An initial analysis of preoperative serum CA 125 levels in patients with early stage ovarian carcinoma

The Role of Mesothelin Expression in Serous Ovarian Carcinoma: Impacts on Diagnosis, Prognosis, and Therapeutic Targets

Mesothelin (MSLN) is a protein expressed in the mesothelial cell lining of the pleura, peritoneum, and pericardium; its biological functions in normal cells are still unknown. Experimental studies using knockout mice have suggested that this molecule does not play an important role in development and reproduction. In contrast, it has been observed that this molecule is produced in abnormal amounts in several malignant neoplasms, such as mesotheliomas and pancreatic adenocarcinomas. Many molecular studies have also demonstrated that mesothelin is overexpressed in HSOCs. Here, we discuss the current knowledge of mesothelin and focus on its role in clinical and pathological diagnoses, as well as its impact on the prognosis of HSOC. Moreover, regarding the binding of MSLN to the ovarian cancer antigen CA125, which has been demonstrated in many studies, we also report on signal transduction pathways that may play an important role in the spread and neoplastic progression of this lethal neoplasm. Given that mesothelin is overexpressed in many solid tumours and has antigenic properties, this molecule could be considered an antigenic target for the treatment of many malignancies. Consequently, we also review the literature to report on mesothelin-targeting therapies for HSOC that have been recently investigated in many clinical studies.

Exploratory Analysis of CA125-MGL and -STn Glycoforms in the Differential Diagnostics of Pelvic Masses

BACKGROUND

The cancer antigen 125 (CA125) immunoassay (IA) does not distinguish epithelial ovarian cancer (EOC) from benign disease with the sensitivity needed in clinical practice. In recent studies, glycoforms of CA125 have shown potential as biomarkers in EOC. Here, we assessed the diagnostic abilities of two recently developed CA125 glycoform assays for patients with a pelvic mass. Detailed analysis was further conducted for postmenopausal patients with marginally elevated conventionally measured CA125 levels, as this subgroup presents a diagnostic challenge in the clinical setting.

METHODS

Our study population contained 549 patients diagnosed with EOC, benign ovarian tumors, and endometriosis. Of these, 288 patients were postmenopausal, and 98 of them presented with marginally elevated serum levels of conventionally measured CA125 at diagnosis. Preoperative serum levels of conventionally measured CA125 and its glycoforms (CA125-MGL and CA125-STn) were determined.

RESULTS

The CA125-STn assay identified EOC significantly better than the conventional CA125-IA in postmenopausal patients (85% vs. 74% sensitivity at a fixed specificity of 90%, P = 0.0009). Further, both glycoform assays had superior AUCs compared to the conventional CA125-IA in postmenopausal patients with marginally elevated CA125. Importantly, the glycoform assays reduced the false positive rate of the conventional CA125-IA.

CONCLUSIONS

The results indicate that the CA125 glycoform assays markedly improve the performance of the conventional CA125-IA in the differential diagnosis of pelvic masses. This result is especially valuable when CA125 is marginally elevated.

[Comparison of serum cancer antigen 125, human epididymis protein 4, ROMA, and CPH-I for diagnosis of ovarian cancer in Chinese patients with ovarian mass]

OBJECTIVE

To compare the performance of serum cancer antigen 125 (CA125), human epididymis protein 4 (HE4), Risk of Ovarian Malignancy Algorithm (ROMA) and Copenhagen index (CPH-I) for differential diagnosis of benign and malignant diseases in patients with ovarian mass.

METHODS

We retrospectively analyzed the data of 719 women with pelvic mass, and the performance of preoperative serum levels of CA125 and HE4, ROMA and CPH-I for differential diagnosis of the masses was compared.

RESULTS

Of the 710 women analyzed, 531 were diagnosed with benign ovarian lesions, 44 with borderline ovarian tumors (BOTs), 119 with epithelial ovarian cancers (EOCs), and 25 with non-EOCs. In differentiating ovarian cancer (OC) and BOT from benign lesions, the area under the receiver-operator characteristic (ROC) curve (AUC) was 0.854 for HE4, 0.856 for ROMA, 0.854 for CPH-I, and 0.792 for CA125, demonstrating better diagnostic performance of HE4, ROMA, and CPH-I than CA125 alone; the diagnostic sensitivity was 56.9% for HE4, 70.2% for CA125, 69.1% for ROMA, and 63.8% for CPH-I; the specificity was the best with HE4 (94.4%) and CPH-I (94.7%). In sub-analysis of EOC vs benign lesions, the AUCs of HE4, ROMA, and CPH-I increased to 0.946, 0.947, and 0.943, respectively, all greater than that of CA125 (0.888). In other sub-analyses, HE4, ROMA, and CPH-I all showed greater AUCs than CA125 alone.

CONCLUSIONS

This study confirms the accuracy of HE4, ROMA, and CPH-I for differentiating malignant from benign ovarian mass, and all these 3 tests show better performance than CA125. Furthermore, HE4 and CPH-I is superior to ROMA and CA125 in terms of specificity, while CA125 and ROMA have better diagnostic sensitivities.

Multi-biomarker panel signature as the key to diagnosis of ovarian cancer

Early detection of ovarian cancer has been a challenge to manage the high mortality rate caused by this deadly disease. The trends in mortality have been reduced by the scientific contributions from the corners across the globe, however accounting for the fifth leading cause of gynecological mortality. The complexities in the clinical presentation, origin of tumor, and gene expression profiles had added to much difficulty in understanding and diagnosis of the disease. Stage 1 diagnosis of ovarian cancer improves the 5-year survival rate to around 92%. Cancer antigen-125 (CA-125) is the gold standard tumor marker found at abnormally high levels in the blood of many women in ovarian cancer. However, many non-cancerous conditions exhibit high levels of CA-125 and several women have normal CA-125 level in the early stage of ovarian cancer, suggesting CA-125 biomarker is not specific enough for the screening of early stage ovarian cancer. In addition, several other biomarkers, including HE4 have been added in the diagnostic field for higher sensitivity and specificity in the diagnosis and progression of ovarian cancer. HE4 is a prospective single serum biomarker which has been approved by the FDA to monitor the disease progression in epithelial ovarian cancer. However, owing to low sensitivity and specificity, combination of a panel of biomarkers has been proposed in the diagnosis of the disease. Based on extensive biomarkers research findings, here we discuss current trends in diagnostic approaches and updated potential several panels of cancer biomarkers for early detection of ovarian cancer. It has been recently reported that CA125 in combinations with two or more biomarkers have outperformed single biomarker assays for early detection of the disease. Moreover, CA-125 with CA 19–9, EGFR, G-CSF, Eotaxin, IL-2R, cVCAM, MIF improved the sensitivity with 98.2 % and specificity of 98.7% in early stage detection of ovarian cancer. Overall, this review demonstrates a panel of biomarkers signature as the potential tool for prototype development in future and other advanced approaches for early diagnosis of ovarian cancer to avoid false-diagnosis and excessive cost.

Diagnostic and prognostic role of HE4 expression in multiple carcinomas: A protocol for systematic review and meta-analysis

BACKGROUND

Human epididymis protein 4 (HE4) protein has garnered a great degree of interest as a complementary biomarker to carbohydrate antigen 125 (CA125), or even as an independent biomarker for monitoring, diagnosis, and prognostication of ovarian cancer. Its use is currently limited to ovarian cancer. Recent studies have suggested that it could also be used in other types of cancers.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines was used to design this meta-analysis protocol. The final study will also be conducted under the PRISMA guidelines for systematic reviews and meta-analyses. The core bibliographic database search will be carried out by 2 reviewers working individually, with each conducting an initial screening based on titles and abstracts. The shortlisted articles will be selected for review and statistical analysis based on predefined inclusion and exclusion criteria. Study characteristics, relevant clinicopathological characteristics and statistical data required for meta-analysis (hazard ratios [HRs] and 95% confidence interval [CIs) will be extracted and compiled into a MS Excel datasheet. Meta-analysis will be performed, using a random-effects model, and the results (pooled HR and 95% CI) will be presented in the form of a forest plot. Publication bias will also be assessed by use of Egger bias indicator test and funnel plot symmetry. If data are insufficient, a narrative line of review will be pursued.

DISCUSSION

HE4 protein has been shown to have great potential for clinical use as a diagnostic and prognostic marker in epithelial ovarian cancer (EOC). However, HE4 is not only limited to expression in ovarian cancer, but is also overexpressed in lung and endometrial cancers. The effectiveness of HE4 as a biomarker in cancers (other than EOC) has not yet been studied in the form of a comprehensive systematic review and meta-analysis. The results of this study should allow for expanded use of HE4 as a multiutility biomarker in multiple cancer types, thereby, elevating HE4's value as a cancer biomarker.

PROSPERO REGISTRATION

CRD42019120326.

Assessment of Diagnostic Values among CA-125, RMI, HE4, and ROMA for Cancer Prediction in Women with Nonfunctional Ovarian Cysts

Objectives

To evaluate the diagnostic performance among CA-125, RMI, HE4, and ROMA for cancer detection in women with nonfunctional ovarian cysts at King Chulalongkorn Memorial Hospital (KCMH). Secondary objective is to reconsider the proper cutoff value of HE4.

Methods

This is a prospective analytic study in women with nonfunctional ovarian cysts larger than 3 cm who scheduled for surgery at KCMH during 3^rd June 2015 to 31^st May 2016. Ultrasonogram and blood sample collection were completed before the operation. Patients' demographic information and pathologic results were obtained. SPSS software version 17 was used for statistical evaluation.

Results

A total of 281 participants were evaluated. 19.9% of them were malignant. Compared with CA-125, HE4 had lower sensitivity (53.4% vs. 87.9%) and NPV (89% vs. 93.6%) but higher specificity (97.8% vs. 46.2%) and PPV (86.1% vs. 29.8%). ROMA had slightly lower sensitivity (79.3% vs. 87.9%) and similar NPV (93.7% vs. 93.6%), but higher specificity (79.8% vs. 46.2%) and PPV (50.5% vs. 29.8%) compared with CA-125. The model that achieves the highest area under the ROC curve in differentiating benign versus malignant ovarian tumor was ROMA. Cutoff value of HE4 at 70 pMol/L (from 150 pMol/L) would give sensitivity 74.1% and specificity 86.5% that are comparable with ROMA.

Conclusions

HE4 and ROMA had better performance (higher specificity, PPV) compared to CA-125 and RMI. HE4 at 70 pMol/L could be the new cutoff value for Thai women with ovarian cysts, giving higher sensitivity and specificity.

Clinical analysis of four serum tumor markers in 458 patients with ovarian tumors: diagnostic value of the combined use of HE4, CA125, CA19-9, and CEA in ovarian tumors

Purpose

To investigate the diagnostic values of human epididymis protein 4 (HE4), carbohydrate antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) for ovarian tumors.

Methods

The participants were divided into three groups: 386 healthy women (control group), 262 patients with benign ovarian tumors (the benign group), and 196 patients with malignant pelvic tumors (the malignant group). The serum levels of HE4, CA125, CA19-9, and CEA were analyzed by electrochemiluminescent immunoassay.

Results

It showed that serum levels of HE4, CA125, CA19-9, and CEA of patients with malignant ovarian tumors were significantly higher than those in the control group and benign group (P<0.01). HE4 had a high specificity (96.56%) in malignant ovarian tumors. The tumor markers HE4, CA125, CA19-9, and CEA had a sensitivity of 63.78%, 62.75%, 35.71%, and 38.78%, respectively. The combined use of two or more tumor markers (parallel test) had a higher diagnostic sensitivity but lower specificity than a single tumor marker. The combined efficiency of HE4 and CA125 was the highest, with a sensitivity and specificity of 80.10% and 69.08%, respectively. HE4 and CA125 combined with the Risk of Ovarian Malignancy Algorithm provided an efficient means of screening and diagnosis of ovarian malignancies. The diagnostic sensitivity increased to 88.52% when three or four tumor markers were used but showed no significant difference compared with the combination of HE4 and CA125 (P>0.05).

Conclusion

The combination of three or four tumor markers did not improve the diagnostic efficacy when compared with the combination of HE4 and CA125.

Ultrasensitive tumour-penetrating nanosensors of protease activity

The ability to identify cancer lesions with endogenous biomarkers is currently limited to tumours ~1 cm in diameter. We recently reported an exogenously administered tumour-penetrating nanosensor that sheds, in response to tumour-specific proteases, peptide fragments that can then be detected in the urine. Here, we report the optimization, informed by a pharmacokinetic mathematical model, of the surface presentation of the peptide substrates to both enhance on-target protease cleavage and minimize off-target cleavage, and of the functionalization of the nanosensors with tumour-penetrating ligands that engage active trafficking pathways to increase activation in the tumour microenvironment. The resulting nanosensor discriminated sub-5 mm lesions in human epithelial tumours and detected nodules with median diameters smaller than 2 mm in an orthotopic model of ovarian cancer. We also demonstrate enhanced receptor-dependent specificity of signal generation in the urine in an immunocompetent model of colorectal liver metastases, and in situ activation of the nanosensors in human tumour microarrays when re-engineered as fluorogenic zymography probes.

Translating epithelial mesenchymal transition markers into the clinic: Novel insights from proteomics

The growing understanding of the molecular mechanisms underlying epithelial-to-mesenchymal transition (EMT) may represent a potential source of clinical markers. Despite EMT drivers have not yet emerged as candidate markers in the clinical setting, their association with established clinical markers may improve their specificity and sensitivity. Mass spectrometry-based platforms allow analyzing multiple samples for the expression of EMT candidate markers, and may help to diagnose diseases or monitor treatment efficiently. This review highlights proteomic approaches applied to elucidate the differences between epithelial and mesenchymal tumors and describes how these can be used for target discovery and validation.

Evaluation of human epididymis protein 4 (HE4) and Risk of Ovarian Malignancy Algorithm (ROMA) as diagnostic tools of type I and type II epithelial ovarian cancer in Japanese women

Human epididymis protein 4 (HE4) levels and the Risk of Ovarian Malignancy Algorithm (ROMA) have recently been shown to improve the sensitivity and specificity of epithelial ovarian cancer (EOC) diagnosis. We evaluated HE4 levels and ROMA as diagnostic tools of type I and type II EOC in Japanese women. Women who had a pelvic mass on imaging and were scheduled to undergo surgery were enrolled as ovarian mass patients. Serum levels of carbohydrate antigen 125 (CA125) and HE4 were tested in 319 women (131 benign, 19 borderline, 75 malignant, and 94 healthy controls). CA125, HE4, and ROMA were evaluated for sensitivity and by receiver operating characteristics (ROC) in type I and type II EOC. The results showed that, at 75% specificity, the sensitivity of CA125 and HE4 for type II was 92.1% for both markers and for type I was 51.5% and 78.8%, respectively. The sensitivities of ROMA (type I, 84.8% and type II, 97.4%) were better than those of CA125 and HE4. CA125, HE4, and ROMA were all highly accurate markers for type II. For type I, HE4 and ROMA showed better sensitivity than CA125. ROMA displayed the best diagnostic power for type I and type II including for the early stage of type I. In conclusion, HE4, CA125, and ROMA are valuable markers for type II EOC diagnosis. HE4 and ROMA analyses may improve differentiation between type I EOC and a benign mass. Measurement of combined HE4 and CA125 levels provides a more accurate method for EOC diagnosis.

Serum soluble mesothelin-related peptide (SMRP): a potential diagnostic and monitoring marker for epithelial ovarian cancer

PURPOSE

To explore the potential and diagnostic performance of soluble mesothelin-related peptide (SMRP) as a tumor marker for epithelial ovarian cancer (EOC).

METHODS

Sera were obtained from 78 EOC patients, 84 benign ovarian tumor patients, 58 healthy volunteers, and 22/78 EOC patients 1 week after surgery. SMRP levels and diagnostic performance were assessed by ELISA using the MESOMARK kit. The combination of SMRP and CA125 in the diagnosis of EOC was assessed.

RESULTS

SMRP concentrations were higher in EOC patients than in benign tumor patients and healthy volunteers, and SMRP levels were shown to decrease in EOC patients after surgery. Histological EOC subtypes showed significant differences in SMRP levels. Stage III-IV patients had a higher level of SMRP than stage I-II patients (P < 0.001). Elevated SMRP levels were also found in higher grade tumors (P < 0.001). The receiver operating characteristic curve for SMRP was 0.891. The best statistical cut-off for SMRP was 1.3109 nM, with 0.821 sensitivity and 0.979 specificity. When compared with CA125, SMRP performed better in specificity, omission diagnostic rate, positive predictive value, and correction rate, but worse for sensitivity and negative predictive value. The combination of SMRP and CA125 gave a sensitivity of 98.4 % and a specificity of 88.9 %.

CONCLUSION

Serum SMRP is a promising marker for the diagnosis and monitoring of EOC, especially in combination with CA125.

HE4 combined with CA125: favorable screening tool for ovarian cancer

Ovarian cancer is one of the most prevalent malignancies in women. Screening of the disease is done using variety of biomarkers. Diagnostic performance of current biomarkers of the disease such as human epididymis protein (HE4) and CA125 shows contradiction in previous studies. The goal of this study was to evaluate serum levels of CA125 and HE4 in Iranian patients with ovarian cancer and compare specificity and sensitivity of HE4, CA125 and HE4 + CA125 in patients with different stages and diverse histology. To evaluate CA125 and HE4, 32 patients and 34 healthy women were selected. Origin of ovarian cancer was verified by expert gynecological oncologist. Significance and diagnostic performance were determined by ANOVA and receiver operator characteristic (ROC) and areas under the curve (AUC), respectively. Serum levels of CA125 and HE4 were significantly increased in patients in comparison with control group, especially for tumor cells originated from epithelium (p < 0.001). ROC-AUC for HE4, CA125 and HE4 + CA125 were 0.91, 0.86 and 0.91, respectively. Specificity of HE4 was more than CA125 (85 vs. 80 %). Conversely, sensitivity of CA125 was higher in comparison with HE4 (90 vs. 80 %). It is being noticed that cutoff point of HE4 and CA125 was 150 pmol/L and 38 U/mL, respectively. HE4 is slightly more specific for diagnosis of early stages of the disease, but the difference is not remarkable. CA125 and HE4 + CA125 have some diagnostic performance for prediction of advanced stages. Generally, the data of present study suggest that combining of HE4 and CA125 is a better screening tool for diagnosis of ovarian cancer.

The use of HE4 in the prediction of ovarian cancer in Asian women with a pelvic mass

OBJECTIVE

The purpose of this study was to evaluate the performance of human epididymis protein 4 (HE4) and the Risk of Ovarian Malignancy Algorithm (ROMA) for distinguishing between benign and malignant pelvis masses in Asian women.

METHODS

This was a prospective, multicenter (n=6) study with patients from six Asian countries. Patients had a pelvic mass on imaging and were scheduled to undergo surgery. Serum CA125 and HE4 were measured on preoperative samples. CA125, HE4, and ROMA were evaluated for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

A total of 414 women with an adnexal mass were evaluated, of which 65 had epithelial ovarian (EOC) cancer, 16 had borderline tumors and 11 had other malignant diseases. Compared to CA125, HE4 had lower sensitivity (56.9% vs 90.8%) and NPV (91.8% vs 97.3%), but improved specificity (96.9% vs 67.1%) and PPV (78.7% vs 35.8%) for differentiating between benign pelvic mass and EOC. ROMA had similar sensitivity (89.2% vs 90.8%) and NPV (97.6% vs 97.3%) as CA125, but showed improved specificity (87.3% vs 67.1%) and PPV (58.6% vs 35.8%). ROMA accurately predicted 87.3% of benign cases as low risk, and 82.6% of stage I/II EOC and 89.2% of all EOC as high risk.

CONCLUSION

ROMA showed similar sensitivity as CA125 but improved specificity and PPV, especially in premenopausal women. Using ROMA may help predict if a pelvic mass is benign or malignant and facilitate subsequent management planning.

Expression of CA125 and cisplatin susceptibility of pleural effusion-derived human lung cancer cells from a Thai patient

Advances in understanding lung cancer biology and tumor markers aid clinicians in managing the disease. Cancer-associated antigen (CA)125 has garnered increasing attention in lung cancer research and may benefit the treatment and follow-up of this type of cancer. In Thai lung cancer patients, knowledge regarding ethnic differences in cancer cell biology is largely absent. We generated lung cancer cells from the pleural effusion fluids of a Thai patient and designated these as P1 cells. P1 cells were assessed for growth rate, response to chemotherapy, and the presence of tumor markers, in particular CA125 expression. Results of immunofluorescence indicated that P1 cells exhibited strong expression levels of CA125, comparable to that of established H460 lung cancer cells. Furthermore, P1 cells were analyzed for the expression of additional markers. Results revealed that H460 cells exhibited strong immunofluorescent signals from cytokeratin-19 fragments (CYFRA 21-1) and squamous cell carcinoma antigen (SCCA) while P1 presented only CYFRA 21-1 signals. We also found evidence of relative cisplatin resistance in P1 compared to the susceptibility level of established lung cancer cells. Thus, the results and methodology described in this study may aid the development of lung cancer diagnostic and therapeutic approaches and, in particular, advance understanding of ethnic differences.

HE4 and CA125 as a diagnostic test in ovarian cancer: prospective validation of the Risk of Ovarian Malignancy Algorithm

Background:

Recently, a Risk of Ovarian Malignancy Algorithm (ROMA) utilising human epididymis secretory protein 4 (HE4) and CA125 successfully classified patients as presenting a high or low risk for epithelial ovarian cancer (EOC). We validated this algorithm in an independent prospective study.

Methods:

Women with a pelvic mass, who were scheduled to have surgery, were enrolled in a prospective study. Preoperative serum levels of HE4 and CA125 were measured in 389 patients. The performance of each of the markers, as well as that of ROMA, was analysed.

Results:

When all malignant tumours were included, ROMA (receiver operator characteristic (ROC)-area under curve (AUC)=0.898) and HE4 (ROC-AUC)=0.857) did not perform significantly better than CA125 alone (ROC–AUC=0.877). Using a cutoff for ROMA of 12.5% for pre-menopausal patients, the test had a sensitivity of 67.5% and a specificity of 87.9%. With a cutoff of 14.4% for post-menopausal patients, the test had a sensitivity of 90.8% and a specificity of 66.3%. For EOC vs benign disease, the ROC–AUC of ROMA increased to 0.913 and for invasive EOC vs benign disease to 0.957.

Conclusion:

This independent validation study demonstrated similar performance indices to those recently published. However, in this study, HE4 and ROMA did not increase the detection of malignant disease compared with CA125 alone. Although the initial reports were promising, measurement of HE4 serum levels does not contribute to the diagnosis of ovarian cancer.

Predictive value of CA 125 and CA 72-4 in ovarian borderline tumors

BACKGROUND

The aim of this study was to assess the prognostic value of cancer antigen (CA) 125 and CA 72-4 in patients with ovarian borderline tumor (BOT).

METHODS

All women diagnosed and treated for BOT at our institution between 1981 and 2008 were included into this retrospective study (n=101). Preoperatively collected serum samples were analyzed for CA 125 (Architect, Abbott and Elecsys, Roche) and CA 72-4 (Elecsys, Roche) with reference to clinical data and compared to healthy women (n=109) and ovarian cancer patients (n=130).

RESULTS

With a median of 34.7 U/mL (range 18.1-385.0 U/mL) for CA 125 and 2.3 U/mL (range 0.2-277.0 U/mL) for CA 72-4, serum tumor markers in BOT patients were significantly elevated as compared to healthy women with a median CA 125 of 13.5 U/mL (range 4.0-49.7 U/mL) and median CA 72-4 of 0.8 U/mL (range 0.2-20.6 U/mL). In addition, there was a significant difference compared with ovarian cancer patients who showed a median CA 125 of 401.5 U/mL (range 12.5-35,813 U/mL), but no difference was observed for CA 72-4 (median 3.9 U/mL, range 0.3-10,068 U/mL). Patients with a pT1a tumor stage had significantly lower values of CA 125 but not of CA 72-4 compared with individuals with higher tumor stages (median CA 125 29.9 U/mL for pT1a vs. 50.9 U/mL for >pT1a; p=0.014). There was a trend for increased concentrations of CA 125 but not of CA 72-4 in the presence of ascites, endometriosis or peritoneal implants at primary diagnosis. With respect to the prognostic value of CA 125 or CA 72-4, CA 125 was significantly higher at primary diagnosis in patients who later developed recurrence (251.0 U/mL vs. 34.65 U/mL, p=0.012).

CONCLUSIONS

Serum CA 125 and CA 72-4 concentrations in BOT patients differ from healthy controls and patients with ovarian cancer. CA 125, but not CA 72-4, at primary diagnosis correlates with tumor stage and tends to be increased in the presence of ascites, endometriosis or peritoneal implants. Moreover, CA 125 at primary diagnosis appears to have prognostic value for recurrence.

Validation and characterization of human kallikrein 11 as a serum marker for diagnosis of ovarian carcinoma

PURPOSE

The serum tumor marker CA 125 is elevated in most clinically advanced ovarian carcinomas, and currently, one of the most promising early detection strategies for ovarian cancer uses CA 125 level in conjunction with imaging. However, CA 125 is elevated in only 50% of early-stage ovarian cancer and is often elevated in women with benign ovarian tumors and other gynecologic diseases. Additional markers may improve on its individual performance if they increase sensitivity and specificity and are less sensitive to other gynecologic conditions. The human kallikrein 11 (hK11) marker has been reported to have favorable predictive value for ovarian cancer, although, by itself, it may be inferior to CA 125.

EXPERIMENTAL DESIGN

We here validate the performance of hK11 on an independent data set and further characterize its behavior in multiple types of controls. We also investigate its behavior when combined with CA 125 to form a composite marker. hK11 had not previously been evaluated on these serum samples. CA 125, hK11, and the composite marker were evaluated for their performance in identifying ovarian cancer and for temporal stability.

RESULTS

hK11 significantly distinguished ovarian cancer cases from healthy controls and is less sensitive to benign ovarian disease than is CA 125.

CONCLUSION

We conclude that hK11 is a valuable new biomarker for ovarian cancer and its temporal stability implies that it may do even better when used in a longitudinal screening program for early detection.

Combining multiple serum tumor markers improves detection of stage I epithelial ovarian cancer

OBJECTIVE

Currently available tumor markers for ovarian cancer are still inadequate in both sensitivity and specificity to be used for population-based screening. Artificial neural network (ANN) as a modeling tool has demonstrated its ability to assimilate information from multiple sources and to detect subtle and complex patterns. In this paper, an ANN model was evaluated for its performance in detecting early stage epithelial ovarian cancer using multiple serum markers.

METHODS

Serum specimens collected at four institutions in the US, The Netherlands and the United Kingdom were analyzed for CA 125II, CA 72-4, CA 15-3 and macrophage colony stimulating factor (M-CSF). The four tumor marker values were then used as inputs to an ANN derived using a training set from 100 apparently healthy women, 45 women with benign conditions arising from the ovary and 55 invasive epithelial ovarian cancer patients (including 27 stage I/II cases). A separate validation set from 27 apparently healthy women, 56 women with benign conditions and 35 women with various types of malignant pelvic masses was used to monitor the ANN's performance during training. An independent test data set from 98 apparently healthy women and 52 early stage epithelial ovarian cancer patients (38 stage I and 4 stage II invasive cases and 10 stage I borderline ovarian tumor cases) was used to evaluate the ANN.

RESULTS

ROC analysis confirmed the overall superiority of the ANN-derived composite index over CA 125II alone (p=0.0333). At a fixed specificity of 98%, the sensitivities for ANN and CA 125II alone were 71% (37/52) and 46% (24/52) (p=0.047), respectively, for detecting early stage epithelial ovarian cancer, and 71% (30/42) and 43% (18/42) (p=0.040), respectively, for detecting invasive early stage epithelial ovarian cancer.

CONCLUSIONS

The combined use of multiple tumor markers through an ANN improves the overall accuracy to discern healthy women from patients with early stage ovarian cancer. Analysis of multiple markers with an ANN may be a better choice than the use of CA 125II alone in a two-step approach for population screening in which a secondary test such as ultrasound is used to keep the overall specificity at an acceptable level.

Radiological staging of ovarian cancer: imaging findings and contribution of CT and MRI

Ovarian cancer is the most lethal among the gynecologic malignancies with approximately 70% of patients presenting with advanced tumor stage. The prognosis of patients with ovarian cancer is directly related to the tumor stage and residual tumor burden after cytoreductive surgery. Exploratory laparotomy has been the cornerstone in the management of ovarian cancer, as it offers staging and tumor debulking. Understaging at initial laparotomy, however, is a problem in up to 30%, mainly due to insufficient technique and unexpected peritoneal spread outside the pelvis. Sites difficult to assess intraoperatively including the posterior aspect of the liver and the dome of the diaphragm can be well demonstrated with multiplanar imaging. CT and alternatively MRI have been accepted as adjunct imaging modalities for preoperative staging ovarian cancer. Of these, multidetector CT is the imaging modality of choice for staging ovarian cancer. In a multidisciplinary team approach patient management may be guided towards an individualized treatment plan. The contribution of imaging includes (1) surgery planning including referral practice, (2) selection of candidates for primary chemotherapy by demonstration of non (optimally) resectable disease, and (3) tissue sampling in peritoneal carcinomatosis.

Surgical management of women with ovarian cancer

Ovarian carcinoma remains a leading cause of cancer-related death among women. Proper treatment of ovarian cancer begins with a thorough staging operation and attempt to totally debulk tumor sites. Despite even maximal surgical efforts, most patients with ovarian cancer require systemic or intraperitoneal chemotherapy. Even though aggressive therapies are effective for the treatment of ovarian cancer, recurrence of the disease is common and often necessitates salvage surgical procedures and chemotherapy.

Quantitating tissue specificity of human genes to facilitate biomarker discovery

We describe a method to identify candidate cancer biomarkers by analyzing numeric approximations of tissue specificity of human genes. These approximations were calculated by analyzing predicted tissue expression distributions of genes derived from mapping expressed sequence tags (ESTs) to the human genome sequence using a binary indexing algorithm. Tissue-specificity values facilitated high-throughput analysis of the human genes and enabled the identification of genes highly specific to different tissues. Tissue expression distributions for several genes were compared to estimates obtained from other public gene expression datasets and experimentally validated using quantitative RT-PCR on RNA isolated from several human tissues. Our results demonstrate that most human genes ( approximately 98%) are expressed in many tissues (low specificity), and only a small number of genes possess very specific tissue expression profiles. These genes comprise a rich dataset from which novel therapeutic targets and novel diagnostic serum biomarkers may be selected.

Screening for Ovarian Cancer

The efficacy of ovarian cancer screening remains to be proven. Advances in ultrasound and tumor marker technology, combined with complex statistical analysis have facilitated 2 large ongoing randomized controlled trials of screening which are powered to determine the impact on mortality. Serum proteomics seems to be a promising area for biomarker discovery, but requires more rigorous validation before it can be used in clinical trials. Current screening tests, clinical trials in the general and high-risk populations, screening acceptability and costs are reviewed in this article.

Familial ovarian cancer screening

Familial predisposition accounts for approximately 10% of epithelial ovarian cancer. Identification and management of at-risk families is therefore an important area that bridges gynaecological and clinical genetic practice. The efficacy of screening for ovarian cancer in both high- and low-risk populations is currently of unproven benefit and is associated with some risks related to false-positive results. In contrast to the general population, preventive surgery is a realistic proposition for many women at high-risk. Although prophylactic bilateral salpingo-oophorectomy prevents ovarian and tubal cancer and reduces the risk of breast cancer, this option is unsuitable for women who have yet to complete their families or who are unwilling to undergo surgery. There is therefore a continued demand for screening in the high-risk population. This chapter discusses the limitations of screening, the circumstances under which screening is appropriate and current screening guidelines. Ongoing and future research that should help to provide additional information about this area is also reviewed.

Screening for ovarian cancer in the general population

Screening for ovarian cancer in the general population presents several unique challenges. Without a clearly identified premalignant state, efforts have focused on detection of early stage disease. Towards this end, investigators have focused on the use of serum markers and transvaginal ultrasound. CA125 determination is the most reliable serum marker in use, and utilization of serial measurements to calculate risk of cancer appears to have greater utility than evaluation of a single value. Multimodality screening focuses on combining serial CA125 measurement with transvaginal ultrasound follow-up for those with abnormal values. Large prospective trials, such as the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), are currently underway to assess the impact of various screening strategies on mortality, and to evaluate feasibility, acceptability, and morbidity of screening. Future research efforts will undoubtedly focus on promising techniques to examine the serum proteosome for patterns to identify early ovarian cancer.

Soluble Epidermal Growth Factor Receptor (SEG-FR) and Cancer Antigen 125 (CA125) as Screening and Diagnostic Tests for Epithelial Ovarian Cancer

Epithelial ovarian cancer (EOC) is the leading cause of death among all gynecologic cancers in the United States. Because women who are diagnosed with early stage disease have a better prognosis than women diagnosed with late stage disease, early detection represents a potentially practical approach to reduce the mortality associated with EOC. Unfortunately, no single screening test has proven to be effective for this purpose, and a valid and feasible screening program to detect early stage EOC in the general population has not yet been devised. Consequently, research has focused on coupling two or more screening modalities to improve program validity and feasibility. Serum cancer antigen 125 (CA125) and a soluble isoform of the epidermal growth factor receptor (p110 sEGFR) have been studied individually as biomarkers of ovarian cancer. In this study, we compare serum CA125 levels and sEGFR concentrations in women with EOC to women with benign gynecologic conditions of ovarian and non-ovarian origin. We show that serum sEGFR concentrations are lower in patients with EOC than in women with benign gynecologic conditions, whereas serum CA125 levels are higher in patients to EOC compared with women with benign gynecologic conditions. These data also reveal that age and serum sEGFR concentrations modify the association between CA125 levels and EOC versus benign gynecologic disease. Hence, age- and sEGFR-dependent CA125 cutoff thresholds improve the ability of CA125 to discern EOC patients from women with benign ovarian tumors and non-ovarian gynecologic conditions. Our analyses show that parallel testing with fixed sEGFR and CA125 cutoff thresholds optimizes sensitivity to detect EOC, whereas serial testing with age- and sEGFR-dependent CA125 cutoff thresholds optimizes test specificity, and overall accuracy to discern patients with EOC from women with benign ovarian and non-ovarian gynecologic conditions. The combined use of serologic sEGFR and CA125, thus, has improved utility for screening and diagnosing EOC, which may increase the positive predictive value of a multimodal screening program that incorporates these biomarkers to detect and subsequently differentiate benign from malignant ovarian tumors.

Combining CA 125 and SMR serum markers for diagnosis and early detection of ovarian carcinoma

OBJECTIVES

The serum tumor marker CA 125 is elevated in most clinically advanced ovarian carcinomas. Because these elevations may precede clinical detection by a year or more, CA 125 is potentially useful for early detection as part of an ovarian cancer screening program. However, CA 125 is often not elevated in clinically detected cancer and is frequently elevated in women with benign ovarian tumors. CA 125 may be more useful in conjunction with one or more other tumor biomarkers. Additional markers could play a role if, when used with CA 125, they identify some carcinomas missed by CA 125 (i.e., they improve sensitivity), rule out false positives (i.e., improve specificity), or are able to detect the same cancers earlier.

METHODS

We have evaluated a composite marker (CM) that combines CA 125 and a previously described soluble mesothelin related (SMR) marker in sera from 52 ovarian cancer cases, 43 controls with benign ovarian tumors, and 220 normal risk controls who participated in a screening program, including 25 healthy women having two serum samples collected 1 year apart. CA 125, SMR, and CM were evaluated for their ability to identify clinical disease and for their temporal stability, which assesses their ability to obtain even greater sensitivity when used in a longitudinal screening program.

RESULTS

CM has the best sensitivity, with specificity equal to CA 125. Importantly, CM has temporal stability at least as high as CA 125.

CONCLUSION

The CM may outperform CA 125 alone in a longitudinal screening program as well as in a diagnostic setting.

Ultrasound, physical examination, and CA 125 measurement for the detection of recurrence after conservative surgery for early borderline ovarian tumors

BACKGROUND

Borderline ovarian tumors often affect women of childbearing age and the prognosis is outstanding. Given the young age of several patients and the good prognosis, fertility-sparing surgery is considered adequate for stage I tumors. However, women treated conservatively have a relatively small but well-defined risk of recurrence and no study has specifically addressed the optimal follow-up technique.

METHODS

From 1981 to 1997, 164 women underwent fertility-sparing surgery for stage I borderline ovarian tumor and were followed prospectively. After surgery all women underwent physical examination and ultrasound examination every 3 months for 2 years after first diagnosis and every 6 months thereafter. Measurement of serum CA 125 levels was planned every 6 months in patients with a serous tumor.

RESULTS

With a median follow-up of 71, months 28 women treated with fertility-sparing surgery (28/164 = 17%) had either recurrence of borderline tumor (23) or recurrence with carcinoma. Complete details of follow-up procedures are available for 24 women and they represent the study population. An abnormal adnexal mass was detected in 18 of 19 women with recurrent borderline tumor. One patient had diagnosis due to persistent free fluid. All five women with invasive carcinoma had diagnosis of a complex adnexal mass. Gynecologic examination was suspicious (palpable mass) in 7 cases and obviously abnormal (large mass or nodules) in another 7. CA 125 serum levels were elevated in 8 cases.

CONCLUSION

Transvaginal ultrasound is currently the most effective diagnostic technique for the follow-up of young patients treated conservatively for early borderline ovarian tumor.

Imaging evaluation of ovarian masses

Adnexal masses present a special diagnostic challenge, in part because benign adnexal masses greatly outnumber malignant ones. Determination of a degree of suspicion for malignancy is critical and is based largely on imaging appearance. Endovaginal ultrasonography (US) is the most practical modality for assessment of ovarian tumors because it is readily available and has a high negative predictive value. Morphologic analysis of adnexal masses is accurate for identifying masses as either low risk or high risk. The most important morphologic features are non-fatty solid (vascularized) tissue, thick septations, and papillary projections. Color Doppler US helps identify solid, vascularized components in a mass. Spectral Doppler waveform characteristics (eg, resistive index, pulsatility index) correlate well with malignancy but generally add little information to morphologic considerations. Computed tomography can help assess the extent of disease in patients before and after primary cytoreductive surgery. Magnetic resonance (MR) imaging is better reserved for problem solving when US findings are nondiagnostic or equivocal because, although it is more accurate for diagnosis, it is also more expensive. The signal intensity characteristics of ovarian masses make possible a systematic approach to diagnosis. Mature cystic teratomas, cysts, endometriomas, leiomyomas, fibromas, and other lesions can be accurately diagnosed on the basis of T1-weighted, T2-weighted, and fat-saturated T1-weighted MR imaging findings.

CA 125 measurement and ultrasonography in borderline tumors of the ovary

OBJECTIVES

Our goal was to perform an analysis of ultrasonographic characteristics and CA 125 levels in ovarian tumors of borderline malignancy.

STUDY DESIGN

We performed a retrospective analysis of CA 125 levels and ultrasonographic parameters in 91 patients with borderline tumors.

RESULTS

Serous tumors of borderline malignancy were associated with elevated CA 125 levels in 75% of patients before surgery (mean, 156 IU/mL) compared with 30% of mucinous tumors (mean, 28 IU/mL; P =.004). CA 125 was elevated in 35% of stage IA serous tumors (mean, 67 IU/mL) compared with 89% of tumors with spread beyond the ovary (mean, 259 IU/mL; P =.001). Mucinous tumors tended to be bigger (13.1 +/- 7 cm) on ultrasonography than serous tumors (9.3 +/- 6.2 cm, P =.016). Mucinous tumors were multilocular in half the patients and contained papillations in 40% of the patients. Serous tumors were multilocular in 30% of the patients but presented with solid or papillary patterns in 78% of the patients (P =.001). A resistance index of <0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13% of patients, ultrasonographic characteristics were compatible with a simple cyst only, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87%, that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93% of patients, 2 were abnormal in 69% of patients, and all 3 were abnormal in 21% of patients.

CONCLUSIONS

A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts.

CA 125: fundamental and clinical aspects

Since the OC 125 monoclonal antibody (Mab) was generated, other Mabs to the CA 125 glycoprotein have been produced and classified into two families associated with two major epitope regions on the CA 125 molecule. New generation assays, combining Mabs to two distinct regions of the molecule, compare favorably with that of the original assays as demonstrated by ROC curves. The original CA 125 assay suffered from interference of HAMA, an important drawback considering the increasing use of murine antibodies for immunodiagnosis and treatment of ovarian cancer. This problem has been solved for the majority of currently available tests. The sensitivity of the assays for early ovarian cancer remains low, precluding its indiscriminate use for screening and diagnosis of ovarian cancer. Its use in screening for early cancer, combined with ultrasonography, is limited to high risk populations, such as women from families with mutations in the BRCA1 or 2 gene. Although CA 125 assessment may play a limited role in the (early) detection of ovarian cancer, its role in the follow-up during and after therapy is well established. The major contribution of CA 125 is in the monitoring of tumor response to chemotherapy, where it is valuable in detecting those patients with an inadequate response to the chosen treatment. The role of CA 125 in early detection of recurrences remains to be established and is currently the subject of two large clinical trials.

Estimation of probability of malignancy using a logistic model combining physical examination, ultrasound, serum CA 125, and serum CA 72-4 in postmenopausal women with a pelvic mass: an international multicenter study

BACKGROUND

To assess the differential diagnostic potential of physical examination, ultrasound, the serum CA 125 assay, and serum CA 72-4 assay, and the contribution of each parameter to a logistic model predicting the probability of malignancy in postmenopausal patients presenting with a pelvic mass.

PATIENTS AND METHODS

In a multicenter, prospective study a total of 155 patients were evaluated preoperatively using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 72-4 (cutoff level 3 U/ml) and CA 125 (cutoff level 35 U/ml).

RESULTS

Fifty-nine malignant (39%) and 92 benign (61%) pelvic tumors were found in addition to 4 borderline tumors (3%). Forty-three patients appeared to have ovarian carcinoma, FIGO Stage III or IV in 28 cases. Borderline tumors were excluded from the statistical calculations. The diagnostic accuracy of each single parameter, i.e., pelvic examination, ultrasound, and serum CA 125 and CA 72-4 in discriminating between benign and malignant pelvic masses gave highly similar results (81, 76, 78, and 81% respectively). Best sensitivity was found in pelvic examination (92%); best specificity was found in CA 72-4 (93%). Using logistic regression analysis the power of pelvic examination appeared to be the most relevant (adjusted odds ratio 12.1), followed by ultrasound (odds ratio 9.7), serum CA 125 (odds ratio 5.0), and serum CA 72-4 (odds ratio 4.9). Age appeared to be nonpredictive. The logistic model gives a correct prediction in 87% of all cases.

CONCLUSIONS

The addition of serum CA 72-4 to the combination of pelvic examination, ultrasound, and serum CA 125 leads to an improved discrimination between malignant and benign pelvic masses.

Peritoneal fluid lactate dehydrogenase in ovarian cancer

In attempt to identify patients with ovarian carcinoma and differentiate them from patients with benign ovarian tumor or other gynecological malignancies, peritoneal fluid and serum lactate dehydrogenase (LDH) levels were measured in 51 patients: 15 with ovarian carcinoma, 15 with endometrial carcinoma, 4 with cervical carcinoma, and 17 with benign ovarian tumor. Peritoneal fluid and serum LDH levels in ovarian cancer patients were significantly higher than those in patients with benign ovarian tumor (P < 0.001) or other gynecological malignancies (P < 0.001 and P < 0.03, respectively). Yet, peritoneal fluid LDH demonstrated higher diagnostic sensitivity (87%) and greater diagnostic accuracy (90%) than serum LDH (60 and 77%, respectively) or serum CA-125 (73 and 83%, respectively). Comparing the histological types of ovarian cancer, serous cystadenocarcinoma presented higher peritoneal fluid LDH levels than endometrioid or mucinous cystadenocarcinoma. No difference in peritoneal fluid LDH was observed comparing different stages of ovarian cancer. The results suggest that peritoneal fluid LDH may be an efficient biochemical marker in diagnosis of ovarian cancer.

Use of a stochastic simulation model to identify an efficient protocol for ovarian cancer screening

The intervention protocol for an ovarian cancer screening trial should be efficient as well as effective, because it may become the standard of care if the trial demonstrates mortality reduction. To identify an efficient ovarian cancer screening protocol, the effectiveness and cost-effectiveness of selected single modality and multimodal screening strategies were estimated using a stochastic simulation model. Screening was simulated over a 30-year period in a hypothetical cohort of 1 million women aged 50 at the beginning of the period. The net present value of the cost per year of life saved was estimated for six protocols involving transvaginal sonography (TVS) and/or the tumor antigen CA 125. Internal and external validation was performed, and sensitivity analyses were conducted to assess the robustness of the ranking of the strategies. A multimodal strategy involving CA 125 with a threshold for positivity of either elevation above 35 U/ml or doubling since the previous screen, followed by TVS only if CA 125 is positive, was found to be efficient in the sense that no other strategies saved as many years of life at lower cost per year of life saved. Used annually, this strategy cost under $100,000 per year of life saved over a range of assumptions. The model's predictions are consistent with results reported in the literature regarding the performance of TVS and CA 125. The multimodal strategy used annually or every six months was efficient compared to either ultrasound or CA 125 used alone, over a range of assumptions. Simulation of screening may be useful in selecting a screening protocol to be tested in a randomized controlled trial.

Screening for ovarian cancer

Ovarian cancer is the leading cause of death from gynecologic cancer. Despite aggressive cytoreductive surgery and platinum-based chemotherapy, the 5-year survival for patients with clinically advanced ovarian cancer is only 15 to 20 percent, although the cure rate for stage I disease is usually greater than 90 percent. These statistics provide the primary rationale for ovarian cancer screening. This overview of the current literature serves to show that mass screening for ovarian cancer is far from being established and fraught with management and procedural dilemmas. The reasonable assumption being that there is little evidence to support widespread screening of large populations of women who do not have familial or genetic risk factors for ovarian cancer.

Geriatric health maintenance

OBJECTIVE

To highlight articles pertaining to geriatric health maintenance and provide clinicians with current evidence supportive of or opposed to screening or treatment for various diseases and conditions.

METHOD

We conducted a computer-assisted search of the relevant medical literature and summarized the results of pertinent studies in the elderly population.

RESULTS

The geriatric population is progressively increasing in numbers. Unfortunately, no consensus exists about health maintenance in this population. To date, the United States Preventive Services Task Force has made several recommendations about preventive services; however, they did not specifically focus on the geriatric age-group. We outline their guidelines and discuss our clinical practices in a wide variety of encounters with geriatric patients.

CONCLUSION

The efficacy of many screening tests and interventions for preventing illness in elderly patients is unclear. As the general population continues to age, further research in this area will be important.

Toward an optimal algorithm for ovarian cancer screening with longitudinal tumor markers

Stored samples from women in the Stockholm screening study were reassayed for CA125II (Centocor, Malvern, PA) and OVX1. The postmenopausal women older than age 50 without ovarian cancer were randomly split into a training set to develop a screening test based on longitudinal marker levels and a second set to validate the test. The CA125II data from each woman is summarized by the slope and intercept from a linear regression of log(CA125II) on time since first sample. The slope versus the intercept for the training set and the ovarian cancer cases formed a bivariate scatter plot. A curve was drawn on the scatter plot that separated most of the women with ovarian cancer from all other women; it delineated a screening test. The specificity of this test was examined on the validation set with a specificity of 99.8%. Bayes' theorem was used to calculate the risk of ovarian cancer (ROC) based on the intercept, slope, and assay variability. It is important to account for assay variability because it can produce large slopes over short periods of time. The maximum risk, which identified 83% (5 of 6) of the ovarian cancers detected within a year of last assay, was applied as a test to the training set and confirmed a high specificity of 99.7%. With this specificity and sensitivity, the ROC algorithm using the CA125II assay has an estimated positive predictive value of 16%, substantially greater than the positive predictive value based on a single assay. Further study is planned to confirm the sensitivity of this approach.

The second generation CA 125 assays

Optimal management of ovarian cancer patients can only be provided using the CA 125 serum test for treatment monitoring, early prediction of outcome and early detection of recurrence. The newly introduced second generation CA 125 assays, the Centocor CA 125 II IRMA, the Boehringer Mannheim Enzymun CA 125 II and the BYK Liamat CA 125 II are one-step heterlogous double-determinant solid phase assays that utilize the M11 as capture antibody and the original OC 125 as tracer. The CA 125 II assays will probably replace the original CA 125 assays within a short period of time. For comparison reasons the Abbot IMx CA 125 assay was also included in this study. Highly similar CA 125 distribution patterns were obtained with these new CA 125 II assays. Linear regression analysis in ovarian cancer patients showed the following: Centocor CA 125 II = 0.98 x CA 125 IRMA + 10.7 (r = 0.8717, P < 0.0001), Syx = 89.9; Enzymun CA 125 II = 1.03 x CA 125 + 9.0 (r = 0.8988, P < 0.0001) Syx = 81.8; BYK Liamat CA 125 II = 1.17 x CA 125 IRMA + 0.6 (r = 0.8930, P < 0.0001), Syx = 96.8. Our first technical and clinical evaluation of these three new CA 125 II assays shows their superior analytical performance, in addition to a high qualitative and quantitative correlation with the original CA 125 IRMA.

CA 72-4 serum marker--a new tool in the management of carcinoma patients

Among the new tumor markers that have been recently proposed, CA 72-4 is of particular interest, not only for its capabilities in diagnosing and monitoring certain neoplastic diseases, but also for its excellent specificity. Several studies focused on the potential clinical usefulness of CA 72-4 in gastrointestinal (GI) and gynecological cancer, showing a sensitivity of approximately 40% in colorectal and gastric cancer and 50% in ovarian cancer, with an overall specificity of more than 95%. Longitudinal evaluations of patients with either GI or gynecological malignant diseases demonstrated that significant elevations of CA 72-4 serum levels may be predictive of recurrent disease. Moreover, the combination of CA 72-4 with other known serum markers, such as CEA and CA 19-9 for GI cancer or CA 125 for ovarian cancer, indicated that an increase in the sensitivity can be achieved without substantial changes in the overall specificity, improving the possibility of monitoring these patients. In conclusion, these results provide a strong argument for the use of CA 72-4 in the management of these neoplastic diseases.

Molecular approaches to prevention and detection of epithelial ovarian cancer

More than 90% of epithelial ovarian cancers arise from single cells. Malignant transformation can be associated with a number of molecular alterations including upregulation of tyrosine kinases and phosphatases, physiologic activation o ras, mutation of p53, amplification of myc, and increased activity of matrix metalloproteinases 2 and 9. Proliferation of transformed epithelial cells can be enhanced through the persistence of autocrine growth stimulation by TGF-alpha, loss of autocrine growth inhibition by TGF-beta, as well as paracrine growth stimulation by macrophage derived cytokines and OCAF, a novel lyso-phospholipid. Ascites tumor cells retain responsiveness to growth inhibition by TGF-beta which induces apoptosis in malignant ovarian epithelial cells, but not in normal ovarian surface epithelium. Proliferation of surface epithelial cells following ovulation may contribute to the pathogenesis of ovarian cancer. Use of oral contraceptives that suppress ovulation has been associated with reduced risk of ovarian cancer in later life. Retinoids also deserve further evaluation for chemoprevention. Treatment with fenretinide was associated with decreased incidence of ovarian cancer. Additive or synergistic inhibition of ovarian tumor cell proliferation has been observed with TGF-beta in combination with all-trans-retinoic acid. Early detection of ovarian cancer could improve survival. Transvaginal sonography (TVS) and serum markers such as CA-125 have been evaluated in multiple clinical trials. The former lacks adequate specificity, whereas the latter is not sufficiently sensitive. Use of multiple serum markers can improve sensitivity. A combination of CA-125, M-CSF and OVX-1 has detected > 95% of Stage I ovarian cancers. If similar results are obtained with different data sets, multiple serum markers could be used to trigger the performance of TVS, providing a potentially cost effective screening strategy. Prospective trials will be required to demonstrate that screening for early stage ovarian actually impacts on survival.

Early detection and screening for ovarian cancer

Ovarian cancer is associated with postmenopausal women of North American or European descent, nulliparous women, and women with a first-degree relative with an epithelial ovarian cancer. Methods for early detection of ovarian cancer are the pelvic examination, ultrasound techniques, and CA-125 monitoring, none of which are highly sensitive or specific for the disease. At the Yale-New Haven Medical Center, first-degree relatives of women with epithelial ovarian cancer were invited to participate in an intense ovarian cancer screening program consisting of tumor markers, endovaginal ultrasound and color Doppler flow studies, and physical examinations performed in a serial fashion. The false-positive rate for the tumor markers varied from 2 to 9% at initial evaluation of the first 247 participants. Endovaginal ultrasound and color Doppler flow techniques were used to evaluate 326 ovaries in 169 women. Resistive indices < 0.5 were present in 26 ovaries (8.4%), and peak systolic velocities > 30 cm/sec occurred in 7 ovaries (2.3%). To date, four breast cancers have been detected, three cervical intraepithelial neoplasias have been identified, and three atypical adenomatous hyperplasias were diagnosed. No epithelial ovarian cancer was found. Isolated screening for ovarian cancer even in high-risk women is not cost effective. Women screened for ovarian cancer should also be evaluated for cancers of the breast, cervix, colon, rectum and endometrium. Isolated abnormal screening test values are not an indication for surgery.

Screening for ovarian cancer: what are the optimal surrogate endpoints for clinical trials?

The inability to identify relevant markers for presymptomatic screening in early stage or "preinvasive" ovarian cancer has plagued investigators and clinicians facing the problems of early detection. The characteristic late stage of disease at initial presentation has hindered our understanding of the biologic progression and stepwise molecular alterations that result in ovarian carcinoma. To date, most screening studies have focused on identifying early anatomic changes using ultrasound or fluctuations in serum biomarkers such as CA-125. These screening methodologies have proven inadequate in both sensitivity and specificity for early stage ovarian cancer detection. Molecular analysis of ovarian carcinomas has revealed alterations in oncogenes and tumor suppressor genes associated with these tumors. The HER-2/neu oncogene, a member of the epidermal growth factor family, is amplified or overexpressed in approximately 25-30% of ovarian carcinomas. Significant data substantiate an important role for HER-2/neu in the pathophysiology of ovarian cancer. While potentially an attractive surrogate endpoint biomarker (SEB), serum HER-2/neu levels have not proven to be a useful screening modality. In response to the urgent need for improved early detection for ovarian cancer, our current research efforts include differential hybridization studies between normal and malignant ovarian epithelium to define potentially unique ovarian cancer antigens which may ultimately have utility; defining physical alterations that occur in malignant ovarian tissues using implanted telemetry systems; studies using positron emission tomography to detect changes in glucose metabolism between normal and malignant ovarian tissues; and screening studies using a 3-dimensional ultrasound unit to improve the accuracy of this technique in recognizing early neoplastic changes. By taking diverse approaches to tackle this problem, an improved understanding of ovarian carcinogenesis should translate into the identification of appropriate SEBs for early detection.

Evaluation of tumor-associated glycoprotein-72 and CA 125 serum markers in patients with gynecologic diseases

OBJECTIVE

This study was performed to evaluate the clinical values of tumor-associated glycoprotein-72 serum levels alone or in combination with CA 125 in the diagnosis and monitoring of patients with ovarian cancer.

STUDY DESIGN

Serum samples from 293 patients, 142 with primary carcinoma and 151 with benign diseases of the genital tract, were evaluated for the presence of CA 125, tumor-associated glycoprotein-72, and carcinoembryonic antigen. All patients underwent surgery for the primary tumor, and stage was defined according to the classification of International Federation of Gynecology and Obstetrics.

RESULTS

When the measurement of serum tumor-associated glycoprotein-72 is combined with that of CA 125, the sensitivity for the detection of primary ovarian cancer increased from 60% to 73%, with no significant change in specificity, and resulted in a more accurate clinical assessment for detection of residual disease before the second-look procedure. In fact, when both markers were positive, 100% specificity was achieved; conversely, when both markers were negative, no residual disease was found.

CONCLUSION

These findings suggest that tumor-associated glycoprotein-72 may be considered as a supplementary serum marker for CA 125, providing further clinical information for the diagnosis of primary and recurrent ovarian cancer.

Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study

BACKGROUND

In a prospective study, the differential diagnostic potential of pelvic examination, ultrasound, and serum CA 125 assay in postmenopausal patients presenting with a pelvic mass was assessed.

METHODS

A total of 228 patients were evaluated preoperatively in an international, multicenter, prospective study using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 125 determination with a cut-off level of 35 U/ml.

RESULTS

Ninety-five malignant (41.7%) and 127 benign (55.7%) pelvic tumors were found in addition to 6 borderline ovarian tumors (2.6%) in the 228 patients. Seventy-two patients had ovarian carcinoma, 49 of whom were International Federation of Gynecology and Obstetrics Stage III or IV. Borderline tumors were excluded from the statistical calculations. The individual accuracy of pelvic examination, ultrasound, and serum CA 125 in discriminating between benign and malignant pelvic masses was approximately the same (76, 74, and 77%, respectively). Using logistic regression analysis, the power of pelvic examination appeared to be the most relevant factor (adjusted odds ratio, 9.2), followed by serum CA 125 (odds ratio, 5.6), and ultrasound (odds ratio, 4.9). Age appeared to be nonpredictive. No cancer was found in any patient in whom all three methods scored negative (n = 53; positive predictive value for malignancy = 0 and 95%; confidence interval, 0-7).

CONCLUSIONS

The combined use of pelvic examination, ultrasound, and serum CA 125 leads to improved discrimination between malignant and benign pelvic masses, because malignancy can be excluded when all three examination methods are negative. A change to a more patient-tailored surgical approach could be considered in those cases.