Elevated serum CA125 and CA19-9 due to the spontaneous rupture of ovarian endometrioma

Enhancing endometrioma management: Diagnostic biomarkers and predictive outcomes in Ruptured vs. Non-Ruptured cases

OBJECTIVE

To compare the outcomes between patients undergoing surgery for ruptured endometrioma versus non-ruptured endometrioma.

STUDY DESIGN

The study was conducted at Health Sciences University, Etlik Zübeyde Hanım Training and Research Hospital Infertility Clinic. All patients who had a histopathology report of endometrioma between January 2014 and December 2020 were recruited. Patient files, surgery notes and laboratory values were extracted from the electronic recording system and patients with ruptured endometriomas (RE) or non-ruptured endometriomas (NRE) were compared.

RESULTS

Overall, 181 patients were recruited to the study. No rupture was detected in 146 (80.7 %) patients while 35 patients (19.3 %) underwent surgery for RE. Pre-operative CRP, CA 125, CA 19-9, CA 15-3, CEA and mean platelet volume (MPV) values and postoperative MPV and neutrophil/lymphocyte ratio (NLR) values were statistically significantly higher (p < 0.01) in the RE group compared to the NRE group. Post-operative lymphocyte (p = 0.029) and eosinophyl (p = 0.015) values were significantly lower in the RE group compared to the NRE group. Among the preoperative biomarkers that are evaluated for prediction of rupture; MPV, CA 19-9 and CA-15.3 had a high specifity (>75 %) but a rather low sensitivity (<60 %), meanwhile CRP, CA-125 and CEA had high sensitivity but a low specifity.

CONCLUSION

RE patients had significantly higher preoperative CRP, CA 125, CA 19-9, CA 15-3, CEA, and MPV values and postoperative MPV and NLR values while postoperative, lymphocyte and eosinophyl values were significantly lower compared with the NRE patients. Prospective studies with larger sample sizes are needed to determine biomarkers and parameters that can be used for non-invasive diagnosis of endometriosis and predict the possibility of endometrioma rupture.

Diagnostic Clues for Women with Acute Surgical Abdomen Associated with Ruptured Endometrioma

(1) Background: An investigation of the preoperative diagnostic clues used to identify ruptured endometrioma by comparing the ruptured and unruptured states in patients who underwent laparoscopic operations due to endometrioma. (2) Methods: Patients with ruptured endometriomas (14 patients) and unruptured endometriomas (60 patients) were included, and clinical symptoms, laboratory findings, and radiological findings were analyzed. (3) Results: There were no significant differences in age, parity, last menstrual cycle days, or median size of endometrioma between two groups (group A: ruptured; group B: unruptured). The median serum level of CA 125 was 345.1 U/mL in group A and 49.8 U/mL in group B (p = 0.000). The median serum levels of CA 19-9 in group A and B were 46.0 U/mL and 19.1 U/mL, respectively (p = 0.005). The median serum level of CRP in group A was 1.2 g/dL, whereas it was 0.3 in group B (p = 0.000). ROC analysis showed that the optimal CA 125 cutoff value was 100.9 U/mL; the optimal CA 19-9 cutoff value was 27.7 U/mL; and the optimal CRP cutoff value was 1.0 g/dL. (4) Conclusions: Ruptured endometrioma can be diagnosed preoperatively using a combination of clinical symptoms, laboratory findings, and radiological findings. If a physician suspects a ruptured endometrioma, surgery should be performed to ensure optimal prognosis.

Spontaneously ruptured endometriomas presenting with symptoms and imaging findings worrisome for carcinomatosis: A case report

INTRODUCTION AND IMPORTANCE

Endometriomas are the most common presenting subtype of endometriosis. Although most endometriomas are asymptomatic, patients can rarely present acutely with spontaneous rupture causing diffuse peritonitis and severe systemic inflammatory response.

CASE PRESENTATION

Here we describe a case of ruptured endometriomas in a 26-year-old nulligravid female with a history of heavy menses, progressive abdominal distension, and a recent urinary tract infection. The patient presented to the emergency department with upper abdominal pain radiating to her back with associated nausea. Computed tomography (CT) scan demonstrated diffuse ascites with a large, multilobulated, and multicystic septated mass arising in the right pelvis and extending into the lower abdomen. Findings were concerning for peritoneal carcinomatosis and the patient was admitted for evaluation. She developed progressive signs of sepsis and was emergently brought to the operating room for surgical exploration on hospital day (HD) number two. She was found to have ruptured pelvic cysts arising from both ovaries with diffuse contamination of the abdomen by cyst contents and bilateral salpingo-oophorectomy (BSO) was performed. Final pathology demonstrated benign bilateral endometriomas.

CLINICAL DISCUSSION

Endometrioma rupture is extremely rare and imaging findings may appear to represent disseminated peritoneal malignancy. CT findings demonstrating a pelvic mass with concurrent ascites should raise clinical suspicion for ruptured endometrioma, particularly in younger patients.

CONCLUSION

Prompt surgical exploration and complete resection of pathologic tissue may be necessary for diagnosis and treatment in some patients with clinical deterioration related to perforated endometriomas. Combined oral contraceptives are recommended in the postoperative period.

Extremely high serum CA19-9 level along with elevated D-dimer in assisting detection of ruptured ovarian endometriosis

BACKGROUND

To clarify clinical importance of serum CA19-9, CA-125, and plasma D-dimer (D-D) levels in detecting spontaneously ruptured ovarian endometriosis (OE).

MATERIALS AND METHODS

We retrospectively examined 173 patients with endometriosis out of 735 cases of OE between 2013 and 2019. Among these, 21 cases were diagnosed as "spontaneously ruptured" after surgery, while the remaining cases were unruptured. Venous blood was collected pre-operatively to detect CA19-9, CA-125, and D-D levels. A receiver operating characteristic curve analysis was applied to test clinical value of each marker.

RESULTS

Among the 21 patients with ruptured OE, 16 had a history of pelvic cysts, 19 claimed sudden onsets of lower abdominal pain, and fluid accumulation were detected in cul-de-sac in only six participants by ultrasound. For serological investigation, both CA19-9 and D-D were significantly elevated in the ruptured OE group (343.09 ± 367.67 U/ml vs. 36.84 ± 40.01 U/ml, 3.39 ± 4.90 mg/L vs. 0.43 ± 0.29 mg/L, both p < .0001). The area under curve (AUC) value for the combination of CA19-9 and D-D was 0.975 (95% CI, 0.939 - 0.993), with specificity of 96.69%, and sensitivity of 85.71%. The combination of CA-125, CA19-9 and D-D showed the highest AUC value that up to 0.976 (95% CI, 0.940-0.993), with sensitivity of 95.24%, and specificity of 87.50%.

CONCLUSION

The combination of CA19-9 and D-D can be chosen as an effective and economical indicators to identify patients with spontaneously ruptured OE in pre-operation assessment. However, from the perspective of differential diagnosis, the combination of CA-125, CA19-9 and D-D is the best choice. Key messagesTaking into account the economic effect, the combination of CA19-9 and D-D can be chosen as an effective indicators to identify patients with spontaneously ruptured OE in pre-operation assessment.From the perspective of differential diagnosis, the combination of CA-125, CA19-9 and D-D is the best choice to identify patients with spontaneously ruptured OE.

Ruptured endometrioma in a nonpregnant patient: a case report

Background

Endometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.

Case presentation

A 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.

Conclusions

Ruptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma.

Acute Diffuse Peritonitis Due to Spontaneous Rupture of an Infected Endometrioma: A Case Report

Background.

Endometriosis is defined as a chronic, inflammatory, estrogen-dependent gynaecologic disease. It affects approximately 5–10% of reproductive-age women worldwide. Ovarian endometriosis is the most frequent form of this condition. Endometriotic cysts are found in about 17–44% of women diagnosed with endometriosis. It is well known, that ovarian endometriomas can cause infertility and chronic pelvic pain. Enlarging cysts can also cause ovarian torsion. In addition, ovarian endometriosis slightly increases the risk for ovarian cancer. The rupture of endometriotic ovarian cysts is an exceptional complication. According to the literature, the prevalence is less than 3% among women with endometriosis. The rupture of an ovarian endometrioma can cause acute peritonitis, which can lead to sepsis, septic shock and can be lethal. The occurrence of abscesses within an ovarian endometrioma is an extremely rare complication. Generally, the origin of infected endometriotic ovarian cysts is related to the previous invasive procedures involving pelvic organs or the use of intrauterine devices. Also, ovarian abscesses can be caused by the hematogenous or lymphatic spread of bacteria. Although, the literature points out that infection of endometriotic ovarian cysts can develop spontaneously. In these rare cases, reservoir and route of infection remains an enigma.

Case report.

A 49-year-old female was brought to the emergency room with severe generalized lower abdominal pain (6/10) and three days lasting fever. Abdominal examination revealed diffuse abdominal pain with anterior abdominal wall muscle tension. Painful solid masses were felt on both sides of the uterus during the pelvic examination. Cystic masses were detected in both ovaries during transvaginal sonography. Computer tomography (CT) of the abdomen and pelvis revealed abnormal changes in both ovaries. A small amount of free fluid was found in the pelvic cavity along with thickened pelvic peritoneum. Suspecting acute peritonitis and bilateral tubo-ovarian abscesses, surgical treatment was performed. Lower midline laparotomy with bilateral adnexectomy and abdominal lavage with 4000 ml normal saline were done. The outcome of peritonitis was evaluated using the Mannheim peritonitis index (MPI=17 – low risk of morbidity and mortality). The histopathological examination revealed the diagnosis of bilateral endometriotic cysts complicated with acute inflammation, with associated acute inflammation of both fallopian tubes. Microbiological cultures from the purulent fluid were negative.

Conclusions.

Although the occurrence of abscesses within an ovarian endometrioma is an extremely rare finding in clinical practice, it has to be considered by gynaecologists because it might result in a surgical emergency that can be life-threatening. Being aware of the risk factors of abscesses within an endometrioma can lead to an early diagnosis of this rare condition and help to avoid serious complications.

Endometriosis: A Malignant Fingerprint

BACKGROUND

Endometriosis is complex, but identifying the novel biomarkers, inflammatory molecules, and genetic links holds the key to the enhanced detection, prediction and treatment of both endometriosis and endometriosis related malignant neoplasia. Here we review the literature relating to the specific molecular mechanism(s) mediating tumorigenesis arising within endometriosis.

METHODS

Guidance (e.g. Cochrane) and published studies were identified. The Published studies were identified through PubMed using the systematic review methods filter, and the authors' topic knowledge. These data were reviewed to identify key and relevant articles to create a comprehensive review article to explore the molecular fingerprint associated with in endometriosis-driven tumorigenesis.

RESULTS

An important focus is the link between C3aR1, PGR, ER1, SOX-17 and other relevant gene expression profiles and endometriosis-driven tumorigenesis. Further studies should also focus on the combined use of CA-125 with HE-4, and the role for OVA1/MIA as clinically relevant diagnostic biomarkers in the prediction of endometriosis-driven tumorigenesis.

CONCLUSIONS

Elucidating endometriosis' molecular fingerprint is to understand the molecular mechanisms that drive the endometriosis-associated malignant phenotype. A better understanding of the predictive roles of these genes and the value of the biomarker proteins will allow for the derivation of unique molecular treatment algorithms to better serve our patients.

Elevated CA 125 in a CASE of Leaking Endometrioma

Extremely elevated CA 125, usually suggestive of ovarian malignancy, can be found in physiological or benign conditions such as endometriosis. We present a case of an extremely elevated serum CA 125 level in a patient with stage four endometriosis and bilateral unruptured ovarian endometriomas, with evidence of leakage unilaterally. To avoid costly and unnecessarily invasive tests and procedures it is important to consider the differential diagnosis of endometriosis and/or leaking endometrioma in patients with a profoundly elevated CA 125 level.

Elevated serum CA 19-9 with adnexal mass: is it always an ovarian malignancy?

Endometriotic cysts a common benign gynaecological disease in women of reproductive age. We report an unusual case of ruptured endometrioma associated with increased CA 19-9. A 27-year-old woman presented with an acute abdomenal adnexal mass and elevated CA 19-9. The initial diagnosis of ovarian malignancy turned out to be a ruptured endometrioma, confirmed during surgery and in the histopathological report.

Spontaneously Ruptured Paraovarian Tumor of Borderline Malignancy with Extremely Elevated Serum Carbohydrate Antigen 125 (CA125) Levels: A Comparison of the Imaging and Pathological Features

Patient: Female, 22

Final Diagnosis: Paraovarian tumor of borderline malignancy

Symptoms: Hypochondriac pain

Medication: —

Clinical Procedure: —

Specialty: Radiology

High CA-125 and CA19-9 levels in spontaneous ruptured ovarian endometriomas

BACKGROUND

To evaluate the clinical significance of serum CA-125 and CA19-9 in women with spontaneous ruptured ovarian endometriomas.

METHODS

From January 2006 to April 2015, a total of 1653 women were diagnosed with ovarian endometriomas, and 43 women were diagnosed with the spontaneous rupture of their ovarian endometrioma. In addition, 70 women diagnosed with unruptured ovarian endometriomas were chosen to serve as control subjects. Serum CA-125 and CA19-9 levels, together with the clinical materials, were collected.

RESULTS

Serum CA-125, CA19-9, and the combined biomarkers were shown to be obviously elevated in the spontaneous ruptured ovarian endometrioma group (p=0.001, p=0.001, p=0.001, respectively). The AUC value for the combined biomarkers was 0.992 (95% CI, 0.981-1.000), with a high sensitivity and specificity of nearly 100% and 93.6%, respectively. Moreover, the maximum diameter of the mass was significantly (p=0.001) increased in the ruptured group.

CONCLUSIONS

Serum CA-125 and CA19-9 were significantly increased in patients with spontaneous ruptured ovarian endometriomas. Moreover, the combined biomarkers were better than either CA-125 or CA19-9 alone in the diagnosis of a spontaneous rupture of the ovarian endometrioma.

The Diagnostic Superiority of the HE-4 Marker over CA-125 and CA 19-9 in the Differentiation of a Large Pelvic Tumor – a Case Report

The HE-4 protein is a promising specific marker for the diagnosis of malignant pelvic tumors. The paper presents the case of a 41-year-old patient with a multi-chamber ovarian tumor several centimeters in diameter suspected to be a primary ovarian cancer or a metastatic one of gastrointestinal origin. The value of the HE-4 marker which is highly specific for an ovarian cancer was within normal limits and amounted to 24.33 pmol/L. The patient underwent surgery involving the unilateral removal of adnexa and the greater omentum during which the sample from the second ovary was collected. Histologic examination revealed ovarian endometriosis; however, diagnosis of the gastrointestinal tract did not reveal any abnormalities. The case presented also confirms the excellent sensitivity of the HE-4 marker in very difficult clinical cases, as well as its utility in the differential diagnosis of advanced endometriosis and malignant ovarian diseases.

Increased levels of CA 125 and CA 19.9 serum tumour markers following cyclic combined hormone replacement therapy

We report a case of increase in serum tumour markers CA 125 and CA 19.9 induced by cyclic combined hormone replacement therapy (HRT). A 52-year-old Caucasian post-menopausal woman presented with a slight enlargement of the right ovary and uterine fibromyomatosis. She was taking HRT for 4 years in a cyclic combined regimen of 2 mg oestradiol with 1 mg cyproterone acetate. The serum tumour markers occasionally measured were in normal range except CA 19.9 (997 U/mL; normal values 0.0-37) and CA 125 (85 U/mL; normal values 0.0-35). However, on one occasion, the CA 19.9 and CA 125 were high and then showed persistently high values (1005 and 81.3 U/mL, respectively). Radiodiagnostic investigations excluded any malignancies and a hysteroscopy showed endometrial thickening. After discontinuation of HRT, CA 125 levels returned to normal after 1 month, whereas CA 19.9 took 6 months to do so. Four months after the beginning subsequent therapy with over-the-counter phyto-oestrogens a new serum test showed an increase in CA 19.9 but CA 125 remained within the normal range. Phyto-oestrogen therapy was then interrupted and 1 month later CA 19.9 returned to normal. In this case, cyclic HRT was the probable cause of CA 19.9 and CA 125 increase. Positive dechallenge and subsequent CA 19.9 increase after phyto-oestrogen intake seem to confirm the role of oestrogens as the cause of the endometrial thickening through hormonal imbalance. Increased CA 19.9 and CA 125 levels in benign gynaecological conditions may be a source of misdiagnosis of malignant disease.

Pathophysiology of cyclic hemorrhagic ascites and endometriosis

Massive hemorrhagic ascites (4470 mL, range 1-10 L) in women with endometriosis is a rare condition occurring predominantly in black women. Of the 43 case reports published, 42 are compatible with the hypothesis that the hemorrhagic ascites is predominantly a consequence of excessive ovarian transudation similar to a Meigs syndrome. Indeed, bilateral ovariectomy cures the condition without recurrences, whereas after unilateral ovariectomy or cystectomy recurrence rate is more than 50%; during ovarian suppression by luteinizing hormone-releasing hormone agonist ascites disappears, but reappears after treatment. Superficial pelvic endometriosis also contributes to the ascites because after superficial endometriosis destruction the recurrence rate is only 4 in 14. Based on these data, it is suggested, to scrutinize the ovaries for tumors given the analogy with Meigs syndrome. In women desiring fertility, conservative treatment with destruction of endometriosis only can be attempted given the cure rate of some 20%. It is unknown what the effect of ovulation induction would be.

Abdominal/pelvic Coccidioidomycosis

BACKGROUND

Coccidioidomycosis is the second most common endemic fungal infection in the southwestern United States. Rarely, this fungal infection exhibits symptoms suggestive of peritoneal malignancy, such as ascites and abdominal pelvic masses.

CASE

We present a case involving a 51-year-old woman who presented with abdominal pain, ascites, and elevated serum CA-125 levels in 1995. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Final pathology revealed Coccidioidomycosis. Following prolonged treatment with fluconazole, her fungal symptoms resolved completely.

CONCLUSION

Patients with Coccidioidomycosis have a good prognosis if they are optimally diagnosed and treated. Ascites and elevated serum CA-125 levels associated with Coccidioidomycosis are not documented in the literature. Although extremely rare, abdominal Coccidioidomycosis could be considered in the differential diagnosis in patients who present with ascites or elevated serum CA-125 levels.