Determination of a normal level of serum CA125 in postmenopausal women as a tool for preoperative evaluation and postoperative surveillance of endometrial carcinoma

A clinical marker-based modeling framework to preoperatively predict lymph node and vascular space involvement in endometrial cancer patients

INTRODUCTION

Endometrial cancer (EC) has high mortality at advanced stages. Poor prognostic factors include grade 3 tumors, deep myometrial invasion, lymph node metastasis (LNM), and lymphovascular space invasion (LVSI). Preoperative knowledge of patients at higher risk of lymph node involvement, when such involvement is not suspected, would benefit surgery planning and patient prognosis. This study implements an ensemble machine learning approach that evaluates Cancer Antigen 125 (CA125) along with histologic type, preoperative grade, and age to predict LVSI, LNM and stage in EC patients.

METHODS

A retrospective chart review spanning January 2000 to January 2015 at a regional hospital was performed. Women 18 years or older with a diagnosis of EC and preoperative or within one-week CA125 measurement were included (n = 842). An ensemble machine learning approach was implemented based on a stacked generalization technique to evaluate CA125 in combination with histologic type, preoperative grade, and age as predictors, and LVSI, LNM and disease stage as outcomes.

RESULTS

The ensemble approach predicted LNM and LVSI in EC patients with AUROCTEST of 0.857 and 0.750, respectively, and predicted disease stage with AUROCTEST of 0.665. The approach achieved AUROCTEST for LVSI and LNM of 0.750 and 0.643 for grade 1 patients, and of 0.689 and 0.952 for grade 2 patients, respectively.

CONCLUSION

An ensemble machine learning approach offers the potential to preoperatively predict LVSI, LNM and stage in EC patients with adequate accuracy based on CA125, histologic type, preoperative grade, and age.

Preoperative serum tissue factor pathway inhibitor‑2 level as a prognostic marker for endometrial cancer

Advanced endometrial cancer (EC) often recurs and has a poor prognosis. Various serum markers have been used for EC but their usefulness as biomarkers is still unclear; therefore, identifying new biomarkers is important. The present study aimed to investigate whether the tissue factor pathway inhibitor-2 (TFPI2) level was elevated in the preoperative serum of patients with EC and if it may be a prognostic factor. The present retrospective study included 207 patients who had a confirmed pathological diagnosis of EC and received surgical therapy as the initial treatment between January 2011 and December 2017. Survival analysis was performed using Kaplan-Meier analysis and the Cox proportional hazards regression model. The 5-year disease-free survival and overall survival (OS) rates were 73.3 and 83.7%, respectively. The cut-off value for predicting OS for TFPI2 level was 177 pg/ml as determined from the receiver operating characteristic curve. A TFPI2 value ≥177 pg/ml was significantly associated with age ≥65 years (P<0.001), diabetes (P=0.035), stage (P<0.001), myometrial invasion (P<0.001), lymphovascular invasion (P=0.004), lymph node metastasis (P=0.010), distant metastasis (P<0.001), cancer antigen (CA) 125 ≥36 U/ml (P<0.001) and CA 19-9 ≥38 U/ml (P<0.001). In multivariate analysis, high-grade carcinoma [hazard ratio (HR), 2.439; P=0.041], lymph node metastasis (HR, 2.116; P=0.038), distant metastasis (HR, 3.604; P=0.009) and TFPI2 level ≥177 pg/ml (HR, 2.42; P=0.043) were significant prognostic factors affecting OS in patients with EC. These results suggest that the preoperative serum TFPI2 level, along with its histological type, lymph node metastasis and distant metastasis, was a prognostic factor for OS in patients with endometrial cancer.

Serum CA125 and HE4 as Biomarkers for the Detection of Endometrial Cancer and Associated High-Risk Features

Early detection of endometrial cancer improves survival. Non-invasive diagnostic biomarkers would improve triage of symptomatic women for investigations. This study aimed to determine the diagnostic accuracy of serum Cancer Antigen 125 (CA125) and Human Epididymis 4 (HE4) for endometrial cancer and associated high-risk features. Serum samples from women investigated for gynaecological symptoms or diagnosed with endometrial cancer were analysed for CA125 and HE4. Conventional diagnostic metrics were calculated. In total, 755 women were included; 397 had endometrial cancer. Serum CA125 and HE4 were significantly elevated in cases compared with controls (both p < 0.001), and with pathological markers of disease severity (p < 0.05). A combination of CA125 and HE4 detected endometrial cancer with an area under the curve (AUC) of 0.77 (95% CI: 0.74−0.81). In a model with body mass index (BMI) and parity, HE4 predicted endometrial cancer in pre-menopausal women with an AUC of 0.91 [sensitivity = 84.5%, specificity = 80.9% (p < 0.001)]. In women with abnormal ultrasound, HE4 ≥ 77 pmol/L improved specificity compared with imaging alone [68.6% (95% CI: 75.0−83.6) vs. 34.4% (95% CI: 27.1−42.3), respectively], but at a cost to sensitivity. HE4 ≥ 77 pmol/L improved the detection of myometrial invasion ≥50% in women with stage I disease compared with magnetic resonance imaging (MRI) alone [sensitivity = 100% (95% CI: 54.1−100)]. CA125 ≥ 35 U/mL did not add to imaging. HE4 is a good predictor of poor prognostic features which could assist staging investigations.

Predictive model for the preoperative assessment and prognostic modeling of lymph node metastasis in endometrial cancer

Lymph node metastasis (LNM) is a well-established prognostic factor in endometrial cancer (EC). We aimed to construct a model that predicts LNM and prognosis using preoperative factors such as myometrial invasion (MI), enlarged lymph nodes (LNs), histological grade determined by endometrial biopsy, and serum cancer antigen 125 (CA125) level using two independent cohorts consisting of 254 EC patients. The area under the receiver operating characteristic curve (AUC) of the constructed model was 0.80 regardless of the machine learning techniques. Enlarged LNs and higher serum CA125 levels were more significant in patients with low-grade EC (LGEC) and LNM than in patients without LNM, whereas deep MI and higher CA125 levels were more significant in patients with high-grade EC (HGEC) and LNM than in patients without LNM. The predictive performance of LNM in the HGEC group was higher than that in the LGEC group (AUC = 0.84 and 0.75, respectively). Patients in the group without postoperative pathological LNM and positive LNM prediction had significantly worse relapse-free and overall survival than patients with negative LNM prediction (log-rank test, P < 0.01). This study showed that preoperative clinicopathological factors can predict LNM with high precision and detect patients with poor prognoses. Furthermore, clinicopathological factors associated with LNM were different between HGEC and LGEC patients.

Factors associated with serum CA125 level in women without ovarian cancer in the United States: a population-based study

Background

Cancer antigen 125 (CA125) is clinically used to monitor response to therapy in ovarian cancer and has been proposed for use in detecting ovarian cancer. This population-based study examines how demographic characteristics, gynecologic/reproductive history, chronic non-malignant medical conditions, history of non-ovarian cancer, lifestyle practices, and biomarkers of inflammation correlate with serum CA125 in both premenopausal and postmenopausal women without ovarian cancer across the United States.

Methods

Participants were identified from the National Health and Nutrition Examination Survey 2001–2002. Linear and logistic regression models were applied.

Results

Higher CA125 levels were found to correlate with younger age, Non-Hispanic White race/ethnicity, and lower body mass index. In premenopausal women (N = 1157), current smoking was associated with lower CA125 (− 24.95%, p = 0.008), and history of non-ovarian cancer was associated with higher CA125 (40.64%, p = 0.045) by multivariable linear regression; both current smoking (odds ratio (OR) = 0.42, p = 0.043) and oral contraceptive pill (OCP) use of 5–10 years (OR = 0.31, p = 0.032) were less likely to be associated with having CA125 level ≥ 35 U/ml by multivariable logistic regression. In postmenopausal women (N = 1116), coronary artery disease (CAD) history was associated with higher CA125 (28.27%, p = 0.047) by multivariable linear regression; history of CAD (OR = 5.00, p = 0.011), history of breastfeeding (OR = 2.46, p = 0.026), and increased CRP level (OR = 1.41, p = 0.042) were more likely to be associated with having CA125 level ≥ 35 U/ml by multivariable logistic regression.

Conclusions

Results suggest CA125 is lower in premenopausal women who are current smokers and OCP users of moderately longer duration but higher in those with non-ovarian cancer. CA125 is higher in those postmenopausal women with CAD, history of breastfeeding and elevated CRP level. These associations can inform clinical interpretation of individual patients’ CA125 levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09637-7.

Current and Emerging Prognostic Biomarkers in Endometrial Cancer

Endometrial cancer is the most common gynaecological malignancy in high income countries and its incidence is rising. Whilst most women with endometrial cancer are diagnosed with highly curable disease and have good outcomes, a significant minority present with adverse clinico-pathological characteristics that herald a poor prognosis. Prognostic biomarkers that reliably select those at greatest risk of disease recurrence and death can guide management strategies to ensure that patients receive appropriate evidence-based and personalised care. The Cancer Genome Atlas substantially advanced our understanding of the molecular diversity of endometrial cancer and informed the development of simplified, pragmatic and cost-effective classifiers with prognostic implications and potential for clinical translation. Several blood-based biomarkers including proteins, metabolites, circulating tumour cells, circulating tumour DNA and inflammatory parameters have also shown promise for endometrial cancer risk assessment. This review provides an update on the established and emerging prognostic biomarkers in endometrial cancer.

Comparison of MRI, CA-125 and HE-4 in determining the depth of myometrial invasion in cases with endometrial cancer

Objective. Endometrial cancer is one of the most common malignancies in the world. There is no effective screening method used for predicting the clinical stage of the disease in the preoperative period and to plan the surgical procedure. The aim of this study is to compare the serum levels of CA-125 and HE-4 with MRI, to evaluate their ability to predict the depth of myometrial invasion in patients diagnosed with endometrial cancer, and to compare the specificity between these two tests. Materials and Methods. This prospective study was conducted at Dokuz Eylul University Faculty of Medicine, Department of Obstetrics and Gynecology, between February 2019 and February 2020. A total of 47 cases were included in the study. The cases were evaluated with MRI preoperatively to determine the extent of the disease. Preoperative serum CA-125 and HE-4 levels were measured by ELISA method and compared, and the superiority of the tests to each other in determining the depth of myometrial invasion was evaluated. Results. In patients with endometrioid cancer, preoperative CA-125 and HE-4 levels were found to be higher if the myometrial invasion is >50% and lymphovascular space invasion is positive, and the difference was statistically significant. A cut-off of 7,05 U/ml for CA-125 could detect the deeper myometrial invasion with a sensitivity of 83% and a specificity of 52%, respectively. A cut-off of 94,25 pmol/L for HE-4 could detect deeper myometrial invasion with a sensitivity of 75% and a specificity of 56%, respectively. The sensitivity of MRI in determining the depth of myometrial invasion was 87,1%, and the specificity was 86,7%. Conclusions. MRI, HE-4 and CA-125 were found to be valuable tests in predicting the extent of the disease and planning the surgical treatment. All three methods successfully predicted the myometrial invasion depth of the disease. The success rates of the tests in predicting the depth of myometrial invasion were MRI, HE-4 and CA-125, respectively. HE-4 and CA-125 could not reach the sensitivity and specificity of MRI in determining the depth of myometrial invasion at any cut-off value. However, it was proved in this study that they can play important roles as simpler and more cost-effective tests in determining the extent of the disease, able to contribute to surgical planning during preoperative evaluation.

HE4 and CA125 as preoperative risk stratifiers for lymph node metastasis in endometrioid carcinoma of the endometrium: A retrospective study in a cohort with histological proof of lymph node status

OBJECTIVES

To investigate whether HE4 and CA125 could identify endometrioid adenocarcinoma patients who might most benefit from full staging surgery with lymphadenectomy.

METHODS

Sequential patients with a preoperative banked serum and histology of endometrioid adenocarcinoma of endometrium who had undergone surgical staging with lymph node dissection over a 5-year period between 2011 and 2016 were included from a tertiary Gynaecological Cancer Centre, Dublin, Ireland. Preoperative serum HE4 and CA125 were measured using ELISA, with the cut-offs HE4 81 pmol/L and CA125 35 U/ml. Predictive values were estimated using AUC, sensitivity, specificity and odds ratios.

RESULTS

9.5% of the cohort had lymph node metastases. A HE4 cut-off of 81 pmol/L yielded a sensitivity of 78.6% and specificity of 53.4% for predicting lymph node metastases. Sensitivity of CA125 at 35 U/ml was 57% and specificity 91.4%. The AUC was 0.66 (0.52-0.80) for HE4 and 0.74 (0.58-0.91) for CA125. Sensitivity was 92.8% and specificity 51.1% when an elevation of either HE4 or CA125 was included, AUC was 0.72 (0.61-0.83), this combination yielded the highest NPV of 98.6%. Sensitivity was 42.9% and specificity 93.8% if both markers were elevated simultaneously, AUC was 0.68 (0.51-0.86). Preoperative clinical predictors of high-grade preoperative histology and radiology had sensitivities of 21.4% and 41.7%, respectively. Patients with a HE4 above 81 pmol/L had an odds ratio of 4.2 (1.12-15.74), p < 0.05, of lymph node metastases and CA125 had an odds ratio of 14.2 (4.16-48.31), p < 0.001.

CONCLUSIONS

Serum HE4 and CA125 improved on existing methods for risk stratification of endometrioid carcinomas and warrant further investigation.

Nadir CA-125 serum levels during neoadjuvant chemotherapy and no residual tumor at interval debulking surgery predict prognosis in advanced stage ovarian cancer

BACKGROUND

Recent phase III randomized trials have suggested that neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) is a treatment option for patients with advanced epithelial ovarian cancer. This study aimed to use CA-125 and computed tomography (CT) scanning to generate a simple and clinically applicable model of predicting complete cytoreduction by interval debulking surgery (IDS) and the overall survival in patients who receive taxane/platinum-based chemotherapy as neoadjuvant chemotherapy (NACT).

METHODS

Patients with stage IIIc or IV epithelial ovarian cancer who underwent taxane/platinum-based NACT followed by IDS in Gunma Prefectural Cancer Center, Takasaki General Medical Center, and Gunma University from April 2009 to March 2015 were included. Patients underwent a CT scan to confirm confirm tumors unresectable by standard surgery before NACT. CA-125 levels were measured pre-NACT, after each cycle of NACT, and before IDS. CT was also performed before IDS to evaluate tumor metastasis. Data were collected retrospectively and analyzed to determine the predictive factors of complete resection and overall survival.

RESULTS

Among 63 patients who received NACT-IDS, 43 and 20 patients had stages IIIc and IV epithelial ovarian cancer at diagnosis, respectively. CT predictors of residual tumors after IDS such as extra-ovarian implants (P = 0.009) and omental cakes (P = 0.038) were not present. Univariate analysis revealed that the independent factors for overall survival were no residual tumor by IDS (P = 0.0016) and CA125 ≤ 20 U/ml before IDS (P = 0.0011).

CONCLUSIONS

Although this study had a small sample size, NACT-IDS used to completely remove macroscopic disease which significantly improved the prognosis of patients with preoperative CA-125 ≤ 20 U/ml. Results from this study provide useful information for future studies on the management of patients with advanced epithelial ovarian cancer.

Preoperative markers for the prediction of high-risk features in endometrial cancer

BACKGROUND

Preoperative evaluations aiming to assess high-risk features in clinical stage 1 endometrial cancer patients are crucial to refer these patients to gynecologic oncologists. Cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) have been reported in endometrial cancer patients with poor prognostic factors.

AIM

To evaluate the association between preoperative levels of CA125 and HE4 and high-risk features and establish optimal cut-off values in clinical stage 1 endometrial cancer.

METHODS

A retrospective study was conducted in clinical stage 1 endometrial cancer patients who underwent primary surgery between January 2013 and December 2018. A total of 128 patients had preoperative serum CA125 and HE4 measurements. High-risk features included grade 3 tumors, large tumor sizes (more than 2 cm), deep myometrial invasion (more than 50%), lymphovascular space invasion (LVSI), cervical involvement, extrauterine involvement and node metastasis. Receiver operating characteristic (ROC) curves were generated to analyze the optimal cut-off values.

RESULTS

The mean age of the patients was 57.4 years, and 69.5% of them were postmenopausal. Most patients presented with stage I disease (67.2%) and had the endometrioid subtype (97.7%). The median CA125 and HE4 levels in all patients were 22.1 U/mL and 104.7 pmol/L, respectively. CA125 and HE4 levels were significantly elevated in those with large tumor sizes, deep myometrial invasion, LVSI, extrauterine metastasis, and advanced stage, but node metastasis was associated with elevated CA125 only. According to the ROC curve, both serum markers had statistical significance for the prediction of high-risk features only in postmenopausal patients, with an optimal cut-off value of 20 U/mL for CA125 [area under the concentration-time curve (AUC) = 0.72, P = 0.002] and 113 pmol/L for HE4 (AUC = 0.70, P = 0.006). The combination of both serum markers had 80% sensitivity and 64.4% positive predictive value. Significantly worse 5-year disease-free survival was observed in patients with high levels of CA125 and HE4 (78.4% and 100%, respectively; P = 0.01).

CONCLUSION

Preoperative CA125 levels greater than 20 U/mL or HE4 levels greater than 113 pmol/L are associated with an increased risk of having high-risk features and present as prognostic factors in clinical stage 1 postmenopausal endometrial cancer patients. This information is helpful for general gynecologists to refer high-risk patients to gynecologic oncologists to perform complete surgical staging.

CA 125 is a better marker to differentiate endometrial cancer and abnormal uterine bleeding

Background

Incidence of endometrial cancer in India is increasing due to lifestyle changes and obesity. As 5 year survival rate of cancer confined to uterus is good, there is need for serum tumor marker for early diagnosis. This study was designed to identify a tumor marker which differentiate endometrial carcinoma and abnormal uterine bleeding (AUB) because common presentation of endometrial carcinoma is AUB.

Objectives

To estimate and compare serum prolactin, Cancer Antigen 125 (CA-125), Cancer Antigen 15-3 (CA15-3), and Carcino embryonic antigen (CEA) levels in patients with endometrial cancer and abnormal uterine bleeding; To evaluate the role of these markers in diagnosing endometrial cancer.

Methodology

Thirty eight patients with endometrial cancer and 40 patients with AUB were recruited in this study. Serum prolactin, CA 125, CEA, and CA 15-3 levels were estimated in both groups.

Results

The levels of CA 15-3, CA 125, CEA, and prolactin were increased in endometrial carcinoma patients, on comparison with AUB patients. CA 125 alone was found to be a better marker to detect endometrial cancer with 52.63% sensitivity, 80.00% specificity.

Conclusion

As individual tumor marker, serum CA 125 has the ability to detect endometrial cancer in patients with abnormal uterine bleeding.

The prognostic role of preoperative serum CA125 levels in patients with advanced endometrial carcinoma

BACKGROUND

Lifetime risk of developing endometrial cancer is 2.17%. There is controversy regarding the predictive value of Cancer Antigen 125 (CA125) in endometrial cancer as well as the significance of its relationship with prognostic factors and appropriate cut-off value.

OBJECTIVE

The aim of the present study was to investigate the prognostic role of CA125 in advanced endometrial carcinoma and determination of the appropriate cut-off value.

METHODS

A sample of 91 patients was retrospectively selected from a population of 501 patients suffering from endometrial cancer during 1995 to 2015 in accordance with the inclusion criteria. The relation between clinicopathological variables and CA125 were analyzed. In order to determine sensitivity and specificity of various cut-off levels, receiver operating characteristic (ROC) curve analysis was performed for associated factors confirmed by logistic regression analysis.

RESULTS

In 35% of patients, CA125 values were 35 u/ml, and in 52%, the values were equal to or greater than 20 u/ml. High preoperative CA125 was significantly related with advanced stage, ovarian involvement, omental metastasis, and myometrial invasion equal to or greater than 50%. According to the ROC curve, the suitable cut-off value for CA125 in advanced stage (sensitivity = 73%, specificity = 55%, positive predictive value = 18%, negative predictive value = 78%) and myometrial invasion equal to or greater than 50% (sensitivity = 64%, specificity = 61%, positive predictive value = 47%, negative predictive value = 74%) was 20 u/ml. Further, the suitable cut-off value for CA125 in involvement of the ovaries (sensitivity = 77%, specificity = 72%, positive predictive value = 31%, negative predictive value = 95%) and omental involvement (sensitivity = 70%, specificity = 70%, positive predictive value = 22%, negative predictive value = 95%) was 35 u/ml.

CONCLUSIONS

In endometrial carcinoma, due to the relationship of CA125 with numerous prognostic factors, it is recommended that CA125 measurement be included in preoperative evaluation. In case of high CA125 levels, complete surgical staging including lymphadenectomy and omentectomy should be considered.

The Value of Preoperative CA 125 Levels in Prediction of Myometrial Invasion in Patients with Early-stage Endometrioid- type Endometrial Cancer

AIM

To evaluate the relationship between pre-operative CA-125 levels and myometrial invasion in patients with early-stage endometrioid-type endometrial cancer.

MATERIALS AND METHODS

Two-hundred and sixty patients were diagnosed with endometrial cancer between January 2007 and December 2012. Of these, 136 patients with stage 1 endometrioid histologic-type and documented pre-operative serum CA-125 levels were included in the study. Age, preoperative CA-125 level, histologic grade, surgical grade, and presence of deep myometrial invasion were recorded. Additionally, 16, 20, and 35 IU/ml cutoff values were used and compared to evaluate the relationship between pre-operative CA-125 levels and myometrial invasion.

RESULTS

The average serum CA-125 level was 35.4±36.7 in patients with deep myometrial invasion, and 21.5±35.8 in cases without deep myometrial invasion. The relationship between the presence of deep myometrial invasion and CA-125 cut-off values (16, 20, 35 IU/ml) was statistically significant, although the correlation was weak (p<0.05). When the relationship between 16, 20 and 35 IU/ml CA-125 cut-off values and the presence of deep myometrial invasion was studied, specifity and sensitivity values were identified as: 0.60-0.68 for 16 IU/ml; 0.73-0.48 for 20 IU/ml; and 0.89-0.33 for 35 IU/ml. The sensitivity of 16 IU/ml cut-off value was higher when compared to other values.

CONCLUSIONS

This study demonstrates that preoperative serum CA-125 values maybe used as a predictive test in patients with early stage endometrioid-type endometrium cancer, and as a prognostic factor alone. Further studies should be conducted to identify different CA-125 cut-off values in patients with low risk endometrial cancer.

Physiopathological factors affecting the diagnostic value of serum HE4-test for gynecologic malignancies

Serum epididymis protein 4 (HE4) represents a useful biomarker for the management of ovarian cancer and endometrial cancer patients. However, HE4 levels are affected by many physiopathological conditions or disorders that should be taken into consideration for an efficient application of this biomarker. Areas covered: The review provides an up-to-date reference on the multiple physiopathological factors that cause fluctuation of HE4 serum levels, and evaluates their impact on HE4-test in clinical settings. Potential mechanisms underlying the regulation of HE4 expression are also discussed. The review is based on data from literature search of PubMed and the author's opinions. Expert commentary: Studies have shown that physiopathological factors such as age, infection/inflammation, renal function, menopause and hormonal levels impose significant impacts on HE4 serum levels. HE4 amount shed into the circulation is related to HE4 expression and secretion by tumor as well as normal tissues, which is affected by cancer heterogeneity, vascular permeability, renal clearance and HE4 degradation. Investigation on interfering factors builds a basis for the construction of a quantitative logarithm for individualized application of HE4-test in clinical settings.

Serum carcinoembryonic antigen as a tumour marker in patients with endometrial cancer

BACKGROUND

No potential tumour markers have been validated for prognosis in endometrial cancer. However, carcinoembryonic antigen (cea) is one of the most widely used tumour markers in various types of cancer. Although cea expression in endometrial cancer has been investigated, its prognostic value remains controversial, and no studies have investigated serum cea levels in large case series. In the present study, we investigated diagnostic and prognostic applications of serum cea for endometrial cancer.

METHODS

This prospective study was approved by our Institutional Review Board. Between January 2006 and December 2012, serum cea was measured prospectively in 215 patients with endometrial cancer and was subsequently measured during treatment and at scheduled follow-up examinations in patients with elevated baseline serum cea.

RESULTS

During the study period, 215 patients (142 stage i, 19 stage ii, 32 stage iii, 22 stage iv) were treated for endometrial cancer. By the time of last follow-up, 52 had relapsed (24.2%), and the median follow-up duration was 45 months (range: 1-95 months). Elevated serum cea was identified in 25 patients (11.6%) and was associated with histologic type (p = 0.04), histologic grade (p = 0.03), and myometrial invasion depth (p = 0.01). Elevated serum cea was not related to clinical stage, lymph node metastasis, distant metastasis, age, menopausal status, or body mass index. Relapse of disease was related to elevated serum cea (p = 0.006).

CONCLUSIONS

Serum cea is a potential prognostic indicator for endometrial cancer.

Utility of HE4 to identify patients with endometrioid endometrial cancer who may require lymphadenectomy

PURPOSE

The aim of the study was to establish whether preoperative serum levels of HE4 and CA125 could be a good predictor for lymphadenectomy in the early stage of endometrioid adenocarcinoma of the uterus.

MATERIAL AND METHODS

Preoperative serum HE4 and CA125 were measured in 78 postmenopausal patients treated surgically. The ROC curves were generated to determine the optimal cutoff values of HE4 and CA125 levels with optimum sensitivity and specificity for the prediction of lymphadenectomy.

RESULTS

Based on ROC curve, we found that the HE4 value of 78pmol/l is the best cutoff to identify candidates who may require lymphadenectomy with the sensitivity of 86.6% and the specificity of 67.2% (NPV=88.4% and PPV=51.2%). The area under the curve (AUC) equals 0.814 (95% CI=0.721-0.886). The cutoff level of CA125 that shows the prognostic indices is 26U/ml, with the sensitivity of 66.6% and the specificity of 61.2% (NPV=69.4% and PPV=44.3%). For CA125 the AUC amounts to 0.671 (95% CI=0.568-0.764). We also found a statistically significant difference, comparing HE4 and CA125 AUC (0.814 vs. 0.671, respectively, p<0.001). The combination of HE4 and CA125 established in our study as the cutoff point has the sensitivity of 81.2% and the specificity of 65.9% with NPV=83.4% and PPV=47.9%.

CONCLUSIONS

Our findings indicate that in the early stage of endometrioid endometrial cancer, HE4 can serve as a preoperative tool that can help to identify postmenopausal women who may require lymphadenectomy.

Serum Sialyl-Tn (STN) as a Tumor Marker in Patients with Endometrial Cancer

There are no potential tumor markers validated for prognosis of endometrial cancer. However, sialyl Tn (STN) is a carbohydrate antigen that is associated with the production of mucin, which reportedly plays important roles in carcinogenesis. Although STN expression in endometrial cancer has been investigated, its prognostic value remains controversial and no studies have investigated serum STN levels in large case series. In this study, we investigated diagnostic and prognostic applications of serum STN for endometrial cancer. Between January 2006 and December 2012, serum STN levels were examined prospectively in patients with endometrial cancer. A total of 146 patients (stage I, 98; stage II, 15; stage III, 17; stage IV, 16) were treated for endometrial cancer. The median age was 60 years (28-83). Subsequently 29 patients (19.9%) relapsed at the time of the last follow-up and the median follow-up time was 44 months (1-83). Elevated serum STN levels were identified in 36 patients (24.7%) and were associated with histological grade (p = 0.02) and lymph node metastasis (p = 0.006). Elevated serum STN levels were not related to histological types, clinical stages, myometrial invasions, distant metastases, age, menopausal status, body mass index, or relapse. Among the 36 patients with elevated serum STN levels, 33 (91.7%) achieved remission and serum STN levels returned to the normal range. Seven patients (21.2%) with elevated serum STN levels at baseline relapsed and their serum STN levels were again elevated. Serum STN levels are a potential prognostic indicator for endometrial cancer.

Preoperative serum CA125: a useful marker for surgical management of endometrial cancer

Background

Surgery plays an important role in the management of endometrial cancer at all stages, particularly early clinical stage. There are still many unanswered questions regarding optimal surgical management of endometrial cancer, particularly regarding which patients should undergo lymphadenectomy. The aim of this study was to evaluate the role of preoperative cancer antigen 125 (CA125) serum levels for surgical management in endometrial cancer patients.

Methods

A total of 995 patients with endometrial cancer, according to inclusion criteria of a preoperative serum level of CA125, were selected. The association between clinicopathological factors and CA125 were analyzed. Receiver operating characteristic (ROC) curve was used to evaluate the role of preoperative serum CA125 in predicting lymph node metastasis, adnexal involement, cervical stromal invasion in all patients, especially patients with clinical stage I. Survival analyses were also performed according to the four groups of preoperative CA125 serum levels.

Results

Elevated CA125 level was significantly associated with all clinicopathological parameters, including age and menopause, but not histology type. ROC curve analysis results showed the CA125 serum level of 25 U/mL was the best cutoff to predict the lymph node metastasis. It was with 78% of sensitivity, 78% of specificity, 77.6% of false positive rate, 2.3% of false negative rate in all patients. In patients with clinical stage I, it was with 71.7% of sensitivity, 77.6% of specificity, 83.3% of false positive rate, 2.2% of false negative rate. The best cutoff to evaluate adnexal involement in patients with clinical stage I was 30U/ml, with 81% sensitivity, and 78.4% specificity. Survival analysis revealed CA125, FIGO stage, histology grade, and positive peritoneal cytology as independent prognostic factors of endometrial cancer.

Conclusion

Preoperative serum CA125 is an important predictor for patients with endometrial cancer and it should be taken into consideration when surgical management is determined, especially if a lymphadenectomy should be undertaken in patients with clinical stage I.

Baseline and post prophylactic tubal-ovarian surgery CA125 levels in BRCA1 and BRCA2 mutation carriers

The aim of this study was to determine whether BRCA1 and BRCA2 mutation carriers have different baseline CA125 levels compared with non-carriers, and whether a significant difference in pre- and post-operative CA125 levels exists in BRCA mutation carriers undergoing risk-reducing bilateral salpingo-oophorectomy (RRBSO). The study also considered whether CA125 measurements should continue in unaffected BRCA mutation carriers after RRBSO. 383 Eligible women were identified through retrospective review of the BRCA Carrier Clinic at The Royal Marsden NHS Foundation Trust, London, UK. These women all had CA125 levels measured as they were either a carrier or at risk of a BRCA1 or BRCA2 mutation. Of these, 76 went on to have a negative predictive test for their familial mutation and so are classed as 'non-carriers'. 133 BRCA1 and 87 BRCA2 carriers had RRBSO, with a further 26 BRCA1 carriers, 28 BRCA2 carriers and one non-carrier developing ovarian cancer. The remaining 21 BRCA1 and 28 BRCA2 carriers did not have RRBSO or develop ovarian cancer in the time of study follow-up. CA125 levels were measured as surveillance or as part of pre-RRBSO care. CA125 measurement post-RRBSO was continued in 48 BRCA1 and 40 BRCA2 carriers. In 154 BRCA1 mutation carriers, the median baseline (i.e. before RRBSO and with no clinical signs of ovarian cancer) CA125 level was 9.0 U/ml (range 2-78) and was 10.0 U/ml (range 1-43) in 115 BRCA2 mutation carriers. When compared with the 75 non-carriers (median baseline CA125 10.0 U/ml; range 2-52), there was no significant difference between the BRCA1, BRCA2 and non-carrier groups. There was a significant reduction in CA125 from pre- to post-RRBSO in 48 BRCA1 carriers (p = 0.04) but no significant difference in 40 BRCA2 mutation carriers (p = 0.5). Out of a total of 220 mutation carriers who underwent RRBSO, two had an incidental ovarian cancer found on histopathology and another developed primary peritoneal cancer during the follow-up period. Our study is the first to compare initial serum CA125 levels in BRCA1 and BRCA2 mutation carriers with those of non-carriers. Our study found no significant difference between the three groups. A drop in CA125 levels after RRBSO in BRCA1 carriers supports the finding of earlier studies, but differed in that the fall was not seen in BRCA2 carriers. The finding of only one case of post-operative peritoneal cancer in 220 carriers undergoing RRBSO supports the discontinuation of post-RRBSO serum CA125 monitoring in BRCA mutation carriers.

CA125 reference values change in male and postmenopausal female subjects

BACKGROUND

In cancer patients, including women with a diagnosis of ovarian cancer, cancer antigen 125 (CA125) is used to evaluate the presence of peritoneal involvement. The aims of the present study were to assess CA125 reference intervals and reference change values (RCV) in postmenopausal reference women, postmenopausal women breast cancer free, reference men and cancer free men.

METHODS

The series consisted of 433 subjects: 105 postmenopausal breast cancer free women and 56 cancer free men in addition to a total of 272 reference subjects (145 postmenopausal women and 127 men). Repeated CA125 measurements were made in a subset of 149 women and 54 men to calculate RCV and index of individuality. Serum CA125 levels were evaluated by a chemiluminescent assay.

RESULTS

In postmenopausal reference women, the mean CA125 value and 2.5th-97.5th percentiles were 6.70, 2.60-11.00 kU/L, respectively, with a unidirectional RCV of 38.4%. In postmenopausal breast cancer free women, the mean CA125 value and 2.5th-97.5th percentile were 7.45, 4.09-10.92 kU/L, respectively, with a RCV of 34.5%. The difference between the means was statistically significant (t=-3.02, p=0.003). In the two male subgroups, the difference between the means for CA125 was not statistically significant (t=0.43, p=0.665). On considering the entire male population, the mean CA125 value and 2.5th-97.5th percentiles were 7.50 and 2.40-13.2 kU/L, respectively, while the unidirectional RCV was 34.3%. In all the studied groups, the indices of individuality were equal to or below 0.6.

CONCLUSIONS

The extremely low index of individuality found underlines the importance of using the RCV instead of absolute values as a parameter when interpreting the CA125 data in the monitoring and follow-up of patients with ovarian cancer.

HE4 and CA125 levels in the preoperative assessment of endometrial cancer patients: a prospective multicenter study (ENDOMET)

OBJECTIVE

To evaluate whether human epididymis protein 4 (HE4) and CA125 correlate with known high-risk prognostic factors for endometrial cancer.

DESIGN

Prospective multicenter study.

SETTING

Three Danish tertiary gynecological oncology centers.

POPULATION

A total of 352 patients with endometrial cancer and atypical endometrial hyperplasia consecutively referred between 1 September 2009 and 1 January 2012.

METHODS

Preoperative blood samples were obtained from all patients. Biomarker levels were correlated with pathological characteristics of hysterectomy specimens.

MAIN OUTCOME MEASURES

FIGO stage, depth of myometrial invasion, cervical involvement, lymph node metastases, and histological type and grade of tumor.

RESULTS

We found that both HE4 and CA125 were significantly positively correlated with histological grade (HE4: p = 0.002 and CA125: p = 0.027), lymph node metastases (HE4: p = 0.013 and CA125: p < 0.0001), myometrial invasion (p < 0.0001) and cervical involvement (p < 0.0001). Furthermore, a significant increase was found with increasing FIGO stage for both markers (p < 0.0001). In a combined index including age, the diagnostic value increases. Area under the receiver operating characteristics curves were higher for the index compared with the markers individually for all our endpoints. The calculated plots for the combined index may assist gynecologists in predicting the risk of deep myometrial invasion, cervical involvement and lymph node metastases. The analyses emphasize that the combined markers should be used in the prediction of prognostic factors.

CONCLUSION

This study confirmed that the markers are significantly elevated in patients with prognostic high-risk factors and may, therefore, be used as an additional tool in combination with imaging and clinical information when planning the treatment of endometrial cancer patients.

Serum CA 125, CA 15-3, CEA, and CA 19-9: a prognostic factor for uterine carcinosarcomas?

PURPOSE

There is a controversy in the literature regarding the role and the prognostic significance of serum markers in uterine carcinosarcomas (CSs). We attempted to determine the utility of serum CA 125, CA 15-3, CA 19-9, and CEA as prognostic factors and disease follow-up in patients with CS of the uterus.

METHODS

Thirty-seven patients with CS of the uterus were included in this study. Information regarding demographic, clinical, pathologic, tumor marker data (CA 125, CA 19-9, CA 15-3, and CEA both pre- and postoperatively) treatment and outcome information was obtained, followed by Statistical analysis.

RESULTS

The mean follow-up period was 3.5 years. None of the study serum markers showed significant association with the outcome. Greater hazard was found for cases that staged from IIIA to IV compared to those staged from IA to IIB (HR = 4.75, 95 % CI: 1.99-11.3). Also, greater hazard was found for adenosquamous histological type compared to the other histological types. When multiple Cox regression analysis with stepwise approach was implied, it indicated stage as the only significant factor for the outcome. Elevated CA19-9 was more frequent in cases with heterologous sarcoma (p = 0.036).

CONCLUSION

In this retrospective study, none of the preoperative serum tumor markers, neither epithelial component, histological type, nor grade showed a significant association with prognosis. This null finding may have significant implications in the common clinical practice; given that there is a controversy in the literature regarding the role and the significance of the prognostic significance of serum CEA, CA 125, CA 19-9, and CA 15-3.

Prognostic significance of gamma-glutamyltransferase in patients with endometrial cancer: a multi-centre trial

Background:

Gamma-glutamyltransferase (GTT), a known marker for apoptotic balance, seems to promote tumour progression, invasion and drug resistance. Recently, high GGT serum levels were shown to be associated with impaired prognosis in patients with cervical cancer. The aim of this study was to investigate the value of pre-therapeutic serum GGT levels as prognostic parameter in patients with endometrial cancer.

Methods:

Within the present multi-centre trial, clinical–pathological parameters and pre-therapeutic serum GGT levels were evaluated in 874 consecutive patients with endometrial cancer. Patients were stratified in GGT risk groups, and univariate and multivariable survival analyses were performed.

Results:

Mean pre-therapeutic serum GGT level was 30.8 (41.5) U l^–1. Elevated and highly elevated serum GGT levels (P=0.03 and P=0.005), tumour stage (P<0.001 and P<0.001), grade (P<0.001 and P=0.02) and age (P<0.001 and P<0.001) were independently associated with progression-free survival in univariate and multivariable survival analyses. Pre-therapeutic GGT was not associated with advanced tumour stage (P=0.6), higher histological grade (P=0.6) or unfavourable histological subtype (P=0.3).

Conclusion:

Pre-therapeutic serum GGT is a novel and independent prognostic parameter for progression-free survival of patients with endometrial cancer. Stratifying patients into prognostic subgroups could be used for patient counselling and individualised treatment planning.

PET/CT imaging in gynecologic malignancies: a critical overview of its clinical impact and our retrospective single center analysis

Gynecologic cancers represent a major global healthcare problem since they are associated with a significant mortality and morbidity. Over the last decade, considerable efforts have been spent in the development and optimization of novel diagnostic modalities to achieve an early diagnosis, aid in choosing appropriate treatment, improving long term surveillance, with the ultimate goal of increasing survival of gynecologic cancer patients. A growing body of evidence defines PET/CT as one of the most powerful tools for tumor, nodal and metastasis (TNM) cancer staging both in pre-treatment and in post treatment follow-up settings. At any phase of cancer evaluation, detection of metastasis represents one of the most critical impediments to the cure of tumor; traditional diagnostic imaging modalities, such as computed tomography (CT), are frequently found to inadequately stage the tumor, based on subsequent outcomes. As a consequence, patients may undergo pointless surgery for disease that could be treated with local medical therapies. In the setting of restaging, the ability to describe primary lesion, lymph nodes, possible metastases to peritoneum, bone, liver, lungs and brain renders PET/CT a potential alternative for a series of tests, including bone scanning, MRI or ultrasound, diagnostic CT, lymph node surgical sampling, that need to be used in combination in order to obtain a level of clinical confidence. In this review, we describe, the theoretical advantage and prognostic implications of PET/CT in the management of gynecologic cancer patients.

The value of FDG-PET/CT in the post-treatment evaluation of endometrial carcinoma: a comparison of PET/CT findings with conventional imaging and CA 125 as a tumour marker

OBJECTIVES

This retrospective study was designed to assess the value of positron emission tomography/computed tomography imaging (PET/CT) in the post-treatment evaluation of the patients with endometrial carcinoma and to compare PET/CT scan with conventional imaging (CI) including computed tomography (CT), ultrasonography (US) and magnetic resonance imaging (MRI) and CA 125 with both 20U/ml and 35U/ml cut-off values.

MATERIALS AND METHODS

A total of 31 patients who were treated for histopathologically proven endometrial adenocarcinoma, underwent PET/CT examination for restaging and suspected recurrence. Thirty five PET/CT studies were performed in 31 patients. Lesion status was determined on the basis of clinical follow-up including radiological imaging (follow-up CT scan) at least 6 months and response to therapy.

RESULTS

Of the 35 PET/CT studies, 13 (37%) studies were positive, whereas 22 (63%) of them were negative. On study-based analysis the overall sensitivity, specificity, accuracy for PET/CT imaging were 100%, 96% and 97%, respectively. The corresponding information for CI were 46%, 87% and 74%, for CA 125 (cut off=20U/ml) measurement were 45%, 88% and 74%, and for CA 125 (cut off=35U/ml) measurement were 27%, 100% and 78%, respectively. On lesion-based analysis, PET/CT revealed only one false positive case. In none of 21 patients with negative 22 PET/CT studies, no subsequent clinical or radiological recurrences were observed with a follow-up of at least 6 months.

CONCLUSION

FDG-PET/CT is found more useful modality than CI and CA 125 in the evaluation of post-treatment endometrial carcinoma patients, for suspected recurrence.

Evaluation of preoperative criteria used to predict lymph node metastasis in endometrial cancer

OBJECTIVE

To evaluate whether we could accurately predict lymph node (LN) metastasis with preoperative tests in endometrial cancer. Design. Retrospective study.

SETTING

Seoul National University Hospital, South Korea. Population. Three hundred patients with endometrial cancer who underwent surgical staging including lymphadenectomy between January 1999 and July 2007.

METHODS

We reviewed the medical records of 300 patients with endometrial cancer. The preoperative factors used to predict LN metastasis were as follows: old age (> or = 55 years), serum CA-125 level [level > or = 20 U/mL (if age < 50 years), level > or = 28 U/mL (if age > or = 50 years)], non-endometrioid histologic type and Grade 3, metastatic LN assessed by pelvic MRI or CT, and deep myometrial invasion assessed by pelvic MRI only. Logistic regression analysis was used to determine the significant predictive factors.

MAIN OUTCOME MEASURES

Sensitivity/specificity and false positive/negative rates.

RESULTS

Thirty patients had LN metastasis. Although LN evaluation by pelvic MRI or CT and high CA-125 level were the significant independent predictors for LN metastasis, the sensitivity/specificity and false positive/negative rates for LN metastasis by these two combined preoperative tests were 86.7%/71.4% and 68.7%/2.7%, respectively. However, the sensitivity/specificity and false positive/negative rates for LN metastasis by six combined preoperative tests were 100%/28.9% and 84.6%/0%, respectively.

CONCLUSIONS

The six combined preoperative tests are useful in selecting patients without LN metastasis in endometrial cancer. Lymphadenectomy could be avoided in about 29% of patients with endometrial cancer who have no LN metastasis by using six combined preoperative tests.

Premenopausal early-stage endometrial carcinoma patients with low CA-125 levels and low tumor grade may undergo ovary-saving surgery

OBJECTIVE

The purpose of this study was to determine the possible predicting factors of coexisting adnexal malignancies, and to evaluate the safety of ovary-saving surgery for early-stage endometrial carcinoma in premenopausal patients.

METHODS

A retrospective review of 107 patients with endometrial carcinoma who underwent surgical treatment at our institution was conducted. All patients were younger than 50 years of age and premenopausal status. Statistical analysis was performed.

RESULTS

Of the 107 patients, 78 patients had stage I to II disease and both preoperative CA-125 levels were measured and tumor grades evaluated. On multivariate analysis, preoperative CA-125 levels (p=0.018) and preoperative tumor grade (p=0.029) were independent predicting factors of adnexal diseases. The risk of coexisting ovarian malignancy was 1.8% in patients with preoperative CA-125 levels less than or equal to 34.5 U/ml and preoperative tumor grade 1 or 2. The risk increases to 20% for low CA-125 and grade 3, 13.3% for high CA-125 and grade 1 or 2, and 100% for high CA-125 and grade 3. Between patients who underwent unilateral salpingo-oophorectomy and those who underwent bilateral salpingo-oophorectomy, there was no statistically significant difference in terms of BMI, preoperative CA-125 levels, FIGO stage, histology, tumor grade, lymphadenectomy, and adjuvant treatment.

CONCLUSION

Ovary-saving surgery for premenopausal, early-stage endometrial cancer patients may be considered as a treatment option in those with low preoperative CA-125 and low tumor grade.

Diagnostic accuracy of FDG PET imaging for the detection of recurrent or metastatic gynecologic cancer

PURPOSE

This study evaluated the diagnostic role and accuracy of positron emission tomography (PET) using 2-[F-18]fluoro-2-deoxy-D-glucose (FDG) for the detection of tumor foci in patients with suspected recurrent or metastatic lesions of gynecologic cancers.

MATERIALS AND METHODS

FDG PET imaging was performed on 51 patients with a previous history of gynecologic cancer who were referred for a clinical suspicion of recurrent disease. PET acquisition was started 50-60 min after the intravenous injection of 5-6 MBq/kg FDG in all patients. The PET images were interpreted visually, and tracer uptake was quantitated as the standardized uptake value adjusted to body weight (SUV) in the lesions showing FDG uptake. The accuracy of the PET results was assessed by a consensual verdict based on histology, cytology, other imaging and clinical follow-up.

RESULTS

FDG PET correctly diagnosed 33 of 36 patients with recurrent disease and 12 of 15 patients without recurrence. On patient-based analysis, the sensitivity, specificity and accuracy of FDG PET were 91.7%, 80.0% and 88.2%, respectively, depending on the selected scheme for visual scoring of the lesions. The area index in receiver-operating characteristic analysis was 0.95 for patient detection. Malignant lesions accumulated significantly more FDG than the benign ones (the mean SUVs were 3.7 +/- 1.9 and 1.6 +/- 1.1, respectively, p = 0.004). The sensitivity and specificity in correct identification of tumor recurrence or metastases using a threshold SUV 1.9 were 88.8% and 66.7% in contrast to the visual analysis (sensitivity 96.4%, specificity 50%) on a lesion-based analysis. The partial volume effect of SUV in a few small lesions and the presence of bone lesions in which FDG uptake was relatively low might be the reason for the lower sensitivity in SUV analysis. FDG PET was valuable when CT/MRI was negative or inconclusive, and in patients with elevated tumor marker levels as well as with normal tumor marker levels when recurrence was suspected clinically. However, PET failed to visualize some small metastatic lesions in lung and bone, and showed falsely high FDG uptake in some benign lesions.

CONCLUSION

The results indicated that FDG PET is a reliable and accurate diagnostic method for detecting recurrent or metastatic gynecologic cancer particularly lymph node metastases. Although the sensitivity of PET for detecting small metastases was relatively limited, the overall sensitivity of FDG PET was significantly higher than morphologic imaging.

Preoperative tumor markers at diagnosis in women with malignant mixed müllerian tumors/carcinosarcoma of the uterus

CA125 is a well-recognized marker for endometrial cancer. Uterine malignant mixed müllerian tumors (MMMTs) are increasingly being recognized as an aggressive adenocarcinoma, not a sarcoma. There are no data in the literature regarding CA125 in this malignancy. One hundred twelve women with surgically staged MMMT, diagnosed between July 1990 and September 2005, had a retrospective chart review performed. Preoperative CA125 levels were available in 29 (26%) women. Seventeen (49%) women had levels above the upper limit of normal of 35 kμ/L. Mean levels increased with increasing surgical stage: stage I 53.4 kμ/L; stage II 122.5 kμ/L; stage III 147.1 kμ/L; and stage IV 428.4 kμ/L. Elevated levels of CA19-9, CEA, and CA15-3 were found in 8%, 12%, and 25%, respectively.

Trefoil factor 3: a novel serum marker identified by gene expression profiling in high-grade endometrial carcinomas

This study identifies the genetic fingerprint of poorly differentiated endometrioid endometrial carcinomas (G3-EEC) and analyses the potential utility of trefoil factor 3 (TFF3) as novel serum marker in G3-EEC. Affymetrix microarrays were used to identify the gene expression patterns of 19 snap-frozen G3-EEC and 15 normal endometrium (NE) biopsies. Quantitative real-time PCR (qRT-PCR) and immunohistochemistry were used to validate TFF3 expression. Finally, TFF3 serum levels were determined by ELISA in 25 G3-EEC patients, 42 healthy controls, and in 13 endometrial hyperplasia patients. Hierarchical cluster analysis showed TFF3 as the top differentially expressed gene between 363 upregulated genes in G3-EEC, when compared with NE. Trefoil factor 3 gene expression levels analysed by qRT-PCR significantly correlated with Affymetrix results (P<0.001; rs=0.85). By immunohistochemistry, TFF3 protein was significatively more expressed in EEC compared with NE (P<0.01), with cytoplasmatic positivity in 79% G3-EEC and 18% NE. Patients harbouring G3-EECs had significantly higher TFF3 serum concentration by ELISA when compared with healthy patients (P<0.001) or patients harbouring endometrial hyperplasia (P=0.012). In conclusion, TFF3 is highly expressed at gene and protein level in G3-EEC. Further investigations on a wider set of samples are warranted to validate TFF3 as a novel serum marker for early detection and/or monitoring of G3-EEC patients.

The epidemiology of CA-125 in women without evidence of ovarian cancer in the Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial

OBJECTIVE

To determine the epidemiology of CA-125 in women without ovarian cancer.

METHODS

We analyzed demographic, medical and lifestyle characteristics related to CA-125, measured using the Centocor CA-125II RIA assay, among 25,608 multi-ethnic U.S. women aged 55-74 years enrolled in a cancer screening trial and found to have no evidence of ovarian cancer.

RESULTS

Mean CA-125 level was 11.9 U/ml (SD 8.3); median 10.0 U/ml, interquartile range 8.0-14.0. High levels, using the clinical cut point of >or=35 U/ml, were associated with increased age (p<0.001) and former smoking (p<0.021), while hysterectomy and obesity were protective (p<0.001). Mean levels were higher with increasing age (p<0.001), ever use of hormone therapy (p<0.001), former smoking (p<0.017) and history of breast cancer (p<0.002), but lower (p<0.001) with non-White status, previous hysterectomy, current smoking, and obesity. Current hormone therapy use was not associated with CA-125 in women without a uterus.

CONCLUSION

In post-menopausal women without ovarian cancer, CA-125 level is influenced by a number of factors, including race/ethnicity, age, hysterectomy, smoking history and obesity.

Post-therapy surveillance of patients with uterine cancers: value of integrated FDG PET/CT in the detection of recurrence

PURPOSE

The purpose of this study was to prospectively determine the diagnostic accuracy of PET/CT in the detection of recurrence in patients with treated uterine cancers.

METHODS

Twenty-five women, ranging in age from 37 to 79 years (mean 58.9 years), who underwent primary surgical treatment for either a cervical or an endometrial cancer met the inclusion criterion of the study, which was suspicion of recurrence based on results of routine follow-up procedures. PET/CT was performed after administration of 18F-fluorodeoxyglucose (FDG); two readers interpreted the images in consensus. Histopathological findings or correlation with results of subsequent clinical and imaging follow-up examinations served as the reference standard. Diagnostic accuracy of PET/CT was reported in terms of the proportion of correctly classified patients and lesion sites.

RESULTS

Tumour recurrence was found at histopathological analysis or follow-up examinations after PET/CT in 14 (56%) of the 25 patients. Patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for detection of tumour recurrence were 92.9%, 100.0%, 100.0%, 91.7% and 96.0%, respectively. Lesion site-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT were 94.7%, 99.5%, 94.7%, 99.5% and 99.0%, respectively.

CONCLUSION

This preliminary study shows that PET/CT may be an accurate method for the evaluation of recurrence in patients who have been treated for uterine cancers and are undergoing follow-up.

Serum CA 125 levels and lymph node metastasis in patients with endometrial cancer

The aim of this study was to evaluate the correlation of preoperative serum CA 125 levels and lymph node metastasis in patients with endometrial cancer. Preoperative levels of serum CA 125 were determined in 64 patients with endometrial cancer treated with total abdominal hysterectomy with a lymph node dissection as initial therapy. Lymph node status, determined by histopathology, was correlated with both normal and elevated CA 125 levels, determined preoperatively. A serum CA 125 level of >30 IU/ml was considered elevated. There were five patients (7.8%) with pelvic or paraaortic lymph node metastases and 59 patients (92.2%) without nodal metastases. In all five patients with lymph node metastases, serum CA 125 was within normal limits. Preoperative serum CA 125 levels were above normal in eight lymph node-negative patients. In the remaining group of 51 node-negative patients, serum CA 125 levels were within normal limits. Among the five lymph node-positive patients, four had endometrioid and one had serous papillary cancer. One patient had histologic grade 2 tumor and four patients had histologic grade 3. Preoperative serum CA 125 levels do not offer any information for predicting lymph node metastasis in patients with endometrial cancer.

Serum tumor markers in the management of ovarian, endometrial and cervical cancer

CA 125 is the most reliable serum marker for ovarian carcinoma. Whereas its role in the screening of the malignancy is controversial, serum CA 125 assay is very useful for both the differential diagnosis of ovarian masses, particularly in postmenopause, and the monitoring of the response to chemotherapy and follow-up of patients with histologically proven ovarian carcinoma. Tumor-associated antigens other than CA 125, such as CA 19.9, CA 15.3 and TAG.72, firstly identified in gastro-intestinal or breast malignancies, have been detected also in tissue and serum samples from patients with ovarian carcinoma. In particular CA19.9 offers the advantage of high sensitivity for mucinous histotype, which often fails to express CA 125. Serum CA 125 correlates with the clinical course of disease better than the other antigens, and in patients with positive CA 125 assay at diagnosis the concomitant evaluation of CA 19.9 or CA 72.4 or CA 15.3 does not offer any additional benefit for monitoring ovarian carcinoma. Conversely, the serial measurements of these other antigens may represent an interesting biochemical tool for the management of patients with negative CA 125 assay. Serum alphaFP and betaHCG are very useful in the preoperative evaluation and management of nondysgerminomatous ovarian germ cell tumors, whereas elevated serum inhibin levels can be detected in patients with granulosa cell tumors of the ovary. As for endometrial carcinoma, preoperative serum CA 125 levels correlate with stage, depth of myometrial invasion, histologic grade, cervical invasion, peritoneal cytology, lymph node status and clinical outcome. Moreover, serial CA 125 assay is a good indicator of disease activity and a useful biochemical tool for post-treatment surveillance of patients with endometrial carcinoma. SCC is the most reliable serum marker for squamous cell cervical carcinoma, and in patients with this malignancy pretreatment SCC levels are related to tumor stage, tumor size, depth of cervical invasion, lymph-vascular space involvement, lymph node status and clinical outcome. Serial SCC measurements parallel the response to radiotherapy and chemotherapy as well as the clinical course of disease after the completion of treatment. Serum CYFRA 21.1 seems to be less sensitive than serum SCC for squamous cell cervical carcinoma. Elevated CA 125 levels can be often detected in patients with cervical adenocarcinoma. The future for tumor marker research is represented by the emerging technologies of transcriptional profiling and proteomics.

Cancer of the endometrium: current aspects of diagnostics and treatment

Background

Endometrial cancer represents a tumor entity with a great variation in its incidence throughout the world (range 1 to 25). This suggests enormous possibilities of cancer prevention due to the fact that the incidence is very much endocrine-related, chiefly with obesity, and thus most frequent in the developed world. As far as treatment is concerned, it is generally accepted that surgery represents the first choice of treatment. However, several recommendations seem reasonable especially with lymphadenectomy, even though they are not based on evidence. All high-risk cases are generally recommended for radiotherapy.

Methods

A literature search of the Medline was carried out for all articles on endometrial carcinoma related to diagnosis and treatment. The articles were systematically reviewed and were categorized into incidence, etiology, precancerosis, early diagnosis, classification, staging, prevention, and treatment. The article is organized into several similar subheadings.

Conclusions

In spite of the overall good prognosis during the early stages of the disease, the survival is poor in advanced stages or recurrences. Diagnostic measures are very well able to detect asymptomatic recurrences. These only seem justified if patients' chances are likely to improve, otherwise such measures increases costs as well as decrease the patients' quality of life. To date neither current nor improved concepts of endocrine treatment or chemotherapy have been able to substantially increase patients' chances of survival. Therefore, newer concepts into the use of antibodies e.g. trastuzumab in HER2-overexpressing tumors and the newer endocrine compounds will need to be investigated. Furthermore, it would seem highly desirable if future studies were to identify valid criteria for an individualized management, thereby maximizing the benefits and minimizing the risks.

[Endometrial cancer: what's new?]

OBJECTIVES

New and much debated data of the endometrial cancer concerning the preoperative assessment of myometrial invasion, the surgical staging, and the adjuvant treatment.

PATIENTS AND METHODS

Medline (1998-2002): searching for "endometrial carcinoma".

RESULTS

The pap smears are useful when it is difficult to have a transvaginal ultrasonography or an MRI. We can perform the pap smears and the endometrial biopsy in the clinic. If a patient has pap smears with malignant cells or elevated preoperative CA 125, it probably is a cancer with poor prognostic factors. Surgical staging with abdominal and node evaluation is necessary. The MRI seems to be the best preoperative imaging because we have information about adnexal and abdominal metastases, pelvic or aortic nodes and the invasion of the myometrium. So it gives us information on the surgical route, and provides indication for a lymphadenectomy. The surgical staging is a part of the treatment of the endometrial cancer: an exploration of the peritoneal cavity, a pelvic lymphadenectomy, a para-aortic lymphadenectomy if the pelvic nodes are positive or if there are factors of bad prognosis (deep stage IC, grade 3, adnexal or abdominal involvement, serous carcinoma of the endometrium). It can be performed if technical conditions are correct. The adjuvant teletherapy in the documented stage IpN0 (surgical staging with pelvic lymphadenectomy) does not seem to be necessary. But we can perform an adjuvant brachytherapy (high-dose rate if it is possible) in patients with a high local recurrence (stage IC, stage I with grade 3, stage IB grade 2).

CONCLUSION

The preoperative MRI is useful choosing the surgical approach, and the depth of the myometrial invasion, which can be an indication for a pelvic lymphadenectomy. The surgical staging must be a part of the treatment of the endometrial cancer. So the adjuvant teletherapy in patients with stage IpN0 documented should not be used.