Serum levels of human epididymis protein 4 are more stable than cancer antigen 125 in early and mid-term pregnancy

Molecular Management of High-Grade Serous Ovarian Carcinoma

High-grade serous ovarian carcinoma (HGSOC) represents the most common form of epithelial ovarian carcinoma. The absence of specific symptoms leads to late-stage diagnosis, making HGSOC one of the gynecological cancers with the worst prognosis. The cellular origin of HGSOC and the role of reproductive hormones, genetic traits (such as alterations in P53 and DNA-repair mechanisms), chromosomal instability, or dysregulation of crucial signaling pathways have been considered when evaluating prognosis and response to therapy in HGSOC patients. However, the detection of HGSOC is still based on traditional methods such as carbohydrate antigen 125 (CA125) detection and ultrasound, and the combined use of these methods has yet to support significant reductions in overall mortality rates. The current paradigm for HGSOC management has moved towards early diagnosis via the non-invasive detection of molecular markers through liquid biopsies. This review presents an integrated view of the relevant cellular and molecular aspects involved in the etiopathogenesis of HGSOC and brings together studies that consider new horizons for the possible early detection of this gynecological cancer.

Exploring the relationship between preeclampsia and human epididymis protein 4

Background/Aim: The level of human epididymis protein 4 (HE4), a glycoprotein and protease inhibitor, increases under many malignancies and inflammatory conditions. HE4 is also associated with cell invasion, migration, and adhesion. In this study, we compared the HE4 protein levels in pregnant patients with preeclampsia to healthy pregnant and non-pregnant individuals with the aim of finding a biomarker that can be used to recognize preeclampsia. Methods: Our study is a prospective case control study and included 20 pregnant women with preeclampsia, 20 pregnant women without preeclampsia, and 20 healthy non-pregnant women (the control). The participants’ serum HE4 levels were analyzed statistically. Results: Data analysis revealed that the mean HE4 levels were significantly lower in the preeclampsia group than in the other two groups (P = 0.002). Mean HE4 protein levels were also lower in the non-pregnant women than in the pregnant women without preeclampsia; however, this difference was not significant. Conclusion: It is difficult to predict preeclampsia, and there is not any sensitive or specific biomarker for determining the condition. This study may support that HE4 protein may be useful and significant in predicting preeclampsia. The results we achieved provide proof that HE4 levels could be a potential biomarker for preeclampsia. Many more comprehensive studies are needed to support the association between HE4 protein and preeclampsia.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Influence of Pregnancy-Related Conditions on Human Epididymis Protein 4 Serum Levels in Comparison to CA 125 - a Prospective Cohort Trial

Introduction HE4 and CA 125, two established biomarkers for assessing adnexal masses in non-pregnant women, are hardly investigated in pregnancy, especially in pregnancy-associated conditions. The aim was to evaluate HE4 and CA 125 levels in the course of pregnancy and to assess the impact of pregnancy disorders, contractions and rupture of membranes on HE4 and CA 125 serum levels in order to use these parameters for evaluation of adnexal masses in pregnancy.

Patients and Methods Blood samples (n = 238) of 201 women seen at the Medical University of Innsbruck, Austria, were prospectively obtained during pregnancy and postpartum. Serum concentrations of HE4 and CA 125 were analyzed. ROMA index was calculated by the premenopausal formula.

Results HE4 serum levels were highest in the third trimester. Contractions (p < 0.001), rupture of membranes (p = 0.005) and pregnancy-associated diseases (p = 0.003) were associated with higher HE4 levels. As much as 97.5% of HE4 measurements remained below the recommended cut-off for premenopausal women (70 pmol/l). CA 125 levels were not altered by pregnancy-associated conditions. Generally, CA 125 exhibited a wider serum level variability, exceeding the established cut-off of 35 U/ml in 16.4%.

Conclusions HE4 serum levels are influenced by several pregnancy-related conditions leading to significantly higher levels in these cases. Despite differing medians according to trimester, the 95th percentile cut-offs and almost all maximum values during the entire course of pregnancy were below the established cut-off for premenopausal women. It was also superior to the performance of ROMA index. Therefore, HE4 can be used as a valuable negative predictive marker for the assessment of adnexal masses during pregnancy.

May human epididymis 4 protein play a role in the etiopathogenesis of hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome?

AIM

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is an extremely advanced form of preeclampsia. Currently, there is no parameter or marker to predict this syndrome; however, it is emphasized that vascular endothelial damage and abnormal immune responses can be the possible etiologies of HELLP syndrome. It is known that human epididymis protein 4 (HE4) is a protease inhibitor and previous studies have shown that HE4 protein levels are increased in many malignancies and inflammatory conditions. Considering that metalloproteinases may also play a role in endothelial damage, which is thought to be involved in the etiopathogenesis of HELLP syndrome, we thought that HE4 protein, which is a protease inhibitor, may be associated with vascular damage. We aimed to investigate the relationship between HELLP syndrome and HE4 protein and to identify a biomarker that can be utilized in the diagnosis of HELLP syndrome.

STUDY DESIGN

In this study, 40 patients with HELLP syndrome and 40 healthy pregnant women with similar characteristics without HELLP syndrome were compared.

RESULTS

When the results were evaluated, no statistically significant difference was found between serum HE4 protein levels in patients with HELLP syndrome and patients without HELLP syndrome in this study (p: 0.29).

CONCLUSION

HE4 protein has no field of use in obstetrics yet. In our study, we aimed to find a new biomarker to identify patients with HELLP syndrome. However, we could not find any statistically significant difference in terms of HE4 protein levels between patients with and without HELLP syndrome. Our study is an important study as it is the first study aiming to use HE4 protein in obstetrics.

Sonographic Assessment of Complex Ultrasound Morphology Adnexal Tumors in Pregnant Women with the Use of IOTA Simple Rules Risk and ADNEX Scoring Systems

Background: To evaluate the accuracy of subjective assessment (SA), the International Ovarian Tumor Analysis (IOTA) group Simple Rules Risk (SRR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model for the preoperative differentiation of adnexal masses in pregnant women. Methods: The study population comprised 36 pregnant women (median age: 28.5 years old, range: 20–42 years old) with a mean gestation age of 13.5 (range: 8–31) weeks at diagnosis. Tumors were prospectively classified by local sonographers as probably benign or probably malignant using SA. Final tumor histological diagnosis was used as the reference standard in all cases. Logistic regression SRR and ADNEX models were used to obtain a risk score for every case. Serum CA125 and human epidydimis protein 4 (HE4) concentrations were also retrieved and the Risk of Ovarian Malignancy Algorithm (ROMA) value was calculated. The calculated predictive values included positive and negative likelihood ratios of ultrasound and biochemical tests. Results: Final histology confirmed 27 benign and 9 malignant (including 2 borderline) masses. The highest sensitivity (89%) and specificity (70%) were found for the subjective tumor assessment. Although no malignancy was classified as benign using the SRR criteria (sensitivity = 100%), the specificity of this scoring system was only 37%. At the cut-off risk level of >20%, the ADNEX model had a sensitivity of 78% and a specificity of 70%. Serum levels of CA125, HE4 and the ROMA risk model correctly identified adnexal malignant tumors with a sensitivity of 67%, 25% and 25%, respectively. Corresponding specificities were 72%, 100% and 100%, respectively. The highest positive and negative likelihood ratios were found for SA (LR+ = 3.0 and LR− = 0.16, respectively). Overall diagnostic accuracy of all predictive methods used in this study were similar (range: 70–75%) except for SRR (53%). Conclusion: Subjective assessment remains the best predictive method in complex adnexal masses found at prenatal ultrasound in pregnant women. For less experienced sonographers, both the SRR and ADNEX scoring systems may be also used for the characterization of such tumors, while serum tumor markers CA125 and HE4, along with the ROMA algorithm appear to be less accurate.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Pregnancy]

OBJECTIVE

To determine the place of imaging, tumour markers, type of treatment and surgical route, follow-up, delivery mode, and re-staging in case of BOT during pregnancy, in order to provide guidelines.

METHOD

A systematic bibliographical analysis on BOT during pregnancy was performed through a PUDMED search on articles published from 1990 to 2019 using keywords « borderline ovarian tumour and pregnancy ».

RESULTS

Pelvic ultrasound is the gold standard and first-line examination for the detection and characterization of adnexal masses during pregnancy (grade C). Pelvic MRI is recommended from 12 gestational weeks in case of indeterminate adnexal masses and should be concluded by a diagnostic score (grade C). Gadolinium injection should be minimized because of proven risk to the fetus and should be discussed on a case-by-case basis after patient information (grade C). In the absence of data in the literature, it is not possible to recommend the use of any tumour marker for the diagnosis of BOT during pregnancy. In case of a surgical treatment of BOT during pregnancy, there is insufficient evidence to recommend either a cystectomy or an oophorectomy. For BOT, the laparoscopic approach should be preferred during pregnancy if it is feasible (grade C). Surgical route and type of surgery should be chosen after taking into account the tumour size, the obstetrical term, and the subsequent desire for pregnancy, following discussion in a multidisciplinary meeting. In the absence of sufficient data in the literature, it is not possible to make any recommendation on the follow-up of a BOT suspected during pregnancy. There is not enough evidence in the literature to change obstetrical management for delivery in patients with BOT. In case of incomplete staging of a BOT treated during pregnancy, restaging can be discussed as for non-pregnant patients (grade C).

CONCLUSION

The diagnosis of BOT occurring during pregnancy remains rare despite systematic screening of adnexal masses in the first trimester of pregnancy and an increasing maternal age. There is limited data in the literature concerning the management of BOT during pregnancy. All decisions must be taken after discussion in a multidisciplinary meeting.

Human Epididymis Protein 4 (HE4) Reference Limits in Polish Population of Healthy Women, Pregnant Women, and Women with Benign Ovarian Tumors

Objectives

Defining precisely the normal range of HE4 protein is crucial for the proper interpretation of tumor marker results and for a more efficient diagnosis of ovarian malignancy. The aim of our study was to evaluate a reference limit of HE4 protein in a population to promote and facilitate the common use of HE4 protein assays. We also tried to identify potential association of HE4 levels with other conditions such as smoking, age, BMI, and creatinine levels.

Methods

Blood samples were collected from 617 patients divided into three groups: healthy, pregnant, and with benign ovarian tumors. Serum HE4 concentrations were measured following a standard procedure. HE4 reference ranges for each group and association of HE4 levels with BMI, creatinine, and smoking were investigated.

Results

HE4 reference limit for healthy patients equals 85 pmol/l, which becomes 73 pmol/l and 93 pmol/l for pre and postmenopausal subgroups, respectively. There is a statistically significant correlation between HE4 serum level and smoking (p = 0.000001) and there is no correlation with creatinine. But if we take into account age and smoking, in multivariate analysis, there is a correlation. For pregnant, the upper limit values of normal HE4 levels are 55 pmol/l (median = 40 pmol/l), 80 pmol/l (median = 43 pmol/l), and 106 pmol/l (median = 53 pmol/l) for the first, second, and third trimesters, respectively.

Conclusions

HE4 protein value strongly depends on the patient's age and smoking. The serum concentration of HE4 marker increases with the duration of pregnancy. Understanding the normal range of HE4 protein enables the correct interpretation of marker measurements. This may result in an earlier and more effective diagnosis of ovarian cancer.