropriate)
84182-AMIBC (if appropriate)
84182-AN1BC (if appropriate)
84182-AN2BC (if appropriate)
86255-CS2CC (if appropriate)
84182-CRMWC (if appropriate)
86255-DPPCC (if appropriate)
86256-DPPTC (if appropriate)
86255-DPPIC (if appropriate)
86255-GABCC (if appropriate)
86256-GABIC (if appropriate)
86341-GD65C (if appropriate)
86255-LG1CC (if appropriate)
86255-GL1CC (if appropriate)
86256-GL1TC (if appropriate)
86255-GL1IC (if appropriate)
86255-NMDCC (if appropriate)
86256-NMDIC (if appropriate)
84182-PC1BC (if appropriate)
84182-PCTBC (if appropriate)
83519-VGKCC (if appropriate)
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| PAC1 | Paraneoplas Autoantibody Eval,CSF | 94818-2 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 89079 | AGNA-1, CSF | 94355-5 |
| 5906 | Amphiphysin Ab, CSF | 94354-8 |
| 3852 | ANNA-1, CSF | 94356-3 |
| 7472 | ANNA-2, CSF | 94357-1 |
| 21633 | ANNA-3, CSF | 94358-9 |
| 21650 | CRMP-5-IgG, CSF | 94706-9 |
| 3988 | PCA-1, CSF | 94363-9 |
| 21632 | PCA-2, CSF | 94364-7 |
| 21631 | PCA-Tr, CSF | 94362-1 |
| 34271 | Paraneoplastic Interpretation, CSF | 69048-7 |
| 36429 | Reflex Added | 77202-0 |
Clinical Reference
1. Lucchinetti CF, Kimmel DW, Lennon VA: Paraneoplastic and oncological profiles of patients seropositive for type 1 anti-neuronal nuclear antibody. Neurology 1998;50:652-657
2. Graus F, Vincent A, Pozo-Rosich P, et al: Anti-glial nuclear antibody: marker of lung cancer-related paraneoplastic neurological syndromes. J Neuroimmunol 2005;154(1-2):166-171
3. Pittock SJ, Lucchinetti CF, Lennon VA: Anti-neuronal nuclear autoantibody type 2: paraneoplastic accompaniments. Ann Neurol 2003;53(5):580-587
4. Chan KH, Vernino S, Lennon VA: ANNA-3 anti-neuronal nuclear antibody: marker of lung cancer-related autoimmunity. Ann Neurol 2001 September;50(3):301-311
5. Hetzel DJ, Stanhope CR, O'Neill BP, Lennon VA: Gynecologic cancer in patients with subacute cerebellar degeneration predicted by anti-purkinje cell antibodies and limited in metastatic volume. Mayo Clin Proc 1990;65:1558-1563
6. Pittock SJ, Lucchinetti CF, Parisi JE, et al: Amphiphysin autoimmunity: paraneoplastic accompaniments. Ann Neurol 2005;58(1):96-107
7. McKeon A, Pittock SJ: Paraneoplastic encephalomyelopathies: pathology and mechanisms. Acta Neuropathol 2011;122:381-400
8. Horta ES, Lennon VA, Lachance DH, et al: Neural autoantibody clusters aid diagnosis of cancer. Clin Cancer Res 2014;20:3862-3869
Method Description
Indirect Immunofluorescence Assay (IFA):
The patient's sample is tested by a standardized IFA that uses a composite frozen section of mouse cerebellum, kidney, and gut tissues. After incubation with sample and washing, fluorescein-conjugated goat-antihuman IgG is applied. Neuron-specific autoantibodies are identified by their characteristic fluorescence staining patterns.. Samples that are scored positive for any neuronal nuclear or cytoplasmic autoantibody are titrated to an endpoint. Interference by coexisting non-neuron-specific autoantibodies can usually be eliminated by serologic absorption.( Honorat JA, Komorowski L, Josephs KA, et al: IgLON5 antibody: neurological accompaniments and outcomes in 20 patients. Neurol Neuroimmunol Neuroinflamm 2017 Jul 18;4(5):e385. doi: 10.1212/NXI.0000000000000385689)
Western Blot:
Neuronal antigens extracted aqueously from adult rat cerebellum, full-length recombinant human collapsin response-mediator protein-5 (CRMP-5), or full-length recombinant human amphiphysin protein is denatured, reduced, and separated by electrophoresis on 10% polyacrylamide gel. IgG is detected autoradiographically by enhanced chemiluminescence. (Yu Z, Kryzer TJ, Griesmann GE, et al: CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Ann Neurol 2001 February;49[2]:146-154; Dubey D, Jitprapaikulsan J, Bi H, et al: Amphiphysin-IgG autoimmune neuropathy: A recognizable clinicopathologic syndrome. Neurology 2019 Oct 17 pii: 10.1212/WNL.0000000000008472. doi: 10.1212/WNL.0000000000008472)
Immunoblot (IB):
All steps are performed at ambient temperature (18-28 degreesC) utilizing the EUROBlot One instrument. Diluted patient serum (1:12.5) is added to test strips (strips containing recombinant antigen manufactured and purified using biochemical methods) in individual channels and incubated for 30 minutes. Positive specimens will bind to the purified recombinant antigen and negative specimens will not bind. Strips are washed to remove unbound antibodies and then incubated with anti-human IgG antibodies (alkaline phosphatase-labelled) for 30 minutes. The strips are again washed to remove unbound anti-human IgG antibodies and nitroblue tetrazolium chloride/5-bromo-4-chloro-3-indolylphosphate (NBT/BCIP) substrate is added. Alkaline phosphatase enzyme converts the soluble substrate into a colored insoluble product on the membrane to produces a black band. Strips are digitized via picture capture on the EUROBlot One instrument and evaluated with the EUROLineScan software. (O'Connor K, Waters P, Komorowski L, et al: GABAA receptor autoimmunity: A multicenter experience. Neurol Neuroimmunol Neuroinflamm 2019 Apr 4;6[3]:e552 doi: 10.1212/NXI.0000000000000552)
Radioimmunoassay (RIA):
Duplicate aliquots of patient specimen are incubated with I(125)-labeled antigen. Immune complexes, formed by adding secondary (goat) antihuman immunoglobulin, are pelleted by centrifugation and washed. Gamma emission from the washed pellet is counted, and mean counts per minute (cpm) are compared with results yielded by high positive and negative control sera. Specimen yielding cpm higher than the background cpm yielded by normal human specimen are retested to confirm positivity and titrated as necessary to obtain a value in the linear range of the assay. The antigen binding capacity (nmol per liter) is calculated from the cpm precipitated at a dilution yielding a linear range value. (Vernino S, Kryzer TJ, Lennon AV: Chapter 114: Autoimmune autonomic neuropathy and neuromuscular hyperexcitability disorders. In Manual of Clinical and Laboratory Immunology. Sixth edition. Edited by NR Rose, RG Hamilton, B Detrick. ASM Press, 2002, pp 1013-1017; Jones AL, Flanagan EP, Pittock SJ, et al: Responses to and Outcomes of Treatment of Autoimmune Cerebellar Ataxia in Adults. JAMA Neurol 2015 Nov;72[11]:1304-1312 doi: 10.1001/jamaneurol.2015.2378)
Cell-Binding Assay (CBA):
Patient serum is applied to a composite slide containing transfected and nontransfected HEK-293 cells. After incubation and washing, fluorescein-conjugated goat-antihuman IgG is applied to detect the presence of patient IgG binding.(Package insert: IIFT: Neurology Mosaics, Instructions for the indirect immunofluorescence test. EUROIMMUN, Lubeck, Germany, FA_112d-1_A_UK_C13, 02/2019)
Analytic Time
8 daysReject Due To
| Gross hemolysis | Reject |
| Gross lipemia | Reject |
| Gross icterus | Reject |
Method Name
AGN1C, AMPHC, AMPIC, ANN1C, ANN2C, ANN3C, CRMC, DPPIC, DPPTC, GABIC, GL1IC, GL1TC, NMDIC, PCA1C, PCA2C, PCTRC: Indirect Immunofluorescence Assay (IFA)
CRMWC: Western Blot
AGNBC, AMIBC, AN1BC, AN2BC, PC1BC, PCTBC: Immunoblot (IB)
GD65C, VGKCC: Radioimmunoassay (RIA)
AMPCC, CS2CC, DPPCC, GABCC, GL1CC, LG1CC, NMDCC: Cell-Binding Assay (CBA)
Forms
If not ordering electronically, complete, print, and send a Neurology Specialty Testing Client Test Request (T732) with the specimen.
Profile Information
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| PNEOI | Paraneoplastic Interpretation, CSF | No | Yes |
| AMPHC | Amphiphysin Ab, CSF | No | Yes |
| AGN1C | Anti-Glial Nuclear Ab, Type 1 | No | Yes |
| ANN1C | Anti-Neuronal Nuclear Ab, Type 1 | No | Yes |
| ANN2C | Anti-Neuronal Nuclear Ab, Type 2 | No | Yes |
| ANN3C | Anti-Neuronal Nuclear Ab, Type 3 | No | Yes |
| CRMC | CRMP-5-IgG, CSF | No | Yes |
| PCTRC | Purkinje Cell Cytoplasmc Ab Type Tr | No | Yes |
| PCA1C | Purkinje Cell Cytoplasmic Ab Type 1 | No | Yes |
| PCA2C | Purkinje Cell Cytoplasmic Ab Type 2 | No | Yes |
Reflex Tests
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| AGNBC | AGNA-1 Immunoblot, CSF | No | No |
| AMPCC | AMPA-R Ab CBA, CSF | No | No |
| AMPIC | AMPA-R Ab IF Titer Assay, CSF | No | No |
| AMIBC | Amphiphysin Immunoblot, CSF | No | No |
| AN1BC | ANNA-1 Immunoblot, CSF | No | No |
| AN2BC | ANNA-2 Immunoblot, CSF | No | No |
| CS2CC | CASPR2-IgG CBA, CSF | No | No |
| CRMWC | CRMP-5-IgG Western Blot, CSF | Yes | No |
| DPPCC | DPPX Ab CBA, CSF | No | No |
| DPPTC | DPPX Ab IFA Titer, CSF | No | No |
| DPPIC | DPPX Ab IFA, CSF | No | No |
| GABCC | GABA-B-R Ab CBA, CSF | No | No |
| GABIC | GABA-B-R Ab IF Titer Assay, CSF | No | No |
| GD65C | GAD65 Ab Assay, CSF | Yes | No |
| LG1CC | LGI1-IgG CBA, CSF | No | No |
| GL1CC | mGluR1 Ab CBA, CSF | No | No |
| GL1TC | mGluR1 Ab IFA Titer, CSF | No | No |
| GL1IC | mGluR1 Ab IFA, CSF | No | No |
| NMDCC | NMDA-R Ab CBA, CSF | No | No |
| NMDIC | NMDA-R Ab IF Titer Assay, CSF | No | No |
| PC1BC | PCA-1 Immunoblot, CSF | No | No |
| PCTBC | PCA-Tr Immunoblot, CSF | No | No |
| VGKCC | VGKC-complex Ab IPA, CSF | No | No |