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Sah S, Bifarin OO, Moore SG, Gaul DA, Chung H, Kwon SY, Cho H, Cho CH, Kim JH, Kim J, Fernández FM. Serum Lipidome Profiling Reveals a Distinct Signature of Ovarian Cancer in Korean Women. Cancer Epidemiol Biomarkers Prev 2024; 33:681-693. [PMID: 38412029 PMCID: PMC11061607 DOI: 10.1158/1055-9965.epi-23-1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/11/2024] [Accepted: 02/23/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Distinguishing ovarian cancer from other gynecological malignancies is crucial for patient survival yet hindered by non-specific symptoms and limited understanding of ovarian cancer pathogenesis. Accumulating evidence suggests a link between ovarian cancer and deregulated lipid metabolism. Most studies have small sample sizes, especially for early-stage cases, and lack racial/ethnic diversity, necessitating more inclusive research for improved ovarian cancer diagnosis and prevention. METHODS Here, we profiled the serum lipidome of 208 ovarian cancer, including 93 early-stage patients with ovarian cancer and 117 nonovarian cancer (other gynecological malignancies) patients of Korean descent. Serum samples were analyzed with a high-coverage liquid chromatography high-resolution mass spectrometry platform, and lipidome alterations were investigated via statistical and machine learning (ML) approaches. RESULTS We found that lipidome alterations unique to ovarian cancer were present in Korean women as early as when the cancer is localized, and those changes increase in magnitude as the diseases progresses. Analysis of relative lipid abundances revealed specific patterns for various lipid classes, with most classes showing decreased abundance in ovarian cancer in comparison with other gynecological diseases. ML methods selected a panel of 17 lipids that discriminated ovarian cancer from nonovarian cancer cases with an AUC value of 0.85 for an independent test set. CONCLUSIONS This study provides a systemic analysis of lipidome alterations in human ovarian cancer, specifically in Korean women. IMPACT Here, we show the potential of circulating lipids in distinguishing ovarian cancer from nonovarian cancer conditions.
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Affiliation(s)
- Samyukta Sah
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia
- Petit Institute of Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
| | - Olatomiwa O. Bifarin
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia
| | - Samuel G. Moore
- Petit Institute of Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
| | - David A. Gaul
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia
- Petit Institute of Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
| | - Hyewon Chung
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, Daegu Republic of Korea
| | - Sun Young Kwon
- Department of Pathology, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Hanbyoul Cho
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chi-Heum Cho
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, Daegu Republic of Korea
| | - Jae-Hoon Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeyeon Kim
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, Indiana
| | - Facundo M. Fernández
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia
- Petit Institute of Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
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Wilczyński J, Paradowska E, Wilczyński M. High-Grade Serous Ovarian Cancer-A Risk Factor Puzzle and Screening Fugitive. Biomedicines 2024; 12:229. [PMID: 38275400 PMCID: PMC10813374 DOI: 10.3390/biomedicines12010229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
High-grade serous ovarian cancer (HGSOC) is the most lethal tumor of the female genital tract. Despite extensive studies and the identification of some precursor lesions like serous tubal intraepithelial cancer (STIC) or the deviated mutational status of the patients (BRCA germinal mutation), the pathophysiology of HGSOC and the existence of particular risk factors is still a puzzle. Moreover, a lack of screening programs results in delayed diagnosis, which is accompanied by a secondary chemo-resistance of the tumor and usually results in a high recurrence rate after the primary therapy. Therefore, there is an urgent need to identify the substantial risk factors for both predisposed and low-risk populations of women, as well as to create an economically and clinically justified screening program. This paper reviews the classic and novel risk factors for HGSOC and methods of diagnosis and prediction, including serum biomarkers, the liquid biopsy of circulating tumor cells or circulating tumor DNA, epigenetic markers, exosomes, and genomic and proteomic biomarkers. The novel future complex approach to ovarian cancer diagnosis should be devised based on these findings, and the general outcome of such an approach is proposed and discussed in the paper.
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Affiliation(s)
- Jacek Wilczyński
- Department of Gynecological Surgery and Gynecological Oncology, Medical University of Lodz, 4 Kosciuszki Str., 90-419 Lodz, Poland
| | - Edyta Paradowska
- Laboratory of Virology, Institute of Medical Biology of the Polish Academy of Sciences, 106 Lodowa Str., 93-232 Lodz, Poland;
| | - Miłosz Wilczyński
- Department of Surgical, Endoscopic and Gynecological Oncology, Polish Mother’s Health Center—Research Institute, 281/289 Rzgowska Str., 93-338 Lodz, Poland;
- Department of Surgical and Endoscopic Gynecology, Medical University of Lodz, 4 Kosciuszki Str., 90-419 Lodz, Poland
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Performance of IOTA Simple Rules Risks, ADNEX Model, Subjective Assessment Compared to CA125 and HE4 with ROMA Algorithm in Discriminating between Benign, Borderline and Stage I Malignant Adnexal Lesions. Diagnostics (Basel) 2023; 13:diagnostics13050885. [PMID: 36900029 PMCID: PMC10000903 DOI: 10.3390/diagnostics13050885] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Borderline ovarian tumors (BOTs) and early clinical stage malignant adnexal masses can make sonographic diagnosis challenging, while the clinical utility of tumor markers, e.g., CA125 and HE4, or the ROMA algorithm, remains controversial in such cases. OBJECTIVE To compare the IOTA group Simple Rules Risk (SRR), the ADNEX model and the subjective assessment (SA) with serum CA125, HE4 and the ROMA algorithm in the preoperative discrimination between benign tumors, BOTs and stage I malignant ovarian lesions (MOLs). METHODS A multicenter retrospective study was conducted with lesions classified prospectively using subjective assessment and tumor markers with the ROMA. The SRR assessment and ADNEX risk estimation were applied retrospectively. The sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) were calculated for all tests. RESULTS In total, 108 patients (the median age: 48 yrs, 44 postmenopausal) with 62 (79.6%) benign masses, 26 (24.1%) BOTs and 20 (18.5%) stage I MOLs were included. When comparing benign masses with combined BOTs and stage I MOLs, SA correctly identified 76% of benign masses, 69% of BOTs and 80% of stage I MOLs. Significant differences were found for the presence and size of the largest solid component (p = 0.0006), the number of papillary projections (p = 0.01), papillation contour (p = 0.008) and IOTA color score (p = 0.0009). The SRR and ADNEX models were characterized by the highest sensitivity (80% and 70%, respectively), whereas the highest specificity was found for SA (94%). The corresponding likelihood ratios were as follows: LR+ = 3.59 and LR- = 0.43 for the ADNEX; LR+ = 6.40 and LR- = 0.63 for SA and LR+ = 1.85 with LR- = 0.35 for the SRR. The sensitivity and specificity of the ROMA test were 50% and 85%, respectively, with LR+ = 3.44 and LR- = 0.58. Of all the tests, the ADNEX model had the highest diagnostic accuracy of 76%. CONCLUSIONS This study demonstrates the limited value of diagnostics based on CA125 and HE4 serum tumor markers and the ROMA algorithm as independent modalities for the detection of BOTs and early stage adnexal malignant tumors in women. SA and IOTA methods based on ultrasound examination may present superior value over tumor marker assessment.
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Zhang R, Siu MKY, Ngan HYS, Chan KKL. Molecular Biomarkers for the Early Detection of Ovarian Cancer. Int J Mol Sci 2022; 23:ijms231912041. [PMID: 36233339 PMCID: PMC9569881 DOI: 10.3390/ijms231912041] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Abstract
Ovarian cancer is the deadliest gynecological cancer, leading to over 152,000 deaths each year. A late diagnosis is the primary factor causing a poor prognosis of ovarian cancer and often occurs due to a lack of specific symptoms and effective biomarkers for an early detection. Currently, cancer antigen 125 (CA125) is the most widely used biomarker for ovarian cancer detection, but this approach is limited by a low specificity. In recent years, multimarker panels have been developed by combining molecular biomarkers such as human epididymis secretory protein 4 (HE4), ultrasound results, or menopausal status to improve the diagnostic efficacy. The risk of ovarian malignancy algorithm (ROMA), the risk of malignancy index (RMI), and OVA1 assays have also been clinically used with improved sensitivity and specificity. Ongoing investigations into novel biomarkers such as autoantibodies, ctDNAs, miRNAs, and DNA methylation signatures continue to aim to provide earlier detection methods for ovarian cancer. This paper reviews recent advancements in molecular biomarkers for the early detection of ovarian cancer.
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Davenport C, Rai N, Sharma P, Deeks JJ, Berhane S, Mallett S, Saha P, Champaneria R, Bayliss SE, Snell KI, Sundar S. Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women. Cochrane Database Syst Rev 2022; 7:CD011964. [PMID: 35879201 PMCID: PMC9314189 DOI: 10.1002/14651858.cd011964.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ovarian cancer (OC) has the highest case fatality rate of all gynaecological cancers. Diagnostic delays are caused by non-specific symptoms. Existing systematic reviews have not comprehensively covered tests in current practice, not estimated accuracy separately in pre- and postmenopausal women, or used inappropriate meta-analytic methods. OBJECTIVES To establish the accuracy of combinations of menopausal status, ultrasound scan (USS) and biomarkers for the diagnosis of ovarian cancer in pre- and postmenopausal women and compare the accuracy of different test combinations. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five other databases and three trial registries from 1991 to 2015 and MEDLINE (Ovid) and Embase (Ovid) form June 2015 to June 2019. We also searched conference proceedings from the European Society of Gynaecological Oncology, International Gynecologic Cancer Society, American Society of Clinical Oncology and Society of Gynecologic Oncology, ZETOC and Conference Proceedings Citation Index (Web of Knowledge). We searched reference lists of included studies and published systematic reviews. SELECTION CRITERIA We included cross-sectional diagnostic test accuracy studies evaluating single tests or comparing two or more tests, randomised trials comparing two or more tests, and studies validating multivariable models for the diagnosis of OC investigating test combinations, compared with a reference standard of histological confirmation or clinical follow-up in women with a pelvic mass (detected clinically or through USS) suspicious for OC. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed quality using QUADAS-2. We used the bivariate hierarchical model to indirectly compare tests at commonly reported thresholds in pre- and postmenopausal women separately. We indirectly compared tests across all thresholds and estimated sensitivity at fixed specificities of 80% and 90% by fitting hierarchical summary receiver operating characteristic (HSROC) models in pre- and postmenopausal women separately. MAIN RESULTS We included 59 studies (32,059 women, 9545 cases of OC). Two tests evaluated the accuracy of a combination of menopausal status and USS findings (IOTA Logistic Regression Model 2 (LR2) and the Assessment of Different NEoplasias in the adneXa model (ADNEX)); one test evaluated the accuracy of a combination of menopausal status, USS findings and serum biomarker CA125 (Risk of Malignancy Index (RMI)); and one test evaluated the accuracy of a combination of menopausal status and two serum biomarkers (CA125 and HE4) (Risk of Ovarian Malignancy Algorithm (ROMA)). Most studies were at high or unclear risk of bias in participant, reference standard, and flow and timing domains. All studies were in hospital settings. Prevalence was 16% (RMI, ROMA), 22% (LR2) and 27% (ADNEX) in premenopausal women and 38% (RMI), 45% (ROMA), 52% (LR2) and 55% (ADNEX) in postmenopausal women. The prevalence of OC in the studies was considerably higher than would be expected in symptomatic women presenting in community-based settings, or in women referred from the community to hospital with a suspicion of OC. Studies were at high or unclear applicability because presenting features were not reported, or USS was performed by experienced ultrasonographers for RMI, LR2 and ADNEX. The higher sensitivity and lower specificity observed in postmenopausal compared to premenopausal women across all index tests and at all thresholds may reflect highly selected patient cohorts in the included studies. In premenopausal women, ROMA at a threshold of 13.1 (± 2), LR2 at a threshold to achieve a post-test probability of OC of 10% and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 77.4%, 95% CI 72.7% to 81.5%; LR2: 83.3%, 95% CI 74.7% to 89.5%; ADNEX: 95.5%, 95% CI 91.0% to 97.8%) compared to RMI (57.2%, 95% CI 50.3% to 63.8%). The specificity of ROMA and ADNEX were lower in premenopausal women (ROMA: 84.3%, 95% CI 81.2% to 87.0%; ADNEX: 77.8%, 95% CI 67.4% to 85.5%) compared to RMI 92.5% (95% CI 90.3% to 94.2%). The specificity of LR2 was comparable to RMI (90.4%, 95% CI 84.6% to 94.1%). In postmenopausal women, ROMA at a threshold of 27.7 (± 2), LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 90.3%, 95% CI 87.5% to 92.6%; LR2: 94.8%, 95% CI 92.3% to 96.6%; ADNEX: 97.6%, 95% CI 95.6% to 98.7%) compared to RMI (78.4%, 95% CI 74.6% to 81.7%). Specificity of ROMA at a threshold of 27.7 (± 2) (81.5, 95% CI 76.5% to 85.5%) was comparable to RMI (85.4%, 95% CI 82.0% to 88.2%), whereas for LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) specificity was lower (LR2: 60.6%, 95% CI 50.5% to 69.9%; ADNEX: 55.0%, 95% CI 42.8% to 66.6%). AUTHORS' CONCLUSIONS In specialist healthcare settings in both premenopausal and postmenopausal women, RMI has poor sensitivity. In premenopausal women, ROMA, LR2 and ADNEX offer better sensitivity (fewer missed cancers), but for ROMA and ADNEX this is off-set by a decrease in specificity and increase in false positives. In postmenopausal women, ROMA demonstrates a higher sensitivity and comparable specificity to RMI. ADNEX has the highest sensitivity in postmenopausal women, but reduced specificity. The prevalence of OC in included studies is representative of a highly selected referred population, rather than a population in whom referral is being considered. The comparative accuracy of tests observed here may not be transferable to non-specialist settings. Ultimately health systems need to balance accuracy and resource implications to identify the most suitable test.
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Affiliation(s)
- Clare Davenport
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nirmala Rai
- School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Pawana Sharma
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sarah Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Sue Mallett
- UCL Centre for Medical Imaging, Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
| | - Pratyusha Saha
- Medical School, University of Birmingham, Birmingham, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Susan E Bayliss
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kym Ie Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Sudha Sundar
- School of Cancer Sciences, University of Birmingham , Birmingham, UK
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Zhu C, Zhang N, Zhong A, Xiao K, Lu R, Guo L. A combined strategy of TK1, HE4 and CA125 shows better diagnostic performance than risk of ovarian malignancy algorithm (ROMA) in ovarian carcinoma. Clin Chim Acta 2022; 524:43-50. [PMID: 34813778 DOI: 10.1016/j.cca.2021.11.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/19/2021] [Accepted: 11/17/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The dual marker algorithm Risk of Ovarian Malignancy Algorithm (ROMA) has been widely used in the clinic for the identification of equivocal pelvic masses in ovarian carcinoma. To obtain higher diagnostic efficiency, we created a new diagnostic index, Risk of Ovarian Malignancy Index (ROMI), by combing thymidine kinase 1 (TK1), HE4 and CA125. METHODS 335 patients with pelvic masses on imaging and 46 healthy controls were enrolled. Serum TK1 was analyzed before further study. ROMI and ROMA were evaluated for diagnostic efficiency. RESULTS The level of TK1 was elevated in malignant ovarian tumors compared to benign masses (p < 0.001) and healthy controls (p < 0.001). TK1 expression was positively correlated with stage, intrapelvic metastasis, lymphatic metastasis and distant metastasis (all p values < 0.001). The area under the receiver operating characteristic curve (AUC) of ROMI was higher than that of ROMA for both pre- and postmenopausal women. ROMI had better sensitivity, specificity, accuracy, and positive and negative predictive values than ROMA in diagnosis of all-stage or stage I + II ovarian carcinoma for both pre- and postmenopausal women. CONCLUSIONS TK1 is a potential biomarker in detection of ovarian carcinoma. ROMI shows better diagnostic performance than ROMA in distinguishing malignant ovarian tumors from benign masses.
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Affiliation(s)
- Cheng Zhu
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Nenghua Zhang
- Department of Clinical Laboratory, Municipal Key-Innovative Discipline of Molecular Diagnostics, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing, China
| | - Ailing Zhong
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Kangjia Xiao
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Renquan Lu
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Lin Guo
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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Zhao X, Zhao M, Gao B, Zhang A, Xu D. Modified HE4, CA125, and ROMA cut-off values and predicted probability of ovarian tumor in Chinese patients. Gland Surg 2021; 10:3097-3105. [PMID: 34926225 PMCID: PMC8637074 DOI: 10.21037/gs-21-666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/29/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Most prior studies investigating the risk of ovarian malignancy algorithm (ROMA) with cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) have involved Caucasian population or other populations. To date, there have been no unique calculations of predicted probability (PP) risk specifically for Chinese populations to help physicians in primary care settings. METHODS A group of 534 women with ovarian tumor diagnoses were enrolled and serum HE4 and CA125 were measured in each individual. Modified cut-off values were obtained by maximizing area under the curve (AUC) values and adjusted by using logistic regression with corresponding sensitivity (SN), specificity (SP), Youden index (YI), positive predictive value (PPV), and negative predictive value (NPV). RESULTS By utilizing the ideal PPV, NPV, and AUC values, in premenopausal women modified HE4, CA125, ROMA, and PP cut-off values were 73.87 pmol/L, 61.60 U/mL, 18.47%, and 0.168, respectively. The same test values for postmenopausal women were 120.90 pmol/L, 76.21 U/mL, 26.48%, and 0.485, respectively. The SN for HE4 with the modified cut-off value was significantly lower than that for CA125 (P=0.040) in premenopausal women and lower than that for ROMA (P=0.001) and PP (P=0.044) in postmenopausal women. The AUC values for CA125, ROMA, and PP were all significantly higher than that for HE4 (P=0.006, 0.007, and 0.002, respectively) in postmenopausal women. CONCLUSIONS The modified cut-off values for HE4, CA125, ROMA, and PP with ideal SN, SP, YI, NPV, PPV were useful of ruling out ovarian malignancy among both pre- and post-menopausal women. In premenopausal women modified HE4, CA125, ROMA, and PP cut-off values were 73.87 pmol/L, 61.60 U/mL, 18.47%, and 0.168, respectively and in postmenopausal women were 120.90 pmol/L, 76.21 U/mL, 26.48%, and 0.485, respectively.
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Affiliation(s)
- Xingping Zhao
- Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Meidan Zhao
- Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Bingsi Gao
- Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Aiqian Zhang
- Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Dabao Xu
- Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
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Azim SA, Mutz-Dehbalaie I, Wieser V, Berger A, Böttcher B, Fiegl H, Marth C, Widschwendter A. Influence of Pregnancy-Related Conditions on Human Epididymis Protein 4 Serum Levels in Comparison to CA 125 - a Prospective Cohort Trial. Geburtshilfe Frauenheilkd 2021; 81:1047-1054. [PMID: 34531611 PMCID: PMC8437581 DOI: 10.1055/a-1475-4296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/05/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Samira Abdel Azim
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Irene Mutz-Dehbalaie
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Wieser
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid Berger
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Böttcher
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Heidi Fiegl
- Department of Gynecology and Obstetrics, Laboratory for Clinical Biochemistry, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Marth
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Widschwendter
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
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Diagnostic measures comparison for ovarian malignancy risk in Epithelial ovarian cancer patients: a meta-analysis. Sci Rep 2021; 11:17308. [PMID: 34453074 PMCID: PMC8397730 DOI: 10.1038/s41598-021-96552-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/09/2021] [Indexed: 11/30/2022] Open
Abstract
Epithelial ovarian cancer has become the most frequent cause of deaths among gynecologic malignancies. Our study elucidates the diagnostic performance of Risk of Ovarian Malignancy Algorithm (ROMA), Human epididymis secretory protein 4 (HE4) and cancer antigen (CA125). To compare the diagnostic accuracy of ROMA, HE-4 and CA125 in the early diagnosis and screening of Epithelial Ovarian Cancer. Literature search in electronic databases such as Medicine: MEDLINE (through PUBMED interface), EMBASE, Google Scholar, Science Direct and Cochrane library from January 2011 to August 2020. Studies that evaluated the diagnostic measures of ROMA, HE4 and CA125 by using Chemilumincence immunoassay or electrochemiluminescence immunoassay (CLIA or ECLIA) as index tests. Using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).
We included 32 studies in our meta-analysis. We calculated AUC by SROC, pooled estimated like sensitivity, specificity, likelihood ratio, diagnostic odds ratio (DOR), Tau square, Cochran Q through random effect analysis and meta-regression. Data was retrieved from 32 studies. The number of studies included for HE4, CA125 and ROMA tests was 25, 26 and 22 respectively. The patients with EOC were taken as cases, and women with benign ovarian mass were taken as control, which was 2233/5682, 2315/5875 and 2281/5068 respectively for the markers or algorithm.
The pooled estimates of the markers or algorithm were sensitivity: ROMA (postmenopausal) (0.88, 95% CI 0.86–0.89) > ROMA (premenopausal) 0.80, 95% CI 0.78–0.83 > CA-125(0.84, 95% CI 0.82–0.85) > HE4 (0.73, 95% CI 0.71–0.75) specificity: HE4 (0.90, 95% CI 0.89–0.91) > ROMA (postmenopausal) (0.83, 95% CI 0.81–0.84) > ROMA (premenopausal) (0.80, 95% CI 0.79–0.82) > CA125 (0.73, 95%CI 0.72–0.74), Diagnostic odd’s ratio ROMA (postmenopausal) 44.04, 95% CI 31.27–62.03, ROMA (premenopausal)-18.93, 95% CI 13.04–27.48, CA-125-13.44, 95% CI 9.97–18.13, HE4-41.03, 95% CI 27.96–60.21 AUC(SE): ROMA (postmenopausal) 0.94(0.01), ROMA (premenopausal)-0.88(0.01), HE4 0.91(0.01), CA125-0.86(0.02) through bivariate random effects model considering the heterogeneity. Our study found ROMA as the best marker to differentiate EOC from benign ovarian masses with greater diagnostic accuracy as compared to HE4 and CA125 in postmenopausal women. In premenopausal women, HE4 is a promising predictor of Epithelial ovarian cancer; however, its utilisation requires further exploration.
Our study elucidates the diagnostic performance of ROMA, HE4 and CA125 in EOC. ROMA is a promising diagnostic marker of Epithelial ovarian cancers in postmenopausal women, while HE4 is the best diagnostic predictor of EOC in the premenopausal group. Our study had only EOC patients as cases and those with benign ovarian masses as controls. Further, we considered the studies estimated using the markers by the same index test: CLIA or ECLIA. The good number of studies with strict inclusion criteria reduced bias because of the pooling of studies with different analytical methods, especially for HE4. We did not consider the studies published in foreign languages. Since a few studies were available for HE4 and CA125 in the premenopausal and postmenopausal group separately, data were inadequate for sub-group analysis. Further, we did not assess these markers' diagnostic efficiency stratified by the stage and type of tumour due to insufficient studies.
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10
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Fujii Y, Wakimoto Y, Omote M, Sugiyama Y, Ukita Y, Kato T, Fukui A, Shibahara H. The chronological change in transvaginal ultrasound images of a hemorrhagic ovarian cyst observed during infertility treatment: A case report and literature review. Clin Case Rep 2021; 9:e04199. [PMID: 34267896 PMCID: PMC8271245 DOI: 10.1002/ccr3.4199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 03/02/2021] [Accepted: 04/02/2021] [Indexed: 11/06/2022] Open
Abstract
Insights gained from chronological ultrasonogram images in the current case report will provide useful information for diagnosing and conservatively treating HOC. This could help avoid unnecessary laparotomy.
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Affiliation(s)
- Yu Fujii
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Yu Wakimoto
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Maya Omote
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Yukiko Sugiyama
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Yuji Ukita
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Toru Kato
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Atushi Fukui
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
| | - Hiroaki Shibahara
- Department of Obstetrics and GynecologyHyogo College of Medicine1‐1 Mukogawa‐choNishinomiyaHyogo663‐8501Japan
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11
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Dai HY, Hu F, Ding Y. Diagnostic value of serum human epididymis protein 4 and cancer antigen 125 in the patients with ovarian carcinoma: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e25981. [PMID: 34032711 PMCID: PMC8154486 DOI: 10.1097/md.0000000000025981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ovarian carcinoma (OC) is considered among the most prevalent triggers of cancer-related deaths in women. Many studies have demonstrated that human epididymis protein 4 (HE-4) as well as cancer antigen 125 (CA-125) are over-expressed in various malignant tumors, such as lung, liver, endometrial, gastric, breast, as well as ovarian cancers. Nonetheless, the overall diagnostic value of serum HE-4, in addition to CA-125 n patients experiencing OC, is still largely undetermined. Therefore, the current study intends to investigate the general diagnostic significance of HE-4 along with CA-125 in patients with OC. METHODS We aim to systematically search retrospective or prospective study for potential eligible studies from electronic databases, such as MEDLINE, EMBASE, Cochrane Library, Web of Science, as well as Chinese National Knowledge Infrastructure. We will relevant articles evaluating the general diagnostic significance of HE-4 and CA-125 in patients with OC from these databases. We will define our search in English and Chinese. Likewise, we will use 2 independent authors to extract the required data, using the Quality Assessment of Diagnostic Accuracy Studies-2 tool to evaluate he procedural quality of all included literature. We will use the appropriate statistical method to complete data analyses. RESULTS The present study aims to investigate the general diagnostic significance of HE-4 and CA-125 in patients suffering from OC. CONCLUSION The present study will systematically summarise current evidence of HE-4 in combination with CA-125 in relation to diagnosing OC. ETHICS AND DISSEMINATION Ethical approval will not be required. PROTOCOL REGISTRATION NUMBER DOI 10.17605/OSF.IO/YQPC7 (https://osf.io/yqpc7/).
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Affiliation(s)
- Hai-Ying Dai
- Department of Clinical Laboratory, Huangshi Central Hospital (Affiliated Hospital of Hubei Polytechnic University), Edong Healthcare Group, Huangshi
| | - Fang Hu
- Department of Clinical Laboratory, Huangshi Central Hospital (Affiliated Hospital of Hubei Polytechnic University), Edong Healthcare Group, Huangshi
| | - Yuan Ding
- Department of Clinical Laboratory, Hanchuan People's Hospital, Hanchuan, Hubei Province, China
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12
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CA125 and Ovarian Cancer: A Comprehensive Review. Cancers (Basel) 2020; 12:cancers12123730. [PMID: 33322519 PMCID: PMC7763876 DOI: 10.3390/cancers12123730] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022] Open
Abstract
Simple Summary CA125 has been the most promising biomarker for screening ovarian cancer; however, it still does not have an acceptable accuracy in population-based screening for ovarian cancer. In this review article, we have discussed the role of CA125 in diagnosis, evaluating response to treatment and prognosis of ovarian cancer and provided some suggestions in improving the clinical utility of this biomarker in the early diagnosis of aggressive ovarian cancers. These include using CA125 to screen individuals with symptoms who seek medical care rather than screening the general population, increasing the cutoff point for the CA125 level in the plasma and performing the test at point-of-care rather than laboratory testing. By these strategies, we would detect more aggressive ovarian cancer patients in stages that the tumour can be completely removed by surgery, which is the most important factor in redusing recurrence rate and improving the survival of the patients with ovarian cancer. Abstract Ovarian cancer is the second most lethal gynecological malignancy. The tumour biomarker CA125 has been used as the primary ovarian cancer marker for the past four decades. The focus on diagnosing ovarian cancer in stages I and II using CA125 as a diagnostic biomarker has not improved patients’ survival. Therefore, screening average-risk asymptomatic women with CA125 is not recommended by any professional society. The dualistic model of ovarian cancer carcinogenesis suggests that type II tumours are responsible for the majority of ovarian cancer mortality. However, type II tumours are rarely diagnosed in stages I and II. The recent shift of focus to the diagnosis of low volume type II ovarian cancer in its early stages of evolution provides a new and valuable target for screening. Type II ovarian cancers are usually diagnosed in advanced stages and have significantly higher CA125 levels than type I tumours. The detection of low volume type II carcinomas in stage IIIa/b is associated with a higher likelihood for optimal cytoreduction, the most robust prognostic indicator for ovarian cancer patients. The diagnosis of type II ovarian cancer in the early substages of stage III with CA125 may be possible using a higher cutoff point rather than the traditionally used 35 U/mL through the use of point-of-care CA125 assays in primary care facilities. Rapid point-of-care testing also has the potential for effective longitudinal screening and quick monitoring of ovarian cancer patients during and after treatment. This review covers the role of CA125 in the diagnosis and management of ovarian cancer and explores novel and more effective screening strategies with CA125.
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13
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Li Z, Hou Y, Zhao M, Li T, Liu Y, Chang J, Ren L. Serum amyloid a, a potential biomarker both in serum and tissue, correlates with ovarian cancer progression. J Ovarian Res 2020; 13:67. [PMID: 32517794 PMCID: PMC7285470 DOI: 10.1186/s13048-020-00669-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/27/2020] [Indexed: 12/24/2022] Open
Abstract
Background Ovarian cancer is the most fatal gynecologic malignancy worldwide due to its vagueness, delay in diagnosis, recurrence, and drug resistance. Therefore, a new type of ovarian cancer treatment prediction biomarker is urgently needed to supplement existing tools. A total of 230 people participated in this study. Out of this figure, 100 participants were patients who underwent an ovarian tumor operation, another 100 participants were ovarian benign patients, and the remaining 30 participants were healthy women. Cancer (experimental) group were 100 patients who underwent ovarian tumor operation, while the control groups were 130 participants consisting of 100 ovarian benign patients and 30 healthy women. Levels of SAA, carbohydrate antigen-125 (CA-125), and human epididymis protein 4 (HE4) were assessed using standard laboratory protocols. A total of 5 ovarian cancer tissues and paracancerous tissues were collected and then stored at − 80 °C until the qRT-PCR assay was conducted. Results The ROC curve of SAA concentration in ovarian cancer was plotted to obtain the area under the curve AUC = 0.889, the cut-off value 17.05 mg/L, the sensitivity 78.4% and specificity 86.5%. Compared with pretreatment, the level of serum SAA decreased significantly after treatment. The results revealed that there was a significant correlation between the level of serum SAA and advanced FIGO stage, histology subtype, lymphatic invasion, and distant metastasis (p = 0.003,0.002,0.000 and 0.001). The quantitative Reverse transcription polymerase chain reaction (qRT-PCR) assay revealed that the Messenger RNA (mRNA) of SAA-1 and SAA-4 was much higher in cancer tissues than in adjacent tissues, and MMPs was up-regulation including MMP-1, MMP-9 and MMP- 12 in OVCAR-3 cell stimulated by SAA. The transwell assay revealed that SAA could promote OVCAR-3 cell migration. Moreover, SAA can regulate EMT markers and promote AKT pathway activation. Conclusions In summary, our results demonstrated that SAA may be a potential diagnosis and treatment prediction biomarker. The SAA promotes OVCAR-3 cell migration by regulating MMPs and EMT which may correlate with AKT pathway activation.
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Affiliation(s)
- Ze Li
- Department of Laboratory, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Human Genetic Resources Sharing Service Platform, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Yongwang Hou
- Department of Laboratory, the First Affiliated Hospital of Hebei North University, Hebei, China
| | - Meng Zhao
- Department of Laboratory, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Human Genetic Resources Sharing Service Platform, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Tianning Li
- School of Medical Laboratory, Tianjin Medical University, Tianjin, China
| | - Yahui Liu
- Department of Laboratory, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Human Genetic Resources Sharing Service Platform, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jiao Chang
- Department of Laboratory, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Human Genetic Resources Sharing Service Platform, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Li Ren
- Department of Laboratory, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Human Genetic Resources Sharing Service Platform, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
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14
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Diagnostic Value of Risk of Malignancy Algorithm (ROMA) in Adnexal Masses. J Obstet Gynaecol India 2020; 70:214-219. [PMID: 32476768 DOI: 10.1007/s13224-019-01295-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 11/01/2018] [Indexed: 10/25/2022] Open
Abstract
Background Differentiating malignancy from benign diseases is the key to successful management of adnexal masses. Risk of malignancy algorithm (ROMA) has been used for this purpose. We have prospectively studied the diagnostic value of ROMA in patients presented with adnexal masses. Methods We prospective calculated ROMA values prior to surgery for adnexal masses. The risk calculated was then correlated with the histological findings, and results were analyzed according to menopausal status. ROMA cutoff value was determined using ROC curve, and sensitivity, specificity and predictive values were calculated. Statistics were performed on SPSS software (version 20.0). Results There were 94 patients with adnexal masses included in the study, 65 (69.1%) had epithelial ovarian cancer and 29 (30.9%) were diagnosed benign on histopathology. In both pre- and postmenopausal patients, ROMA values were significantly higher in patients with malignancy compared to those with benign disease (p < 0.05). ROMA score was of a significant diagnostic value in both premenopausal (AUC = 0.914, Z = 10.81, p < 0.001) and postmenopausal patients (AUC = 0.975, Z = 21.51, p < 0.001). In premenopausal females, ROMA > 13.3% was able to discriminate malignant from benign patients with 97.06% sensitivity and 85.00% specificity. The positive and negative predictive values were 91.7% and 94.4%. Similarly, in postmenopausal females, ROMA value of > 76% achieved 87.10% sensitivity and 100.00% specificity in discriminating malignant from benign patients with 100% positive and 69.2% negative predictive value. The overall accuracy of ROMA in pre- and postmenopausal patients was 87.0% and 85%, respectively. Conclusions ROMA is a useful and accurate test for differentiating epithelial ovarian cancer from benign ovarian masses. Further studies are needed to compare performance of ROMA with the Risk of Malignancy Index (RMI), CA 125 and HE4. Such comparative studies will be helpful to the clinician in deciding the best diagnostic tool for women with adnexal masses.
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15
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Lee YJ, Kim YM, Kang JS, Nam SH, Kim DY, Kim YT. Comparison of Risk of Ovarian Malignancy Algorithm and cancer antigen 125 to discriminate between benign ovarian tumor and early-stage ovarian cancer according to imaging tumor subtypes. Oncol Lett 2020; 20:931-938. [PMID: 32566022 DOI: 10.3892/ol.2020.11629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 04/01/2020] [Indexed: 01/23/2023] Open
Abstract
The present study aimed to compare the accuracy of the Risk of Ovarian Malignancy Algorithm (ROMA) and cancer antigen (CA)125 to discriminate between benign ovarian tumors and early-stage ovarian cancer according to imaging tumor subtypes associated with post-operative histopathological findings. A total of 1,207 patients who were assessed using the ROMA test due to suspected early-stage ovarian cancer and underwent surgery at Asan Medical Center (Seoul, Korea) between September 2014 and March 2018 were identified. A total of 981 patients who met the inclusion criteria were included in the retrospective analysis. Among the 981 subjects, 816 had benign tumors, 90 had malignant tumors and 75 had borderline tumors. Of the patients diagnosed with ovarian cancer or borderline tumor, 47.3% were judged as high-risk by the ROMA test and 58.2% had CA125 levels of >35 U/ml. The specificity and accuracy of ROMA were higher compared with those of CA125 in pre-menopausal females. However, the superiority of the ROMA test in the identification of malignant ovarian tumors compared with CA125 was only observed in patients with endometriotic-type tumors but not in any of the other tumor subtypes. In the endometriotic type of ovarian tumor, the superiority of the ROMA test compared to CA125 was confirmed in triage of ovarian tumor. However, the sensitivity and specificity of ROMA and CA125 were similar for the other tumor types. Therefore, future development of better tumor-specific biomarkers for triage of ovarian tumor is required.
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Affiliation(s)
- Young-Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Yong-Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Ji-Sik Kang
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - So-Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
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16
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Shin KH, Kim HH, Kwon BS, Suh DS, Joo JK, Kim KH. Clinical Usefulness of Cancer Antigen (CA) 125, Human Epididymis 4, and CA72-4 Levels and Risk of Ovarian Malignancy Algorithm Values for Diagnosing Ovarian Tumors in Korean Patients With and Without Endometriosis. Ann Lab Med 2020; 40:40-47. [PMID: 31432638 PMCID: PMC6713655 DOI: 10.3343/alm.2020.40.1.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/10/2019] [Accepted: 08/02/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tumor markers are useful for detection and preoperative evaluation of ovarian tumors. We evaluated the clinical usefulness of cancer antigen (CA) 125, human epididymis 4 (HE4), and CA72-4 levels and Risk of Ovarian Malignancy Algorithm (ROMA) values for differential diagnosis of malignant and borderline tumors among suspected ovarian tumors, and the effects of endometriosis on these tumor markers. METHODS In a total of 266 patients (213, 14, and 39 with benign, borderline and malignant tumors, respectively), CA125, HE4, and CA72-4 levels were measured, and ROMA values were calculated. Medians of each marker were compared among the three groups. The area under the ROC curve (AUC), sensitivity, and specificity were calculated to analyze the diagnostic performance of each marker. RESULTS All markers were significantly higher in the malignant group than in the benign group. HE4 levels and ROMA values were significantly higher in the malignant group than in the borderline group. ROMA value had the highest AUC for distinguishing the malignant and borderline groups from the benign group in premenopausal (0.773) and postmenopausal (0.927) patients. CA125 level was significantly higher in patients with endometriosis than in those without (P<0.001), whereas HE4 and CA72-4 levels were not affected by endometriosis (P=0.128 and 0.271, respectively). CONCLUSIONS ROMA value is the best marker to distinguish malignant and borderline tumors from benign tumors in pre- and postmenopausal patients. HE4 and CA72-4 levels provide information on possible CA125 elevation due to endometriosis.
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Affiliation(s)
- Kyung Hwa Shin
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Hospital and Pusan National University School of Medicine, Busan, Korea
| | - Hyung Hoi Kim
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Hospital and Pusan National University School of Medicine, Busan, Korea.
| | - Byung Su Kwon
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Soo Suh
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jong Kil Joo
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ki Hyung Kim
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Park H, Shin JE, Lee DW, Kim MJ, Lee HN. Diagnostic Accuracy of the Risk of Ovarian Malignancy Algorithm in Clinical Practice at a Single Hospital in Korea. Ann Lab Med 2019; 39:252-262. [PMID: 30623617 PMCID: PMC6340842 DOI: 10.3343/alm.2019.39.3.252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/02/2018] [Accepted: 11/07/2018] [Indexed: 01/10/2023] Open
Abstract
Background The risk of ovarian malignancy algorithm (ROMA) is used for assessing ovarian cancer risk in women with a pelvic mass. Its diagnostic accuracy is variable. We investigated whether the clinically acceptable minimal sensitivity of >80.0% could be obtained with the suggested cutoff of 7.4%/25.3% for pre/postmenopausal women and with adjusted cutoffs set to a specificity of ≥75.0% or a sensitivity of 95.0%, in a hospital with a lower ovarian cancer (OC) prevalence than previously reported. Methods ROMA scores were calculated from measurements of human epididymis protein 4 and cancer antigen 125 in blood specimens from 443 patients with a pelvic mass. The ROMA-based risk group was compared against biopsy (N=309) or clinical follow-up with imaging (N=134) results. The ROMA sensitivity and specificity for predicting epithelial OC (EOC) and borderline ovarian tumor (BOT) were calculated for the suggested and adjusted cutoff values. Results When targeting BOT and EOC, the prevalence was 7.4% and sensitivity and specificity at the suggested cutoff were 63.6% and 90.7%, respectively. Sensitivity was 81.8% at the 4.65%/13.71% cutoff set to a specificity of 75.0%. When targeting only EOC, the prevalence was 4.1% and sensitivity and specificity at the suggested cutoff were 77.8% and 89.4%, respectively. Sensitivity was 88.9% at the 4.78%/14.35% cutoff set to a specificity of 75.0%. Conclusions The sensitivity of ROMA was lower than expected when using the suggested cutoff. When using the adjusted cutoff, its sensitivity reached 80.0%.
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Affiliation(s)
- Haeil Park
- Department of Laboratory Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Eun Shin
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Woo Lee
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Jeong Kim
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae Nam Lee
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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18
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Carvalho VPD, Grassi ML, Palma CDS, Carrara HHA, Faça VM, Candido Dos Reis FJ, Poersch A. The contribution and perspectives of proteomics to uncover ovarian cancer tumor markers. Transl Res 2019; 206:71-90. [PMID: 30529050 DOI: 10.1016/j.trsl.2018.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 12/13/2022]
Abstract
Despite all the advances in understanding the mechanisms involved in ovarian cancer (OC) development, many aspects still need to be unraveled and understood. Tumor markers (TMs) are of special interest in this disease. Some aspects of clinical management of OC might be improved by the use of validated TMs, such as differentiating subtypes, defining the most appropriate treatment, monitoring the course of the disease, or predicting clinical outcome. The Food and Drug Administration (FDA) has approved a few TMs for OC: CA125 (cancer antigen 125; monitoring), HE4 (Human epididymis protein; monitoring), ROMA (Risk Of Malignancy Algorithm; HE4+CA125; prediction of malignancy) and OVA1 (Vermillion's first-generation Multivariate Index Assay [MIA]; prediction of malignancy). Proteomics can help advance the research in the field of TMs for OC. A variety of biological materials are being used in proteomic analysis, among them tumor tissues, interstitial fluids, tumor fluids, ascites, plasma, and ovarian cancer cell lines. However, the discovery and validation of new TMs for OC is still very challenging. The enormous heterogeneity of histological types of samples and the individual variability of patients (lifestyle, comorbidities, drug use, and family history) are difficult to overcome in research protocols. In this work, we sought to gather relevant information regarding TMs, OC, biological samples for proteomic analysis, as well as markers and algorithms approved by the FDA for use in clinical routine.
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Affiliation(s)
| | - Mariana Lopes Grassi
- Department of Biochemistry and Immunology, FMRP, University of São Paulo, Ribeirão Preto, SP, Brazil; Center for Cell Based Therapy, Hemotherapy Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Camila de Souza Palma
- Department of Biochemistry and Immunology, FMRP, University of São Paulo, Ribeirão Preto, SP, Brazil; Center for Cell Based Therapy, Hemotherapy Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | | | - Vitor Marcel Faça
- Department of Biochemistry and Immunology, FMRP, University of São Paulo, Ribeirão Preto, SP, Brazil; Center for Cell Based Therapy, Hemotherapy Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | | | - Aline Poersch
- Department of Biochemistry and Immunology, FMRP, University of São Paulo, Ribeirão Preto, SP, Brazil; Center for Cell Based Therapy, Hemotherapy Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil.
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19
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Bendifallah S, Body G, Daraï E, Ouldamer L. [Diagnostic and prognostic value of tumor markers, scores (clinical and biological) algorithms, in front of an ovarian mass suspected of an epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:134-154. [PMID: 30733191 DOI: 10.1016/j.gofs.2018.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the diagnostic value of serum/urinary biomarkers and the operability diagnosis strategy to make management recommendations. METHODS Bibliographical search in French and English languages by consultation of Pubmed, Cochrane and Embase databases. RESULTS For the diagnosis of a suspicious adnexal mass on imaging: Serum CA125 antigen is recommended (grade A). Serum CAE is not recommended (grade C). The low evidence in literature concerning diagnostic value of CA19.9 does not allow any recommendation concerning its use. Serum Human epididymis protein 4 (HE4) is recommended (grade A). Comparison of data concerning diagnosis value of CA125 and HE4 show similar results for the prediction of malignancy in case of a suspicious adnexal mass on imaging (NP1). Urinary HE4 is not recommended (grade A). The use of circulating tumor DNA is not recommended (grade A). Tumor associated antigen-antibodies (AAbs) is not recommended (grade B). The use of ROMA score (Risk of Ovarian Malignancy Algorithm) is recommended (grade A). The use of Copenhagen index (CPH-I), R-OPS score, OVA500 is not recommended (grade C). For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of a primary debulking surgery: It is not recommendend to use serum CA125 (grade A). The low evidence in literature concerning diagnostic value of HE4 does not allow any recommendation concerning its use in this context. No recommendation can be given concerning CA19.9 and CAE. For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of surgery after neoadjuvant chemotherapy: the low evidence in literature concerning diagnostic value of serum markers in this context does not allow any recommendation concerning their use in this context. Place of laparoscopy for the prediction of resectability in case of upfront surgery of an ovarian cancer with peritoneal carcinomatosis robust data shows that the use of laparoscopy significantly reduce futile laparotomies (LE1). Laparoscopy is recommended in this context (grade A). Fagotti score is a reproducible tool (LE1) permitting the evaluation of feasibility of an optimal upfront debulking (NP4), its use is recommended (grade C). A Fagotti score≥8 is correlated to a low probability of complete or optimal debulking surgery (LE4) (grade C). There is no sufficient evidence to recommend the use of the modified Fagotti score or any other laparoscopic score (LE4). In case of laparotomy for an ovarian cancer with peritoneal carcinomatosis, the use of Peritoneal Cancer Index (PCI) is recommended (grade C). For the prediction of overall survival, disease free survival and the prediction of postoperative complications, the clinical and statistical of actually available tools do not allow any recommendation.
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Affiliation(s)
- S Bendifallah
- Département de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris (AP-HP), 4, rue de la Chine, 75020 Paris, France; UMR_S938, université de Sorbonne, 75000 Paris, France
| | - G Body
- Département de gynécologie, centre hospitalier universitaire de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Inserm U1069, université François-Rabelais, 37044 Tours, France
| | - E Daraï
- Département de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris (AP-HP), 4, rue de la Chine, 75020 Paris, France; Inserm UMR S 938, université Pierre-et-Marie-Curie, 75000 Paris, France
| | - L Ouldamer
- Département de gynécologie, centre hospitalier universitaire de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Inserm U1069, université François-Rabelais, 37044 Tours, France.
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Plotti F, Scaletta G, Terranova C, Montera R, De Cicco Nardone C, Luvero D, Rossini G, Gatti A, Schirò T, Moncelli M, Guzzo F, Angioli R. The role of human epididymis protein 4 as a biomarker in gynecologic malignancies. ACTA ACUST UNITED AC 2019; 71:36-43. [DOI: 10.23736/s0026-4784.18.04328-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Assessment of Diagnostic Values among CA-125, RMI, HE4, and ROMA for Cancer Prediction in Women with Nonfunctional Ovarian Cysts. Obstet Gynecol Int 2018; 2018:7821574. [PMID: 30402106 PMCID: PMC6196978 DOI: 10.1155/2018/7821574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/11/2018] [Accepted: 09/20/2018] [Indexed: 12/02/2022] Open
Abstract
Objectives To evaluate the diagnostic performance among CA-125, RMI, HE4, and ROMA for cancer detection in women with nonfunctional ovarian cysts at King Chulalongkorn Memorial Hospital (KCMH). Secondary objective is to reconsider the proper cutoff value of HE4. Methods This is a prospective analytic study in women with nonfunctional ovarian cysts larger than 3 cm who scheduled for surgery at KCMH during 3rd June 2015 to 31st May 2016. Ultrasonogram and blood sample collection were completed before the operation. Patients' demographic information and pathologic results were obtained. SPSS software version 17 was used for statistical evaluation. Results A total of 281 participants were evaluated. 19.9% of them were malignant. Compared with CA-125, HE4 had lower sensitivity (53.4% vs. 87.9%) and NPV (89% vs. 93.6%) but higher specificity (97.8% vs. 46.2%) and PPV (86.1% vs. 29.8%). ROMA had slightly lower sensitivity (79.3% vs. 87.9%) and similar NPV (93.7% vs. 93.6%), but higher specificity (79.8% vs. 46.2%) and PPV (50.5% vs. 29.8%) compared with CA-125. The model that achieves the highest area under the ROC curve in differentiating benign versus malignant ovarian tumor was ROMA. Cutoff value of HE4 at 70 pMol/L (from 150 pMol/L) would give sensitivity 74.1% and specificity 86.5% that are comparable with ROMA. Conclusions HE4 and ROMA had better performance (higher specificity, PPV) compared to CA-125 and RMI. HE4 at 70 pMol/L could be the new cutoff value for Thai women with ovarian cysts, giving higher sensitivity and specificity.
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Huang J, Chen J, Huang Q. Diagnostic value of HE4 in ovarian cancer: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018; 231:35-42. [PMID: 30317143 DOI: 10.1016/j.ejogrb.2018.10.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/26/2018] [Accepted: 10/02/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze and evaluate the overall diagnostic value of Serum Human Epididymis Protein 4 (HE4) in ovarian cancer. METHODS We searched PubMed, EMBASE, Cochrane Library and Web of Science databases to collect articles in English that evaluated the diagnostic value of HE4 in patients with gynecological or pelvic masses. Two reviewers independently assessed the methodological quality of each study using the QUADAS-2 tool. A chart of literature quality was made using Revman 5.3 software. Finally, we built Summary Receiver Operating Characteristic (SROC) curves, Hierarchical Summary Receiver Operating Characteristic (HSROC) models, a Deek's funnel figure as well as a meta-analysis of included studies using STATA12.0 and Meta-Disc1.4 software. RESULTS Eighteen studies from the published literature met all inclusion criteria for this analysis. Remarkably, no publication bias was found among the included studies. HE4 had a pooled sensitivity of 81% (95% confidence interval (CI): 77-85) and a pooled specificity of 91% (95% CI: 86-93,). Overall, the positive likelihood ratio (PLR) was 8.2, (95% CI: 5.60-12.00,) the negative likelihood ratio (NLR) was 0.21 (95% CI: 0.17-0.26), the diagnostic odds ratio (DOR) was 39 (95% CI: 25-62), the AUC of SROC was 0.91, and Cochrane-Q value was 86.02. CONCLUSIONS HE4 is a valuable marker in the clinical diagnosis of ovarian cancer with both high AUC and Cochrane-Q. More studies are needed to determine if HE4 in the range of 100 mmol/L ≤ cutoff≤150 mmol/L than 60 mmol/L<cutoff<100 mmol/L holds more diagnostic value.
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Affiliation(s)
- Jinbing Huang
- Department of Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, 530022, China
| | - Junying Chen
- Department of Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, 530022, China.
| | - Qiaoqiao Huang
- Department of Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, 530022, China
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Špacir Prskalo Z, Bulić P, Langer S, Gaće M, Puljiz M, Danolić D, Alvir I, Mamić I, Šušnjar L, Mayer L. Proofs for implementation of higher HE4 and ROMA index cut-off values in ovarian cancer preoperative stratification. J OBSTET GYNAECOL 2018; 39:195-201. [PMID: 30207507 DOI: 10.1080/01443615.2018.1476471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This study aimed to identify and quantify the clinical significance of the HE4 and ROMA index in patients with an adnexal tumour. We recruited 159 women and the HE4 and CA125 were measured with an electrochemiluminescence immunoassay in the sera. We used the Kolmogorov-Smirnov test, Mann-Whitney's test and logistic regression to interpret the data. In the premenopausal group (n = 57), the ROC analysis (with cut-off: 86.1 pmol/L for HE4; 40.7 U/L for CA125 and 21.9% for ROMA) demonstrated the superior prognostic potential of those markers when the higher cut-offs used are compared to producers. The AUC for HE4/CA125/ROMA were 0.846/0.867/0.846, respectively. The HE4/ROMA showed 85.7% sensitivity and 94% specificity. In the postmenopausal group (n = 102), the ROC analysis cut-off values were: 99.8 pmol/L for HE4; 45.8 U/L for CA125 and 38.4% for ROMA. AUC for HE4/CA125/ROMA were 0.928/0.899/0.927, respectively. HE4 had an 86.1% sensitivity at 92.4% specificity, while ROMA showed an 88.9% sensitivity at a 90.9% specificity. Impact Statement What is already known on this subject? The incidence of ovarian cancer has been increasing, despite the improvement of diagnostic, operative and therapeutic procedures. As a part of the multiparametric approach, the HE4 and ROMA index improve the diagnostic sensitivity and specificity of CA125 in the detection of ovarian cancer. What the results of this study add? The evaluation of HE4 and ROMA efficacy in the preoperative stratification was made by logistic regression analysis. The better prognostic potential of ROMA index, in patients with present adnexal mass, was obtained using our higher cut-offs for the ROMA index (21.9% for premenopausal and 38.4% for postmenopausal) in comparison to the producer's (11.7% for premenopausal and 29.9% for postmenopausal). The HE4 and ROMA index had 14.29 +LR, 0.15 -LR, 67% PPV and 97.9% NPV in the premenopausal patients. In the postmenopausal group, the HE4 had 11.37 +LR, 0.15 -LR, 75.6% PPV and 92.4% NPV, the ROMA showed 9.78 +LR, 0.12 -LR, 91.2% PPV and 95.2% NPV. What the implications are of these findings for clinical practice and/or further research? Application of a higher cut-off for HE4/CA125/ROMA index can significantly reduce the percentage of FP and FN in the preoperative stratification of ovarian cancer and justify speculations about this subject in the future.
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Affiliation(s)
- Zvjezdana Špacir Prskalo
- a Department of Medical Biochemistry in Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Petra Bulić
- a Department of Medical Biochemistry in Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Sanja Langer
- a Department of Medical Biochemistry in Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Mihaela Gaće
- a Department of Medical Biochemistry in Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Mario Puljiz
- b Department of Gynecologic Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Damir Danolić
- b Department of Gynecologic Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Ilija Alvir
- b Department of Gynecologic Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Ivica Mamić
- b Department of Gynecologic Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Lucija Šušnjar
- b Department of Gynecologic Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
| | - Ljiljana Mayer
- a Department of Medical Biochemistry in Oncology , University Hospital for Tumors, Sestre milosrdnice University Hospital Center , Zagreb , Croatia
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Westwood M, Ramaekers B, Lang S, Grimm S, Deshpande S, de Kock S, Armstrong N, Joore M, Kleijnen J. Risk scores to guide referral decisions for people with suspected ovarian cancer in secondary care: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-264. [PMID: 30165935 PMCID: PMC6139475 DOI: 10.3310/hta22440] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ovarian cancer is the sixth most common cancer in UK women and can be difficult to diagnose, particularly in the early stages. Risk-scoring can help to guide referral to specialist centres. OBJECTIVES To assess the clinical and cost-effectiveness of risk scores to guide referral decisions for women with suspected ovarian cancer in secondary care. METHODS Twenty-one databases, including MEDLINE and EMBASE, were searched from inception to November 2016. Review methods followed published guidelines. The meta-analysis using weighted averages and random-effects modelling was used to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). The cost-effectiveness analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different risk-scoring methods, and subsequent care pathways. Modelling comprised a decision tree and a Markov model. The decision tree was used to model short-term outcomes and the Markov model was used to estimate the long-term costs and QALYs associated with treatment and progression. RESULTS Fifty-one diagnostic cohort studies were included in the systematic review. The Risk of Ovarian Malignancy Algorithm (ROMA) score did not offer any advantage over the Risk of Malignancy Index 1 (RMI 1). Patients with borderline tumours or non-ovarian primaries appeared to account for disproportionately high numbers of false-negative, low-risk ROMA scores. (Confidential information has been removed.) To achieve similar levels of sensitivity to the Assessment of Different NEoplasias in the adneXa (ADNEX) model and the International Ovarian Tumour Analysis (IOTA) group's simple ultrasound rules, a very low RMI 1 decision threshold (25) would be needed; the summary sensitivity and specificity estimates for the RMI 1 at this threshold were 94.9% (95% CI 91.5% to 97.2%) and 51.1% (95% CI 47.0% to 55.2%), respectively. In the base-case analysis, RMI 1 (threshold of 250) was the least effective [16.926 life-years (LYs), 13.820 QALYs] and the second cheapest (£5669). The IOTA group's simple ultrasound rules (inconclusive, assumed to be malignant) were the cheapest (£5667) and the second most effective [16.954 LYs, 13.841 QALYs], dominating RMI 1. The ADNEX model (threshold of 10%), costing £5699, was the most effective (16.957 LYs, 13.843 QALYs), and compared with the IOTA group's simple ultrasound rules, resulted in an incremental cost-effectiveness ratio of £15,304 per QALY gained. At thresholds of up to £15,304 per QALY gained, the IOTA group's simple ultrasound rules are cost-effective; the ADNEX model (threshold of 10%) is cost-effective for higher thresholds. LIMITATIONS Information on the downstream clinical consequences of risk-scoring was limited. CONCLUSIONS Both the ADNEX model and the IOTA group's simple ultrasound rules may offer increased sensitivity relative to current practice (RMI 1); that is, more women with malignant tumours would be referred to a specialist multidisciplinary team, although more women with benign tumours would also be referred. The cost-effectiveness model supports prioritisation of sensitivity over specificity. Further research is needed on the clinical consequences of risk-scoring. STUDY REGISTRATION This study is registered as PROSPERO CRD42016053326. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre and CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, the Netherlands
| | - Shona Lang
- Kleijnen Systematic Reviews Ltd, York, UK
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre and CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, the Netherlands
| | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre and CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, the Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
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Teh BH, Yong SL, Sim WW, Lau KB, Suharjono HN. Evaluation in the predictive value of serum human epididymal protein 4 (HE4), cancer antigen 125 (CA 125) and a combination of both in detecting ovarian malignancy. Horm Mol Biol Clin Investig 2018; 35:/j/hmbci.ahead-of-print/hmbci-2018-0029/hmbci-2018-0029.xml. [PMID: 30063463 DOI: 10.1515/hmbci-2018-0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 06/19/2018] [Indexed: 11/15/2022]
Abstract
Background This study was conducted to evaluate the performance of human epididymal protein 4 (HE4), cancer antigen 125 (CA 125) and a combination of both via the Risk of Ovarian Malignancy Algorithm (ROMA) in detecting ovarian malignancy. Methods This was a diagnostic study enrolling 129 patients with pelvic mass(es) suspected of originating in the ovary who had been scheduled for surgery or radiological-guided biopsy. Serum HE4 and CA 125 levels were measured. HE4, CA 125 and ROMA were evaluated for sensitivity, specificity, positive predictive value and negative predictive value. The receiver operating characteristic (ROC) plots were graphed and area under the curve (AUC) values were calculated to investigate the accuracy of each marker for predicting ovarian malignancy. Results Overall, CA 125 remained significantly more sensitive (88.9% vs. 51.9%, p = 0.006) but less specific (56.9% vs. 95.1%, p < 0.001) than HE4. HE4 was superior to CA 125 in specificity (97.7% vs. 54.5%, p < 0.001) for premenopausal women. ROMA was non-significantly more sensitive (100.0% vs. 92.3%, p = 1.000) than CA 125 but both were equally specific (71.4%) for the postmenopausal group. In the premenopausal group, the AUC of serum HE4 was higher than serum CA 125 (0.851 vs. 0.817) but was equivalent to ROMA (0.851 vs. 0.859). In the postmenopausal group, ROMA exhibited an excellent AUC value as compared to CA 125 and HE4 (AUC of 0.907 vs. 0.874 vs. 0.863, respectively). Conclusion HE4 is useful in ruling out ovarian malignancy among premenopausal women. For postmenopausal women, ROMA appears to be an all-rounder with overall good sensitivity and specificity.
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Affiliation(s)
- Beng Hock Teh
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Sarawak, Malaysia
| | - Soon Leong Yong
- Department of Obstetrics and Gynaecology, Sibu Hospital, Batu 5 ½, Jalan Ulu Oya, 96000 Sibu, Sarawak, Malaysia, Phone: +6017-9197139
| | - Wee Wee Sim
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Sarawak, Malaysia
| | - Kim Bee Lau
- Department of Pathology, Sarawak General Hospital, Sarawak, Malaysia
| | - Haris Njoo Suharjono
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Sarawak, Malaysia
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Standard and optimal cut-off values of serum ca-125, HE4 and ROMA in preoperative prediction of ovarian cancer in Vietnam. Gynecol Oncol Rep 2018; 25:110-114. [PMID: 30109256 PMCID: PMC6090087 DOI: 10.1016/j.gore.2018.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/30/2022] Open
Abstract
Objectives To evaluate the validity of serum CA-125, Human Epididymis protein 4 (HE4) and Risk of Malignancy Algorithm (ROMA) at standard and optimal cut-offs, in preoperative prediction of epithelial ovarian carcinoma (EOC) in Vietnam. Subjects and methods Cross-sectional, descriptive study on 277 patients with ovarian masses hospitalized at the OBGYN Departments, Hue University Hospital and Hue Central Hospital, Vietnam, from 01/2016 to 11/2017. All patients had measurements of serum CA-125 by Elecsys 2010 system and HE4 by immunoassay ARCHITECT® HE4 kits; ROMA calculated, and preoperative malignancy risk estimated. Matching these values to postoperative histopathology resulted in the preoperative prediction values. Results There were 30 (10.8%) cases of EOC. Median values of CA 125, HE4, and ROMA of EOC and benign tumors were 214.20 U/ml, 18.91 U/ml; 90.00 pmol/l, 39.80 pmol/l; and 55.20%, 4.80%, respectively. The sensitivities and specificity of CA125, HE4, and ROMA to distinguish between malignant and benign tumors at standard cut-offs were 83.3% and 78.5%; 50% and 98.38%; 80.0% and 84,6%, and those at optimal cut-offs were 83.3% and 86.6%; 80.0% and 91.5%, 86.7% and 88.7%, respectively. AUCs of CA-125, HE4, and ROMA were 0.872, 0.894, 0.912; and those for the post-menopausal group were 0.900, 0.894 and 0.924, respectively. Conclusion Serum CA 125 and HE4 levels and ROMA have good validity in the diagnosis of EOC, of which ROMA gives the best result. The ROMA index should be applied in clinical practice to help in the assessment and management of patients with suspected ovarian cancer. HE4 and ROMA yielded good validity in the preoperative diagnosis of epithelial ovarian cancer. In pre-menopausal group, the modified ROMA cut-off value (9.89%) yielded a better specificity. ROMA can help with the assessment and management of patients with suspected ovarian cancer.
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Lang S, Armstrong N, Deshpande S, Ramaekers B, Grimm S, de Kock S, Kleijnen J, Westwood M. Clinically inappropriate post hoc exclusion of study participants from test accuracy calculations: the ROMA score, an example from a recent NICE diagnostic assessment. Ann Clin Biochem 2018; 56:72-81. [PMID: 29848041 DOI: 10.1177/0004563218782722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore how the definition of the target condition and post hoc exclusion of participants can limit the usefulness of diagnostic accuracy studies. METHODS We used data from a systematic review, conducted for a NICE diagnostic assessment of risk scores to inform secondary care decisions about specialist referral for women with suspected ovarian cancer, to explore how the definition of the target condition and post hoc exclusion of participants can limit the usefulness of diagnostic accuracy studies to inform clinical practice. RESULTS Fourteen of the studies evaluated the ROMA score, nine used Abbott ARCHITECT tumour marker assays, five used Roche Elecsys. The summary sensitivity estimate (Abbott ARCHITECT) was highest, 95.1% (95% CI: 92.4 to 97.1%), where analyses excluded participants with borderline tumours or malignancies other than epithelial ovarian cancer and lowest, 75.0% (95% CI: 60.4 to 86.4%), where all participants were included. Results were similar for Roche Elecsys tumour marker assays. Although the number of patients involved was small, data from studies that reported diagnostic accuracy for both the whole study population and with post hoc exclusion of those with borderline or non-epithelial malignancies suggested that patients with borderline or malignancies other than epithelial ovarian cancer accounts for between 50 and 85% of false-negative ROMA scores. CONCLUSIONS Our results illustrate the potential consequences of inappropriate population selection in diagnostic studies; women with non-epithelial ovarian cancers or non-ovarian primaries, and those borderline tumours may be disproportionately represented among those with false negative, 'low risk' ROMA scores. These observations highlight the importance of giving careful consideration to how the target condition has been defined when assessing whether the diagnostic accuracy estimates reported in clinical studies will translate into clinical utility in real-world settings.
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Affiliation(s)
- Shona Lang
- 1 Kleijnen Systematic Reviews Ltd, York, UK
| | | | | | - Bram Ramaekers
- 2 Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre & CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sabine Grimm
- 2 Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre & CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Jos Kleijnen
- 3 School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Diagnostic Performance of Risk of Ovarian Malignancy Algorithm Against CA125 and HE4 in Connection With Ovarian Cancer: A Meta-analysis. Int J Gynecol Cancer 2018; 26:1586-1593. [PMID: 27540691 DOI: 10.1097/igc.0000000000000804] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine whether the Risk of Ovarian Malignancy Algorithm (ROMA) is more accurate than the human epididymis 4 (HE4) or carbohydrate antigen 125 (CA125) biomarkers with respect to the differential diagnosis of women with a pelvic mass. The secondary objective is to assess the performance of ROMA in early-stage ovarian cancer (OC) and late-stage OC, as well as premenopausal and postmenopausal patient populations. METHODS/MATERIALS The PubMed and Google Scholar databases were searched for relevant clinical studies. Eligibility criteria included comparison of ROMA with both HE4 and CA125 levels in OC (unspecified, epithelial, and borderline ovarian tumors), use of only validated ROMA assays, presentation of area under the curve and sensitivity/specificity data, and results from early-stage OC, late-stage OC and premenopausal and postmenopausal women. Area under the curve (AUC), sensitivity/specificity, and the diagnostic odds ratio (DOR) results were summarized. RESULTS Five studies were selected comprising 1975 patients (premenopausal, n = 1033; postmenopausal, n = 925; benign, n = 1387; early stage, n = 192; and late stage, n = 313). On the basis of the AUC (95% confidence interval) data for all patients, ROMA (0.921 [0.855-0.960]) had a numerically greater diagnostic performance than CA125 (0.883 [0.771-0.950]) and HE4 (0.899 [0.835-0.943]). This was also observed in each of the subgroup populations, in particular, the postmenopausal patients and patients with early OC. The sensitivity and specificity (95% confidence interval) results showed ROMA (sensitivity, 0.873 [0.752-0.940]; specificity, 0.855 [0.719-0.932]) to be numerically superior to CA125 (sensitivity, 0.796 [0.663-0.885]; specificity, 0.825 [0.662-0.919]) and HE4 (sensitivity, 0.817 [0.683-0.902]; specificity, 0.851 [0.716-0.928]) in all patients and for the early- and late-stage OC subgroups. Finally, the ROMA log DOR results were better than HE4 and CA125 log DOR results especially for the early-stage patient group. CONCLUSIONS The results presented support the use of ROMA to improve clinical decision making, most notably in patients with early OC.
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Bakrani M, Poor KS, Mehrzad V, Razmi N. Comparison of the Serum Level of Cancer Antigen 125 and Human Epididymis Protein 4 in Ovarian Cancer Patients and Healthy Groups in Isfahan City. Adv Biomed Res 2017; 6:124. [PMID: 29142887 PMCID: PMC5672644 DOI: 10.4103/2277-9175.216778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Ovarian cancer is the most common fatal malignancy of the gynecology tract. The purpose of this study was to compare serum levels of tumor markers cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) in both healthy groups and patients with ovarian cancer. Materials and Methods: this case–control study was performed on Seyed Al-Shohada Hospital in Isfahan. Research on the treatment of 44 patients with ovarian cancer and 44 healthy controls was performed. CA125 and HE4 were measured in serum by sandwich ELISA method. Results: Average CA125 in ovarian cancer patients (83.30 ± 43.99 μ/ml) was significantly higher than in healthy controls (12.39 ± 5.50 μ/ml) (P < 0.001). Average HE4 in ovarian cancer patients (295.41 ± 133.33 PM) was significantly higher than in healthy controls (114.64 ± 17.31 PM) (P < 0.001). Conclusions: HE4 test is complementary of CA125 test in women with epithelial ovarian cancer. It is also used to study the disease process.
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Affiliation(s)
- Mahnaz Bakrani
- Department of Biochemistry, Shiraz Sciences and Research Branch, Islamic Azad University, Shiraz, Isfahan, Iran
| | - Kahin Shahani Poor
- Department of Biochemistry, Falavarjan Branch, Islamic Azad University, Isfahan, Iran
| | - Valiollah Mehrzad
- Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nematallah Razmi
- Department of Biochemistry, Shiraz Sciences and Research Branch, Islamic Azad University, Shiraz, Isfahan, Iran
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Scaletta G, Plotti F, Luvero D, Capriglione S, Montera R, Miranda A, Lopez S, Terranova C, De Cicco Nardone C, Angioli R. The role of novel biomarker HE4 in the diagnosis, prognosis and follow-up of ovarian cancer: a systematic review. Expert Rev Anticancer Ther 2017; 17:827-839. [PMID: 28756722 DOI: 10.1080/14737140.2017.1360138] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Ovarian cancer is the leading cause of death from gynecologic cancers, in fact, >80% of cases are diagnosed as advanced-stage disease associated with a high mortality rate (<40% of women cured). A systematic review was performed to estimate the role of HE4 in the diagnosis, prognosis and follow-up of ovarian tumors. Areas covered: A comprehensive search of the literature from January 1952 to August 2016 was conducted using the terms 'ovarian tumor' and 'ovarian cancer' combined with 'HE4' and 'human epididymis protein 4'. The search identified a total of 259 citations, of which 141 were potentially relevant after initial evaluation. Of these studies, 75 primary studies met the inclusion criteria and were analyzed, with a total of 14,773 patients. Expert commentary: Serum HE4 dosage is a useful preoperative test for predicting the benign or malignant nature of pelvic masses. It seems to have a promising role in the prediction of clinical and surgical outcomes. Moreover, HE4 seems to better predict recurrence in comparison to CA-125.
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Affiliation(s)
- Giuseppe Scaletta
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Francesco Plotti
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Daniela Luvero
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Stella Capriglione
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Roberto Montera
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Andrea Miranda
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Salvatore Lopez
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Corrado Terranova
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Carlo De Cicco Nardone
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
| | - Roberto Angioli
- a Department of Obstetrics and Gynaecology , Campus Bio-Medico University of Rome , Rome , Italy
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Będkowska GE, Gacuta E, Zajkowska M, Głażewska EK, Osada J, Szmitkowski M, Chrostek L, Dąbrowska M, Ławicki S. Plasma levels of MMP-7 and TIMP-1 in laboratory diagnostics and differentiation of selected histological types of epithelial ovarian cancers. J Ovarian Res 2017; 10:39. [PMID: 28662671 PMCID: PMC5492921 DOI: 10.1186/s13048-017-0338-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/11/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND MMP-7 and TIMP-1 may play a role in the pathogenesis of cancer disease. In this study we investigated plasma levels of selected metalloproteinase and its tissue inhibitor in comparison to plasma levels of the commonly accepted tumor markers (CA 125 and HE4) in selected histological types of epithelial ovarian cancer patients as compared to control groups: patients with a benign ovarian tumor and healthy subjects. Plasma levels of MMP-7 and TIMP-1 were determined using ELISA, CA 125 and HE4 - by CMIA methods. RESULTS Plasma levels of all biomarkers studied were significantly higher in ovarian cancer patients as compared to both control groups. MMP-7 demonstrated comparable to HE4 or CA125 values of diagnostic sensitivity (SE: 61%; 68%; 58%, respectively), specificity (SP: 95%; 95%; 98%, respectively), positive (PPV: 93%; 96%; 98%, respectively) and negative predictive values (NPV: 61%; 66%; 60%, respectively) in the groups tested. The combined use of the aforementioned biomarkers resulted in a further increase in diagnostic criteria and AUC, especially in the early stages of the disease. CONCLUSIONS These findings suggest the usefulness of combining MMP-7 with CA 125 and HE4 in the diagnosis of epithelial ovarian cancer as a new tumor marker panel.
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Affiliation(s)
- Grażyna Ewa Będkowska
- Department of Haematological Diagnostics, Medical University Bialystok, Waszyngtona 15A, 15-269, Bialystok, Poland.
| | - Ewa Gacuta
- Department of Perinatology, Medical University Bialystok, Bialystok, Poland
| | - Monika Zajkowska
- Department of Biochemical Diagnostics, Medical University Bialystok, Bialystok, Poland
| | | | - Joanna Osada
- Department of Haematological Diagnostics, Medical University Bialystok, Waszyngtona 15A, 15-269, Bialystok, Poland
| | - Maciej Szmitkowski
- Department of Biochemical Diagnostics, Medical University Bialystok, Bialystok, Poland
| | - Lech Chrostek
- Department of Biochemical Diagnostics, Medical University Bialystok, Bialystok, Poland
| | - Milena Dąbrowska
- Department of Haematological Diagnostics, Medical University Bialystok, Waszyngtona 15A, 15-269, Bialystok, Poland
| | - Sławomir Ławicki
- Department of Biochemical Diagnostics, Medical University Bialystok, Bialystok, Poland
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Shen F, Lu S, Peng Y, Yang F, Chen Y, Lin Y, Yang C, Wu L, Li H, Zheng Y. Performance of ROMA based on Architect CA 125 II and HE4 values in Chinese women presenting with a pelvic mass: A multicenter prospective study. Clin Chim Acta 2017; 471:119-125. [PMID: 28549533 DOI: 10.1016/j.cca.2017.05.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/04/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND We evaluated the performance of human epididymis protein 4 (HE4), cancer antigen 125(CA 125) and Risk of Ovarian Malignancy Algorithm (ROMA) in distinguishing between benign and malignant pelvic masses in Chinese women. METHOD From April to December 2012, women with a pelvic mass scheduled to have surgery were enrolled in a prospective, multi-center study conducted in 5 different regions in China. Preoperative serum concentrations of HE4 and CA 125 were examined and ROMA was calculated. RESULTS A total of 684 women with a pelvic mass were included, of which 482 were diagnosed with benign conditions and 202 were diagnosed with malignant ovarian tumors. At cutoffs of 7.4% and 25.3% for ROMA, the sensitivities and specificities were 85.6% and 81.7% for all patients, 85.7% and 81.5% for premenopausal women, and 85.6% and 83.9% for postmenopausal women, respectively. The ROC-AUC of ROMA was significantly better than that of HE4 (P=0.0003) or CA 125 (P<0.0001) for all malignant diseases (including EOC, Non-EOC, LMP, metastases and other pelvic malignancy with no involvement of the ovaries) compared with benign diseases for all patients. CONCLUSIONS We demonstrated the efficiency of ROMA in the distinction of ovarian cancers from benign disease in a multiple-regions Chinese population, especially in premenopausal women.
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Affiliation(s)
- Fengxian Shen
- Woman's Hospital, School of Medicine, Zhejiang University, Xueshi Road #2, Hangzhou 310006, China
| | - Shiming Lu
- Woman's Hospital, School of Medicine, Zhejiang University, Xueshi Road #2, Hangzhou 310006, China.
| | - Yibing Peng
- Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Ruijin 2nd Road #197, Shanghai 200025, China
| | - Fan Yang
- Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Ruijin 2nd Road #197, Shanghai 200025, China
| | - Yan Chen
- Fujian Provincial Cancer Hospital, Fuma Road #420, Jin'an District, Fuzhou 350014, China
| | - Yingying Lin
- Fujian Provincial Cancer Hospital, Fuma Road #420, Jin'an District, Fuzhou 350014, China
| | - Chen Yang
- Suzhou Municipal Hospital, Daoqian Street #26, Suzhou 215002, China
| | - Li Wu
- Suzhou Municipal Hospital, Daoqian Street #26, Suzhou 215002, China
| | - Huijun Li
- Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1095, Wuhan 430030, China
| | - Yijie Zheng
- Medical Scientific Affairs, Abbott Diagnostics Division, Abbott Laboratories, Shanghai 200003, China
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Terlikowska KM, Dobrzycka B, Witkowska AM, Mackowiak-Matejczyk B, Sledziewski TK, Kinalski M, Terlikowski SJ. Preoperative HE4, CA125 and ROMA in the differential diagnosis of benign and malignant adnexal masses. J Ovarian Res 2016; 9:43. [PMID: 27436085 PMCID: PMC4952144 DOI: 10.1186/s13048-016-0254-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/14/2016] [Indexed: 12/24/2022] Open
Abstract
Background The aim of this study was to evaluate HE4, CA125 and ROMA in the preoperative differentiation benign ovarian diseases from epithelial ovarian cancer depending on the menopausal status. Methods In order to estimate markers’ concentrations in the serum of women with benign ovarian disease (n = 128) and with epithelial ovarian carcinoma (n = 96) the electrochemiluminescence (ECLIA) technique has been applied. Results Using the ROC analysis, although no statistical differences were found among their AUCs, the ROMA algorithm seems to be effective in gathering the diverse performance of HE4 and CA125. The AUC for HE4, CA125 and ROMA for all patients were: 0.895; 0.879 and 0.918, respectively. At established new optimal cutoff values for HE4, CA125 and ROMA we found higher specificity in postmenopausal compared to premenopausal women (96.9 vs 89.8 % and 97.7 vs 84.1 % and 95.9 vs 89.1 %, respectively). The sensitivity of HE4 in pre- and postmenopausal women was similar (83.5 vs 83.8 %), while for CA125 was the highest in premenopausal women (87.0 vs 84.1 %). For HE4, CA125 and ROMA the negative predictive value was high (97.6, 93.9 and 94.4 %, respectively). Conclusions The ROMA algorithm shows the best diagnostic performance to distinguish epithelial ovarian cancer from benign ovarian disease. We found the high specificity of HE4 and CA125 while differentiating ovarian benign diseases from epithelial ovarian cancer in postmenopausal women and the high sensitivity of CA125 in detecting epithelial ovarian cancer in premenopausal patients.
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Affiliation(s)
- Katarzyna M Terlikowska
- Department of Food Science and Technology, Medical University of Bialystok, 37 Szpitalna Street, 15-295, Bialystok, Poland
| | - Bozena Dobrzycka
- Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Bialystok, 15 Warszawska Street, 15-062, Bialystok, Poland
| | - Anna M Witkowska
- Department of Food Science and Technology, Medical University of Bialystok, 37 Szpitalna Street, 15-295, Bialystok, Poland
| | - Beata Mackowiak-Matejczyk
- Department of Gynaecologic Oncology, Maria Sklodowska-Curie Memorial Bialystok Oncology Center, 12 Ogrodowa Street, 15-027, Bialystok, Poland
| | - Tomasz Kamil Sledziewski
- Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Bialystok, 15 Warszawska Street, 15-062, Bialystok, Poland
| | - Maciej Kinalski
- Department of Gynaecology and Obstetrics, Jedrzej Sniadecki Memorial Hospital, 15 Warszawska Street, 15-062, Bialystok, Poland
| | - Slawomir J Terlikowski
- Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Bialystok, 15 Warszawska Street, 15-062, Bialystok, Poland. .,Department of Obstetrics, Gynaecology and Maternity Care, Medical University of Bialystok, Szpitalna 37, 15-295, Bialystok, Poland.
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Yu S, Lee JK, Kim JH, Park H, Lee MY, Ryu S, Kwon MJ, Woo HY. Diagnostic performance and establishment of reference limits of HE4 in Korean healthy women. Gynecol Oncol 2016; 143:128-134. [PMID: 27426308 DOI: 10.1016/j.ygyno.2016.07.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 06/27/2016] [Accepted: 07/10/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We aimed to establish distribution and reference limits of HE4 and risk of ovarian malignancy algorithm (ROMA) in healthy Korean women and investigated the factors influencing HE4 levels. We also investigated the diagnostic performances of HE4 and ROMA score, compared with CA125. METHODS We collected specimens from 1809 healthy Korean women, 140 specimens from patients with ovarian cancers (OCs) and 123 specimens from patients with benign ovarian tumor. Serum HE4 and CA125 concentrations were measured using an electrochemiluminescence immunoassay. The receiver operator characteristic (ROC) curve analysis was done for ROMA, HE4, CA125 and combining of HE4 and CA125. RESULTS HE4 level was influenced by age, not by menopausal status. The 97.5th percentile upper reference limit of HE4 of subjects <50years and ≥50year-old was 63.87pmol/L and 88.28pmol/L, respectively. The 97.5th percentile upper reference limits of ROMA score were 13.66 in premenopausal and 19.30 in postmenopausal women. The serum HE4 level was even lower in the patients with benign tumor compared to those in healthy controls. HE4 had significantly higher concentrations in OCs than benign ovarian tumor (P<0.001). ROMA and HE4 combined with CA125 or not performed better diagnostically than CA125 alone for distinguishing OCs, with AUCs of 0.844 for ROMA, 0.827 for combining of HE4 and CA125, 0.825 for HE4, and 0.795 for CA125. CONCLUSIONS The reference limit of HE4 was different from those reported by other studies, suggesting racial or regional difference. HE4 and ROMA were better than CA125 for differentiation normal and benign ovarian tumor from OCs. (Word count: 253).
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Affiliation(s)
- Shinae Yu
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Kyung Lee
- KIRAMS Radiation Biobank, Korea Institute of Radiological and Medical Sciences, Seoul, Republic of Korea
| | - Jae-Hoon Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyosoon Park
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Yeon Lee
- Department of Biostatistics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Min-Jung Kwon
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hee-Yeon Woo
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Li L, Wan J, Cai G, Yuan L, Liang J, Song J, Wang F, Liu M. Value of serum human epididymis secretory protein 4 as a marker for differential diagnosis of malignant and benign gynecological diseases of patients in southern China. Clin Chim Acta 2016; 459:170-176. [PMID: 27302312 DOI: 10.1016/j.cca.2016.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/05/2016] [Accepted: 06/10/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study investigated the clinical value of HE4 in distinguishing malignant and benign gynecological diseases of patients in southern China. METHODS Preoperative serum CA125 and HE4 concentrations were tested in samples of women with malignant or benign gynecological diseases using fully automated methods (Abbott ARCHITECT) and validated cutoff values. RESULTS For the discrimination of ovarian cancer from benign gynecological diseases, in premenopausal women, the sensitivity and specificity were 89.8% and 67.5% for CA125, 68.5% and 97.8% for HE4, and 88.9% and 78.6% for ROMA, whereas in postmenopausal women, the sensitivity and specificity were 86.6% and 88.9% for CA125, 57.3% and 100% for HE4, and 85.4% and 94.4% for ROMA. For the discrimination of endometrial cancer from benign gynecological diseases, in premenopausal women, the sensitivity and specificity were 20.3% and 67.5% for CA125, 56.8% and 97.8% for HE4, and 74.3% and 78.6% for ROMA, whereas in postmenopausal women, the sensitivity and specificity were 17.8% and 88.9% for CA125, 31.5% and 100% for HE4, and 32.9% and 94.4% for ROMA. CONCLUSIONS We showed that HE4 had better specificity than CA125 in discriminating ovarian cancer, and endometrial cancer from benign gynecological diseases in southern China population.
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Affiliation(s)
- Laisheng Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Jianxin Wan
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Gaorong Cai
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Linjing Yuan
- Department of Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Jianbo Liang
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Junli Song
- Department of Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Fen Wang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Min Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
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HE4, CA125 and risk of ovarian malignancy algorithm (ROMA) as diagnostic tools for ovarian cancer in patients with a pelvic mass: An Italian multicenter study. Gynecol Oncol 2016; 141:303-311. [PMID: 26801941 DOI: 10.1016/j.ygyno.2016.01.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This multicenter study aims to evaluate HE4, CA125 and risk of ovarian malignancy algorithm (ROMA) performance in the differential diagnosis of epithelial ovarian cancer (EOC). METHODS A total of 405 patients referred to gynecological oncologist with suspicious pelvic mass requiring a surgery for identification of EOC were consecutively enrolled; 387 patients satisfied inclusion criteria: 290 benign diseases; 15 borderline neoplasia and 82 tumors (73 EOC). RESULTS Good diagnostic performance in discriminating benign from EOC patients was obtained for CA125, HE4 and ROMA when calculating optimal cut-off values: premenopause, specificity (SP) >86.6, sensitivity (SN) >82.6, area under the curves (AUC)≥0.894; postmenopause, SP>93.2, SN>82, AUC≥0.928. Fixing SP at 98%, performance indicators obtained for benign vs EOC patients were: premenopause, SN:65.2%, positive predictive value (+PV): 75%, positive likelihood ratio (+LR): 26.4 for CA125; SN:69.6%, +PV:76.2%, +LR:28.1 for HE4; SN:69.6%, +PV: 80%; +LR:35.1 for ROMA; postmenopause, SN:88%, +PV: 95.7%, +LR:38.7 for CA125; SN:78%, +PV:95.1%, +LR:34.3 for HE4; SN:88%, +PV:97.8%, +LR:77.4 for ROMA. When using routine cut-off thresholds, ROMA showed better well-balanced values of both SP and SN (premenopause, SN:87%, SP:86.1%; postmenopause, SN:90%; SP:94.3%). CONCLUSIONS Overall, ROMA showed well balanced diagnostic performance to differentiate EOC from benign diseases. Meaningful differences of +PVs and +LRs between HE4 and CA125 suggest that the two markers may play at least in part different roles in EOC diagnosis, with HE4 seeming to be more efficient than CA125 in ruling in EOC patients in the disease group, also in early stages tumors, both in pre and postmenopause.
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Cho HY, Park SH, Park YH, Kim HB, Kang JB, Hong SH, Kyung MS. Comparison of HE4, CA125, and Risk of Ovarian Malignancy Algorithm in the Prediction of Ovarian Cancer in Korean Women. J Korean Med Sci 2015; 30:1777-83. [PMID: 26713052 PMCID: PMC4689821 DOI: 10.3346/jkms.2015.30.12.1777] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/01/2015] [Indexed: 12/15/2022] Open
Abstract
This study is a multi-center clinical study, which aimed to compare CA125, HE4, and risk of ovarian malignancy algorithm (ROMA) in predicting epithelial ovarian cancer of Korean women with a pelvic mass. Prospectively, serum from 90 Korean women with ovarian mass was obtained prior to surgery. For control group, serum from 79 normal populations without ovarian mass was also obtained. The HE4 and CA125 data were registered and evaluated separately and ROMA was calculated for each sample. Total 67 benign tumors and 23 ovarian cancers were evaluated. Median serum levels of HE4 and CA125, and ROMA score were significantly higher in patients with ovarian cancer than those with benign ovarian tumor and normal population (P < 0.001). In ROC curve analysis for women with a pelvic mass, area under the curve (AUC) for HE4 and ROMA was higher than CA125. Statistical differences in each study compared to CA125 were marginal (P compared to CA125; 0.082 for HE4 and 0.069 for ROMA). Sub-analysis revealed that AUC for HE4 and ROMA was higher than AUC for CA125 in post-menopausal women with a pelvic mass, but there were no statistically significant differences (P compared to CA125; 0.160 for HE4 and 0.127 for ROMA). Our data suggested that both HE4 and ROMA score showed better performance than CA125 for the detection of ovarian cancer in women with a pelvic mass. HE4 and ROMA can be a useful independent diagnostic marker for epithelial ovarian cancer in Korean women.
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Affiliation(s)
- Hye Yon Cho
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
| | - Sung Ho Park
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
| | - Young Han Park
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
| | - Hong Bae Kim
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
| | - Jung Bae Kang
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
| | - Seung Hwa Hong
- Department of Obstetrics & Gynecology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Min Sun Kyung
- Department of Obstetrics & Gynecology, Hallym University Medical Center, Hwaseong, Korea
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Zhang P, Wang C, Cheng L, Zhang P, Guo L, Liu W, Zhang Z, Huang Y, Ou Q, Wen X, Tian Y. Comparison of HE4, CA125, and ROMA Diagnostic Accuracy: A Prospective and Multicenter Study for Chinese Women With Epithelial Ovarian Cancer. Medicine (Baltimore) 2015; 94:e2402. [PMID: 26717395 PMCID: PMC5291636 DOI: 10.1097/md.0000000000002402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Risk of Ovarian Malignancy Algorithm (ROMA) combing human epididymis secretary protein 4 (HE4) and CA125 showed better diagnostic accuracy for epithelial ovarian cancer (EOC) when compared with HE4 or CA125 alone; however, other studies showed no or worse diagnostic accuracy. We aim to conduct a prospective and multicenter clinical trial to compare the diagnostic accuracy of HE4, CA125, and ROMA for EOC.A prospective and multicenter (n = 9) trial including 2481 individuals was performed in Chinese women. HE4, CA125, and ROMA diagnostic accuracy were evaluated according to different menopausal status and stages of EOC. Their diagnostic values were evaluated by the area under curve (AUC) and compared by the Z scores. Diagnostic specificity of other kinds of participants (n = 1098) was also evaluated.For discriminating between healthy control (HC) and EOC, only CA125 showed significant difference for discriminating HC and EOC in all the individuals when compared with HE4 and ROMA (P < 0.001 and P = 0.02, respectively), at the cutoff value of 31.5, the sensitivity (SN) and specificity (SP) were 88.6% and 97.1%. For discriminating between benign pelvic mass (BPM) and EOC, ROMA showed significant difference for discriminating BPM and EOC in the all individuals (P = 0.01 and P = 0.02, respectively) and the postmenopausal individuals (P = 0.03 and P = 0.04, respectively), at the cutoff value of 27.3 and 34.5, the SNs were 97.0% and 89.4%, SPs were 81.4% and 82.5%, separately. Within all kinds of diseases, there was no significant difference in specificity between CA125 and HE4.In conclusions, when HE4, CA125, and ROMA were compared with each other according to different menopausal status, and stages. Only CA125 showed significant difference for discriminating HC and EOC in all the individuals, and ROMA for discriminating BPM and EOC in the all individuals and postmenopausal individuals when compared with HE4 or CA125. HE4 has showed no significant difference in specificity with all kinds of diseases when compared with CA125.
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Affiliation(s)
- Pengjun Zhang
- From the Core Laboratory of Translational Medicine, State Key Laboratory of Kidney Disease (PJ Zhang, YP Tian) and Department of Clinical Biochemistry, State Key Laboratory of Kidney Disease (PJ Zhang, XY Wen, YP Tian), Chinese PLA General Hospital, Beijing, China; Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, China (CX Wang); Department of Clinical Laboratory, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (LM Cheng); Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (P Zhang); Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China (L Guo); Department of Clinical Laboratory, Sun Yat-Sen University Cancer Hospital, Guangzhou, China (WL Liu); Department of Clinical Laboratory, Zhongshan Hospital Xiamen University, Xiamen, China (ZY Zhang); Department of Clinical Laboratory, The Tumor Hospital Affiliated to XinJiang Medical University, Urumqi, China (YC Huang); and Department of Clinical Laboratory, First Affiliated Hospital of Fujian Medical University, Fuzhou, China (QS Ou)
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Zhang P, Wang C, Cheng L, Zhang P, Guo L, Liu W, Zhang Z, Huang Y, Ou Q, Wen X, Tian Y. Development of a multi-marker model combining HE4, CA125, progesterone, and estradiol for distinguishing benign from malignant pelvic masses in postmenopausal women. Tumour Biol 2015; 37:2183-91. [DOI: 10.1007/s13277-015-4037-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/02/2015] [Indexed: 01/04/2023] Open
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Antovska V, Trajanova M. An original risk of ovarian malignancy index and its predictive value in evaluating the nature of ovarian tumour. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2015. [DOI: 10.1080/20742835.2015.1081486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Xu Y, Zhong R, He J, Ding R, Lin H, Deng Y, Zhou L, Li X, Jiang J, Bao Y, Luo X, Duan C. Modification of cut-off values for HE4, CA125 and the ROMA algorithm for early-stage epithelial ovarian cancer detection: Results from 1021 cases in South China. Clin Biochem 2015; 49:32-40. [PMID: 26285075 DOI: 10.1016/j.clinbiochem.2015.07.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/16/2015] [Accepted: 07/26/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the performance of human epididymis protein 4 (HE4) and the Risk of Ovarian Malignancy Algorithm (ROMA) in early stage epithelial ovarian cancer (EOC) detection in patients in southern China. Additionally, this study proposes a possible ideal cut-off value for each marker to its own population in South China. DESIGN AND METHODS Serum HE4 and CA125 were measured in 756 patients with pelvic masses (275 malignancies, 53 borderline tumors and 428 benign diseases), and their ROMA values were calculated. Areas under the receiver operator characteristic (ROC) curves (AUC) were assessed for HE4, CA125, ROMA and combinations of these biomarkers. RESULTS Both HE4 and ROMA performed better diagnostically than CA125 alone for early stage EOC, with AUCs ranging from 0.714 for HE4, 0.699 for ROMA, and 0.463 for CA125 in premenopausal subjects, and 0.902 for ROMA, 0.880 for HE4, and 0.256 for CA125 in postmenopausal subjects. CONCLUSIONS HE4 and ROMA alone were found to be better than CA125 for detecting borderline tumors and early-stage EOC. The optimal cut-off values (HE4: 70pmol/l for all; CA125: 60U/ml for pre- and 35U/ml for postmenopausal women) could notably improve diagnostic performance in EOC detection in patients in southern China.
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Affiliation(s)
- Ying Xu
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Rihui Zhong
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jian He
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Rui Ding
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Haixiong Lin
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Yawen Deng
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Lijun Zhou
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Xiaohui Li
- Clinical Laboratory, Cancer Center of Sun Yat-Sen University, Guangzhou, 510060, People's Republic of China
| | - Junyi Jiang
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Yunwen Bao
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Xiaohong Luo
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Chaohui Duan
- Clinical Laboratory, The Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China.
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Jia LT, Zhang YC, Li J, Tian Y, Li JF. The role of human epididymis protein 4 in the diagnosis of epithelial ovarian cancer. Clin Transl Oncol 2015. [PMID: 26220095 DOI: 10.1007/s12094-015-1365-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Epithelial ovarian cancer is one of the most lethal female genital tract cancers. Early diagnosis of EOC would benefit the patients a lot. Human epididymis protein 4 (HE4) has been regarded as a new powerful biomarker in diagnosis of EOC; we hope to obtain system knowledge of HE4 and understand the role of HE4 in diagnosis of epithelial ovarian cancer (EOC). METHODS We searched Pubmed, Embase, Medline, and Chinese National Knowledge Infrastructure (CNKI) for articles that included HE4's origin, characteristics, detection methods, clinical efficacy alone or combined with CA125, the risk of malignancy index, and the risk of ovarian malignancy algorithm. The diagnostic performance for the EOC and the role in the recurrence and procession in EOC were also discussed. RESULTS We got 83 most related articles and found that there were significantly difference existing among the studies, such as the clinical characteristics of patients, the methodology for measuring HE4, the different cut-offs for HE4 and so on. CONCLUSION HE4 is a promising biomarker for the early diagnosis of EOC. However, each lab should establish its own reference internal of HE4.
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Affiliation(s)
- L-T Jia
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street 7, Zhengzhou, 450052, People's Republic of China.
| | - Y-C Zhang
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street 7, Zhengzhou, 450052, People's Republic of China
| | - J Li
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street 7, Zhengzhou, 450052, People's Republic of China
| | - Y Tian
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street 7, Zhengzhou, 450052, People's Republic of China
| | - J-F Li
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Street 7, Zhengzhou, 450052, People's Republic of China
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Karlsen MA, Høgdall EVS, Christensen IJ, Borgfeldt C, Kalapotharakos G, Zdrazilova-Dubska L, Chovanec J, Lok CAR, Stiekema A, Mutz-Dehbalaie I, Rosenthal AN, Moore EK, Schodin BA, Sumpaico WW, Sundfeldt K, Kristjansdottir B, Zapardiel I, Høgdall CK. A novel diagnostic index combining HE4, CA125 and age may improve triage of women with suspected ovarian cancer - An international multicenter study in women with an ovarian mass. Gynecol Oncol 2015; 138:640-6. [PMID: 26086566 DOI: 10.1016/j.ygyno.2015.06.021] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/12/2015] [Accepted: 06/14/2015] [Indexed: 11/18/2022]
Abstract
AIM To develop and validate a biomarker-based index to optimize referral and diagnosis of patients with suspected ovarian cancer. Furthermore, to compare this new index with the Risk of Malignancy Index (RMI) and Risk of Ovarian Malignancy Algorithm (ROMA). PATIENTS AND METHODS A training study, consisting of patients with benign ovarian disease (n=809) and ovarian cancer (n=246), was used to develop the Copenhagen Index (CPH-I) utilizing the variables serum HE4, serum CA125 and patient age. Eight international studies provided the validation population; comprising 1060 patients with benign ovarian masses and 550 patients with ovarian cancer. RESULTS Overall, 2665 patients were included. CPH-I was highly significant in discriminating benign from malignant ovarian disease. At the defined cut-off of 0.070 for CPH-I the sensitivity and specificity were 95.0% and 78.4% respectively in the training cohort and 82.0% and 88.4% in the validation cohort. Comparison of CPH-I, ROMA and RMI demonstrated area-under-curve (AUC) at 0.960, 0.954 and 0.959 respectively in the training study and 0.951, 0.953 and 0.935 respectively in the validation study. Using a sensitivity of 95.0%, the specificities for CPH-I, ROMA and RMI in the training cohort were 78.4%, 71.7% and 81.5% respectively, and in the validation cohort 67.3%, 70.7% and 69.5% respectively. CONCLUSION All three indices perform well at the clinically relevant sensitivity of 95%, but CPH-I, unlike RMI and ROMA, is independent of ultrasound and menopausal status, and may provide a simple index to optimize referral of women with suspected ovarian cancer.
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Affiliation(s)
- Mona A Karlsen
- Department of Pathology, Molecular Unit, Herlev University Hospital, University of Copenhagen, Herlev, Denmark; Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Estrid V S Høgdall
- Department of Pathology, Molecular Unit, Herlev University Hospital, University of Copenhagen, Herlev, Denmark
| | - Ib J Christensen
- Finsen Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Biotech Research and Innovation Center (BRIC), University of Copenhagen, Copenhagen, Denmark
| | - Christer Borgfeldt
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
| | | | | | - Josef Chovanec
- Department of Gynecologic Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek Hospital, The Netherlands
| | - Anna Stiekema
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek Hospital, The Netherlands
| | - Irene Mutz-Dehbalaie
- Department of Gynecology and Obstetrics, Innsbruck Medical University, Innsbruck, Austria
| | - Adam N Rosenthal
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, London, UK; Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
| | - Elizabeth K Moore
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge, UK
| | | | - Walfrido W Sumpaico
- Department of Obstetrics and Gynecology, MCU-FDT Medical Foundation, Philippines
| | - Karin Sundfeldt
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, University of Gothenburg, Gothenburg, Sweden
| | - Björg Kristjansdottir
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, University of Gothenburg, Gothenburg, Sweden
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | - Claus K Høgdall
- Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Będkowska GE, Ławicki S, Gacuta E, Pawłowski P, Szmitkowski M. M-CSF in a new biomarker panel with HE4 and CA 125 in the diagnostics of epithelial ovarian cancer patients. J Ovarian Res 2015; 8:27. [PMID: 25935153 PMCID: PMC4426179 DOI: 10.1186/s13048-015-0153-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 04/22/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We investigated plasma levels of M-CSF and conventional tumor markers (HE4 and CA 125) in epithelial ovarian cancer patients as compared to control groups: benign ovarian tumor patients (cysts) and healthy subjects. METHODS M-CSF levels were determined by ELISA, HE4 and CA 125 levels - by CMIA method. RESULTS Our results have demonstrated significant differences in the concentration levels of M-CSF, CA 125 and HE4 between the groups of ovarian cancer patients, cysts patients and the healthy controls. In the groups tested M-CSF demonstrated equal to or higher values than both CA 125 and HE4 in diagnostic sensitivity (SE), positive and negative predictive values (PPV, NPV), and in the area under the ROC curve (AUC), particularly in the group with the serous epithelial sub-type of OC. Moreover, CA 125 showed better results of the aforementioned diagnostic criteria than HE4. The combined use of the parameters studied resulted in a further, significant increase in the value of the diagnostic indicators and in the value of the diagnostic power (AUC), especially in the early stages of ovarian cancer. CONCLUSIONS These findings suggest a high usefulness of M-CSF in diagnosing the serous sub-type of epithelial ovarian cancer and in discriminating between cancer and non-carcinoma lesions, particularly in new diagnostic panels in combination with CA 125 and HE4 for the detection of EOC in the early stages.
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Affiliation(s)
| | - Sławomir Ławicki
- Department of Biochemical Diagnostics, Medical University Białystok, Waszyngtona 15A, Białystok, 15-269, Poland.
| | - Ewa Gacuta
- Department of Perinatology, Medical University, Białystok, Poland.
| | - Przemysław Pawłowski
- Department of Pediatric Ophthalmology with Squint Treatment Unit, Medical University, Białystok, Poland.
| | - Maciej Szmitkowski
- Department of Biochemical Diagnostics, Medical University Białystok, Waszyngtona 15A, Białystok, 15-269, Poland.
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ROMA, an algorithm for ovarian cancer. Clin Chim Acta 2015; 440:143-51. [DOI: 10.1016/j.cca.2014.11.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/03/2014] [Accepted: 11/14/2014] [Indexed: 11/23/2022]
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Fujiwara H, Suzuki M, Takeshima N, Takizawa K, Kimura E, Nakanishi T, Yamada K, Takano H, Sasaki H, Koyama K, Ochiai K. Evaluation of human epididymis protein 4 (HE4) and Risk of Ovarian Malignancy Algorithm (ROMA) as diagnostic tools of type I and type II epithelial ovarian cancer in Japanese women. Tumour Biol 2014; 36:1045-53. [PMID: 25326813 PMCID: PMC4342513 DOI: 10.1007/s13277-014-2738-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/13/2014] [Indexed: 01/03/2023] Open
Abstract
Human epididymis protein 4 (HE4) levels and the Risk of Ovarian Malignancy Algorithm (ROMA) have recently been shown to improve the sensitivity and specificity of epithelial ovarian cancer (EOC) diagnosis. We evaluated HE4 levels and ROMA as diagnostic tools of type I and type II EOC in Japanese women. Women who had a pelvic mass on imaging and were scheduled to undergo surgery were enrolled as ovarian mass patients. Serum levels of carbohydrate antigen 125 (CA125) and HE4 were tested in 319 women (131 benign, 19 borderline, 75 malignant, and 94 healthy controls). CA125, HE4, and ROMA were evaluated for sensitivity and by receiver operating characteristics (ROC) in type I and type II EOC. The results showed that, at 75% specificity, the sensitivity of CA125 and HE4 for type II was 92.1% for both markers and for type I was 51.5% and 78.8%, respectively. The sensitivities of ROMA (type I, 84.8% and type II, 97.4%) were better than those of CA125 and HE4. CA125, HE4, and ROMA were all highly accurate markers for type II. For type I, HE4 and ROMA showed better sensitivity than CA125. ROMA displayed the best diagnostic power for type I and type II including for the early stage of type I. In conclusion, HE4, CA125, and ROMA are valuable markers for type II EOC diagnosis. HE4 and ROMA analyses may improve differentiation between type I EOC and a benign mass. Measurement of combined HE4 and CA125 levels provides a more accurate method for EOC diagnosis.
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Affiliation(s)
- Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan,
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Wilailak S, Chan KKL, Chen CA, Nam JH, Ochiai K, Aw TC, Sabaratnam S, Hebbar S, Sickan J, Schodin BA, Charakorn C, Sumpaico WW. Distinguishing benign from malignant pelvic mass utilizing an algorithm with HE4, menopausal status, and ultrasound findings. J Gynecol Oncol 2014; 26:46-53. [PMID: 25310857 PMCID: PMC4302285 DOI: 10.3802/jgo.2015.26.1.46] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/24/2014] [Accepted: 10/06/2014] [Indexed: 12/03/2022] Open
Abstract
Objective The purpose of this study was to develop a risk prediction score for distinguishing benign ovarian mass from malignant tumors using CA-125, human epididymis protein 4 (HE4), ultrasound findings, and menopausal status. The risk prediction score was compared to the risk of malignancy index and risk of ovarian malignancy algorithm (ROMA). Methods This was a prospective, multicenter (n=6) study with patients from six Asian countries. Patients had a pelvic mass upon imaging and were scheduled to undergo surgery. Serum CA-125 and HE4 were measured on preoperative samples, and ultrasound findings were recorded. Regression analysis was performed and a risk prediction model was developed based on the significant factors. A bootstrap technique was applied to assess the validity of the HE4 model. Results A total of 414 women with a pelvic mass were enrolled in the study, of which 328 had documented ultrasound findings. The risk prediction model that contained HE4, menopausal status, and ultrasound findings exhibited the best performance compared to models with CA-125 alone, or a combination of CA-125 and HE4. This model classified 77.2% of women with ovarian cancer as medium or high risk, and 86% of women with benign disease as very-low, low, or medium-low risk. This model exhibited better sensitivity than ROMA, but ROMA exhibited better specificity. Both models performed better than CA-125 alone. Conclusion Combining ultrasound with HE4 can improve the sensitivity for detecting ovarian cancer compared to other algorithms.
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Affiliation(s)
- Sarikapan Wilailak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Karen K L Chan
- Department of Obstetrics and Gynecology, University of Hong Kong, Hong Kong
| | - Chi An Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Joo Hyun Nam
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kazunori Ochiai
- Department of Obstetrics and Gynecology, The Jikei University, Tokyo, Japan
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Subathra Sabaratnam
- Department of Pathology, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
| | | | | | | | - Chuenkamon Charakorn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Walfrido W Sumpaico
- Department of Obstetrics and Gynecology, MCU-FDT Medical Foundation, Caloocan, Philippines
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Cohen JG, White M, Cruz A, Farias-Eisner R. In 2014, can we do better than CA125 in the early detection of ovarian cancer? World J Biol Chem 2014; 5:286-300. [PMID: 25225597 PMCID: PMC4160523 DOI: 10.4331/wjbc.v5.i3.286] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/12/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Ovarian cancer is a lethal gynecologic malignancy with greater than 70% of women presenting with advanced stage disease. Despite new treatments, long term outcomes have not significantly changed in the past 30 years with the five-year overall survival remaining between 20% and 40% for stage III and IV disease. In contrast patients with stage I disease have a greater than 90% five-year overall survival. Detection of ovarian cancer at an early stage would likely have significant impact on mortality rate. Screening biomarkers discovered at the bench have not translated to success in clinical trials. Existing screening modalities have not demonstrated survival benefit in completed prospective trials. Advances in high throughput screening are making it possible to evaluate the development of ovarian cancer in ways never before imagined. Data in the form of human “-omes” including the proteome, genome, metabolome, and transcriptome are now available in various packaged forms. With the correct pooling of resources including prospective collection of patient specimens, integration of high throughput screening, and use of molecular heterogeneity in biomarker discovery, we are poised to make progress in ovarian cancer screening. This review will summarize current biomarkers, imaging, and multimodality screening strategies in the context of emerging technologies.
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Diagnostic accuracy of serum HE4, CA125 and ROMA in patients with ovarian cancer: a meta-analysis. Tumour Biol 2014; 35:6127-38. [DOI: 10.1007/s13277-014-1811-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 02/28/2014] [Indexed: 12/17/2022] Open
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Winarto H, Laihad BJ, Nuranna L. Modification of Cutoff Values for HE4, CA125, the Risk of Malignancy Index, and the Risk of Malignancy Algorithm for Ovarian Cancer Detection in Jakarta, Indonesia. Asian Pac J Cancer Prev 2014; 15:1949-53. [DOI: 10.7314/apjcp.2014.15.5.1949] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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