Plasma and peritoneal fluid levels of CA 125 in women with endometriosis

Catamenial haemothorax-A rare cause of pleural effusion

Common causes of haemorrhagic pleural effusions include malignancy (primary or metastatic), tuberculosis, pulmonary embolism, collagen vascular diseases, trauma and iatrogenic causes. Clinical history along with pathologic, microbiologic and biochemical evaluation of pleural fluid confirms the diagnosis in most cases. However, if there is recurrent haemorrhagic effusion without corroborative history or mass lesion in lung, or evidence of microorganisms, then we should think of uncommon causes. Catamenial haemothorax (CHt) is a rare cause of haemorrhagic pleural effusion, which recurs during each menstrual cycle. This is a manifestation of thoracic endometriosis syndrome (TES) caused by ectopic endometrial tissue in the thoracic cavity in women of child-bearing age. This extremely rare condition is difficult to diagnose, unless direct correlation with the menstrual cycle is established. TES consists of pleural forms such as catamenial pneumothorax, non-catamenial endometriosis-related pneumothorax and haemothorax; and parenchymal forms such as catamenial haemoptysis and lung nodules. Here we report a case of CHt in a 43-year-old female whose diagnosis was established by thoracoscopic pleural biopsy.

CA 125 in Benign Gynecological Conditions

The tumor marker CA 125 was initially thought to be specific for ovarian malignancies. Subsequently it was found to be raised in a variety of benign conditions, including pregnancy, pelvic inflammatory disease, tuberculosis and cirrhosis of the liver. With respect to gynecological tumors, CA 125 may be elevated in benign ovarian cysts, tubo-ovarian abscess, endometriosis, hyperstimulation syndrome, ectopic pregnancy and fibroids. These results demonstrate that CA 125 is a marker of non-specific peritoneal conditions.

Blood biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive or minimally invasive tests available in clinical practice to accurately diagnose endometriosis. Although other reviews have assessed the ability of blood tests to diagnose endometriosis, this is the first review to use Cochrane methods, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To evaluate blood biomarkers as replacement tests for diagnostic surgery and as triage tests to inform decisions on surgery for endometriosis. Specific objectives include:1. To provide summary estimates of the diagnostic accuracy of blood biomarkers for the diagnosis of peritoneal, ovarian and deep infiltrating pelvic endometriosis, compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as these databases to 20 April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more blood biomarkers with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two authors independently collected and performed a quality assessment of data from each study. For each diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis, and we calculated sensitivity and specificity estimates. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient datasets were available. The predetermined criteria for a clinically useful blood test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of ≥ 0.95 and a specificity of ≥ 0.50, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of ≥ 0.50 and a specificity of ≥ 0.95, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

We included 141 studies that involved 15,141 participants and evaluated 122 blood biomarkers. All the studies were of poor methodological quality. Studies evaluated the blood biomarkers either in a specific phase of the menstrual cycle or irrespective of the cycle phase, and they tested for them in serum, plasma or whole blood. Included women were a selected population with a high frequency of endometriosis (10% to 85%), in which surgery was indicated for endometriosis, infertility work-up or ovarian mass. Seventy studies evaluated the diagnostic performance of 47 blood biomarkers for endometriosis (44 single-marker tests and 30 combined tests of two to six blood biomarkers). These were angiogenesis/growth factors, apoptosis markers, cell adhesion molecules, high-throughput markers, hormonal markers, immune system/inflammatory markers, oxidative stress markers, microRNAs, tumour markers and other proteins. Most of these biomarkers were assessed in small individual studies, often using different cut-off thresholds, and we could only perform meta-analyses on the data sets for anti-endometrial antibodies, interleukin-6 (IL-6), cancer antigen-19.9 (CA-19.9) and CA-125. Diagnostic estimates varied significantly between studies for each of these biomarkers, and CA-125 was the only marker with sufficient data to reliably assess sources of heterogeneity.The mean sensitivities and specificities of anti-endometrial antibodies (4 studies, 759 women) were 0.81 (95% confidence interval (CI) 0.76 to 0.87) and 0.75 (95% CI 0.46 to 1.00). For IL-6, with a cut-off value of > 1.90 to 2.00 pg/ml (3 studies, 309 women), sensitivity was 0.63 (95% CI 0.52 to 0.75) and specificity was 0.69 (95% CI 0.57 to 0.82). For CA-19.9, with a cut-off value of > 37.0 IU/ml (3 studies, 330 women), sensitivity was 0.36 (95% CI 0.26 to 0.45) and specificity was 0.87 (95% CI 0.75 to 0.99).Studies assessed CA-125 at different thresholds, demonstrating the following mean sensitivities and specificities: for cut-off > 10.0 to 14.7 U/ml: 0.70 (95% CI 0.63 to 0.77) and 0.64 (95% CI 0.47 to 0.82); for cut-off > 16.0 to 17.6 U/ml: 0.56 (95% CI 0.24, 0.88) and 0.91 (95% CI 0.75, 1.00); for cut-off > 20.0 U/ml: 0.67 (95% CI 0.50 to 0.85) and 0.69 (95% CI 0.58 to 0.80); for cut-off > 25.0 to 26.0 U/ml: 0.73 (95% CI 0.67 to 0.79) and 0.70 (95% CI 0.63 to 0.77); for cut-off > 30.0 to 33.0 U/ml: 0.62 (95% CI 0.45 to 0.79) and 0.76 (95% CI 0.53 to 1.00); and for cut-off > 35.0 to 36.0 U/ml: 0.40 (95% CI 0.32 to 0.49) and 0.91 (95% CI 0.88 to 0.94).We could not statistically evaluate other biomarkers meaningfully, including biomarkers that were assessed for their ability to differentiate endometrioma from other benign ovarian cysts.Eighty-two studies evaluated 97 biomarkers that did not differentiate women with endometriosis from disease-free controls. Of these, 22 biomarkers demonstrated conflicting results, with some studies showing differential expression and others no evidence of a difference between the endometriosis and control groups.

AUTHORS' CONCLUSIONS

Of the biomarkers that were subjected to meta-analysis, none consistently met the criteria for a replacement or triage diagnostic test. A subset of blood biomarkers could prove useful either for detecting pelvic endometriosis or for differentiating ovarian endometrioma from other benign ovarian masses, but there was insufficient evidence to draw meaningful conclusions. Overall, none of the biomarkers displayed enough accuracy to be used clinically outside a research setting. We also identified blood biomarkers that demonstrated no diagnostic value in endometriosis and recommend focusing research resources on evaluating other more clinically useful biomarkers.

Altered sensitivity to anti-endometriosis medicines in an adenomyosis patient with thyroid dysfunction

We report the rare case of a patient with adenomyosis who showed thyroid dysfunction of unknown etiology during treatment for endometriosis. She responded to nafarelin acetate and danazol when she was euthyroid but not to buserelin acetate when she was hyperthyroid. This suggests that the response to anti-endometriotic medicine in our patient was altered by impaired thyroid function and that this could occur in other such patients.

Immunohistochemical and molecular studies on malignant transformation in mature cystic teratoma of the ovary

OBJECTIVES

To determine a useful tumor marker for detecting squamous cell carcinoma arising in a dermoid cyst, and to find the molecular pathogenesis of this condition.

METHODS

In 4 cases of squamous cell carcinoma arising in a dermoid cyst and 22 cases of dermoid cyst, we studied tissue expressions and serum levels of squamous cell carcinoma antigen (SCC), CA 19-9 and CA 125, and the mutation of the p53 tumor suppressor gene.

RESULTS

Three of 4 malignant cases had either positive SCC expressions or elevated serum SCC levels. The mean serum SCC level in benign cases was below the cut-off level. CA 19-9 and CA 125 were not detected in squamous cell carcinoma. p53 overexpressions were observed in all malignancies.

CONCLUSION

These results suggested that the serum SCC might be a useful marker for detecting squamous cell carcinoma arising in a dermoid cyst, and that the mutation of p53 might be one of the genetic events in the malignant transformation of a dermoid cyst.

Plasma insulin-like growth factor-I, CA-125, estrogen, and progesterone in women with leiomyomas

OBJECTIVE

To determine plasma levels of insulin-like growth factor-I (IGF-I), CA-125, estrone (E1), E2, and P in women with uterine leiomyomas compared with normal women.

DESIGN

Women with leiomyomas were compared with normal women (control).

SETTING

University Department of Obstetrics and Gynecology.

PATIENTS

Fifty-one premenopausal women with uterine myomas > 14 weeks gestation and 30 normal fertile women (controls) were studied. Peripheral blood samples were obtained before myomectomy or hysterectomy and during the nonmenstruating phase in the controls.

MAIN OUTCOME MEASURES

Plasma levels of E1, E2, P, CA-125, and IGF-I were determined by specific and sensitive RIAs and immunoradiometric assays.

RESULTS

Plasma IGF-I levels were 2,006 +/- 185 mU/mL (mean +/- SEM, n = 35) and 2,335 +/- 287 mU/mL (n = 16) in women with leiomyomas during the follicular and luteal phases, respectively, whereas the corresponding values for normal women were 1,702 +/- 120 (n = 30) and 1,774 +/- 239 mU/mL (n = 30). Similarly, plasma CA-125 levels were unchanged in women with leiomyomas (myomas: 18.8 +/- 2.4, 21.5 +/- 3.7 U/mL; normal: 15.9 +/- 1.5, 15.8 +/- 1.3 U/mL during follicular and luteal phases, respectively). Women with leiomyomas had plasma E1, E2, and P levels during the follicular phase (91.9 +/- 11.5 pg/mL; conversion factor to SI unit, 3.699; 94.6 +/- 19.0 pg/mL; conversion factor to SI unit, 3.671; and 1.5 +/- 0.4 ng/mL; conversion factor to SI unit, 3.180, respectively) and the luteal phase (105.8 +/- 11.2 pg/mL; conversion factor to SI unit, 3.699; 128.7 +/- 24.8 pg/mL; conversion factor to SI unit, 3.671; and 9.6 +/- 1.6 ng/mL; conversion factor to SI unit, 3.180) similar to normal women.

CONCLUSION

Plasma levels of IGF-I, CA-125, E1, E2, and P are normal in women with leiomyomas.

Markers for endometriosis

Screening for endometriosis is subject to general rules. The two most important conditions, i.e. the disorder should be well-defined and serious, and there must be an effective way to treat or prevent it through screening, are not satisfied for endometriosis. Given the lack of understanding of the pathogenesis of this disease and the disreputable evidence of treatment effectiveness, other criteria for worthwhile screening programmes, such as prevalence, cost effectiveness and screening test performance, cannot be evaluated. Markers may be applied in the diagnostic process in the individual patient, although it should be realized that the best results will be obtained in patients with advanced disease, in whom routine pelvic examination will establish the diagnosis on purely clinical grounds anyway. The development of appropriate tissue markers may in the future shed more light on the intricate mechanisms involved in the pathogenesis of endometriosis.

High CA-125 concentrations in peritoneal fluid of normal cyclic women with various infertility-related factors as demonstrated with two-step immunoradiometric assay

OBJECTIVE

To determine CA-125 concentrations and total amounts in peritoneal fluid (PF) of women with various infertility-related factors throughout the menstrual cycle.

DESIGN

Peritoneal fluid was obtained at laparoscopy. CA-125 was determined using the assessed two-step immunoradiometric assay (IRMA) which, in contrast to the one-step IRMA, gives valid results.

SETTING

University Hospital Nijmegen, Nijmegen, The Netherlands.

PATIENTS

One hundred six infertile women with a regular and ovulatory cycle were included.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The mean PF CA-125 concentration and total amount were significantly lower during the luteal phase as compared with other phases of the menstrual cycle. No correlation was found with the presence or absence of endometriosis, adhesions, a male and/or cervical mucus infertility factor, and with patent or closed fallopian tubes.

RESULTS

Peritoneal fluid CA-125 concentrations varied from 630 to 12,000 arbitrary units/mL (mean +/- SD = 3,437 +/- 2,286). Total PF CA-125 amounts (concentration x PF volume) varied from 1,760 to 13,300 arbitrary units (mean +/- SD = 30,219 +/- 26,841).

CONCLUSIONS

CA-125 secretion into the abdominal cavity varies during the menstrual cycle. Retrograde menstruation is not the main source of CA-125 in PF.

Does intraperitoneal CA-125 reflect disease status?

The relationship of serum CA-125 to intraperitoneal (IP) CA-125 was studied in 45 patients with a variety of gynecologic diseases including ovarian carcinoma. In 43 of 45 patients the IP level exceeded the serum level of CA-125. Paracentesis may dramatically alter both levels, thus mimicking surgical debulking. All IP levels of CA-125 measured at second-look coeliotomy for the ovarian cancer patients were within the normal range of IP CA-125 measured at surgery for benign disease. Therefore, intraperitoneal CA-125 is less sensitive than serum CA-125 in predicting intraperitoneal disease status. Likewise it cannot be used to predict the subgroup of ovarian cancer patients with negative second-look coeliotomy who are destined to develop a recurrence of disease.

Correlation between peripheral CA-125 levels and ovarian activity

Serum CA-125 concentrations were measured at three different times in normal cycles, pill-suppressed cycles, and cycles stimulated for intrauterine insemination (IUI) or oocyte retrieval, i.e., (1) during the first half of the cycle, (2) at midcycle or at the moment of oocyte retrieval, and (3) the second half of the cycle. Significant variations of serum CA-125 concentrations were not seen during the cycle in normally cycling women or in women taking oral contraceptives: mean +/- SD 28.9 +/- 13.3 U/mL and 26.9 +/- 11.3 U/mL, respectively. In patients stimulated for in vitro fertilization, luteal phase CA-125 levels (60.6 +/- 38 U/mL) were significantly higher than during stimulation (21.5 +/- 5.9 U/mL) or at oocyte retrieval (19.6 +/- 6.4 U/mL). In stimulated cycles for IUI, without laparoscopy or follicular puncture, a comparable rise of CA-125 was observed in the luteal phase (49.6 +/- 37.8 U/mL). However, in patients undergoing laparoscopic sterilization, serum CA-125 concentrations before and after laparoscopy were not significantly different (22.8 +/- 6.3 U/mL and 25 +/- 4.2 U/mL, respectively).

CA 125 in peritoneal fluid and serum from patients with benign gynecologic conditions and ovarian cancer

CA 125 was measured in peritoneal fluid from 200 patients with primary ovarian malignancies (35) and benign gynecologic conditions (165). In 86 patients CA 125 was measured both in peritoneal fluid and in serum. Patients with ovarian cancer had markedly greater serum CA 125 levels compared to patients with benign disease. CA 125 levels in peritoneal fluid were usually higher than serum levels. Twenty-six (93%) of 28 patients with ovarian cancer had peritoneal fluid levels which exceeded serum levels in paired samples. peritoneal fluid CA 125 values greater than 200 U/ml identified ovarian cancer patients with 96% sensitivity and 99% specificity. Serum CA 125 values greater than 35 U/ml identified ovarian cancer patients bearing ascites with a sensitivity of 99% and specificity of 94%. Only 2 of 165 patients with benign gynecological conditions had peritoneal fluid values above 200 U/ml. By contrast, only two values below 200 U/ml were found in ascitic fluids from 35 patients with ovarian cancer. CA 125 levels in peritoneal fluid deserve further evaluation for follow-up of patients with ovarian cancer.

Serum CA-125 levels in women with endometriosis

Forty-two women with laparoscopically-confirmed pelvic endometriosis (assessed according to the American Fertility Society modified classification) had serum levels of the cell-surface antigen CA-125 measured before, during and after medical therapy with nafarelin acetate or danazol combined with follow-up laparoscopic surgery or laparotomy. Serum levels before treatment (39.3 [SE 6.6] U/ml) were elevated above accepted normal levels in many subjects, and these were highly significantly suppressed during medical therapy with both nafarlin and danazol (13.1 [SE 1.5] U/ml at 5 months); t = 3.198; p = 0.002). Levels tended to rise following therapy but a clear correlation between a rise in serum CA-125 and recurrence of disease was not demonstrated. In 3 individuals treated with nafarelin a dramatic rise in serum CA-125 levels was seen after 2 weeks of therapy. This did not correlate with any exacerbation of symptoms or with any rise in serum oestradiol or with pretreatment AFS scoring. Serum CA-125 levels provide a potential approach to the monitoring of treatment and recurrence in a substantial proportion of women with endometriosis, although preliminary evidence suggests that there will be individual exceptions to any broad correlations.