High CA 19-9 levels in benign biliary tract diseases. Report of four cases and review of the literature

A Case of Choledocholithiasis and Obstructive Jaundice With a Very High Serum Carbohydrate Antigen 19-9 (CA 19-9) Level: A Case Report and Review of Literature

Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker used clinically to support the diagnosis and recurrence of pancreatic adenocarcinoma. CA 19-9 levels may be found to be elevated too in benign conditions, including hepatobiliary diseases such as choledocholithiasis, cholangitis, or cholestasis of any etiology. In this case, we are presenting a case of a 66-year-old man who has presented with diffuse abdominal pain and has been then found to have choledocholithiasis and obstructive jaundice treated with biliary sphincterotomy and balloon extraction. In the setting of extensive unclear gastroenterological surgeries, tumor markers were obtained, and the results revealed markedly elevated CA 19-9 with negative other tumor markers and a negative workup for malignancy. After reviewing the literature, we found that although CA 19-9 has been studied in diagnosing pancreatic and biliary malignancies, the serum level may also be elevated in many other benign conditions. As a result, the results must be individualized according to the clinical scenario of each patient.

Tumor-Specific miRNA Signatures in Combination with CA19-9 for Liquid Biopsy-Based Detection of PDAC

Pancreatic ductal adenocarcinoma (PDAC) is considered one of the most aggressive malignancies and has high mortality and poor survival rates. Therefore, there is an urgent need to discover non-invasive biomarkers for early detection before PDAC reaches the incurable stage. We hypothesized that liquid biopsy of PDAC-derived extracellular vesicles (PDEs) containing abundant microRNAs (miRNAs) could be used for early diagnosis of PDAC because they can be selectively enriched and because they are biologically stable. We isolated PDEs by immunocapture using magnetic beads, and we identified 13 miRNA candidates in 20 pancreatic cancer patients and 20 normal controls. We found that expression of five miRNAs, including miR-10b, miR-16, miR-155, miR-429, and miR-1290, was markedly higher in PDEs. Furthermore, the miRNA signatures along with serum carbohydrate antigen 19-9 (CA19-9) were optimized by logistic regression, and the miRNA signature and CA19-9 combination markers (CMs) were effective at differentiating PDAC patients from normal controls. As a result, the CMs represented a high sensitivity (AUC, 0.964; sensitivity, 100%; specificity, 80%) and a high specificity (AUC, 0.962; sensitivity, 85.71%; specificity, 100%). These findings suggest that five miRNAs expressed in PDEs and CA19-9 are valuable biomarkers for screening and diagnosis of pancreatic cancer by liquid biopsy.

Predicting Adverse Pathologic Features and Clinical Outcomes of Resectable Pancreas Cancer With Preoperative CA 19-9

Background

We evaluated preoperative CA 19-9 levels in patients with resected pancreatic cancer to analyze whether they were predictive of clinical outcomes and could help select patients for additional therapy. We hypothesized that elevated CA 19-9 would be associated with worse pathologic findings and oncologic outcomes.

Methods

This study assessed 509 patients with non-metastatic pancreatic adenocarcinoma who underwent resection at our institution from 1995-2011 and had preoperative CA 19-9 recorded. No patients received neoadjuvant therapy. CA 19-9 level was analyzed as a continuous and a dichotomized (> vs. ≤ 55 U/mL) variable using logistic and Cox models.

Results

Median follow-up was 7.8 years, and the median age was 66 years (33-90). 64% of patients had elevated preoperative CA 19-9 (median: 141 U/mL), that did not correlate with bilirubin level or tumor size. Most patients had ≥ T3 tumors (72%) and positive lymph nodes (62%). The rate of incomplete (R1 or R2) resection was 19%. Increasing preoperative CA 19-9 was associated with extra-pancreatic extension (p=0.0005), lymphovascular space invasion (p=0.0072), incomplete resection [HR (95% CI) 2.0 (1.2-3.5)], and lower OS [HR = 1.6 (1.3-2.0)]. Each doubling in preoperative CA 19-9 value was associated with an 8.3% increased risk of death [HR = 1.08 (1.02-1.15)] and a 10.0% increased risk of distant recurrence [HR = 1.10 (1.02-1.19)]. Patients classified as non-secretors had comparable outcomes to patients with normal CA 19-9.

Conclusions

Elevated preoperative CA 19-9 level was associated with adverse pathologic features, incomplete resection, and inferior clinical outcomes. Neither tumor size nor bilirubin confound an elevated CA 19-9 level. Preoperative CA 19-9 level may help select patients for additional therapy.

Carbohydrate antigen 19-9 elevation without evidence of malignant or pancreatobiliary diseases

Although carbohydrate antigen 19-9 (CA 19-9) may be elevated in benign diseases, elevated CA 19-9 may cause a fear of cancer and unnecessary follow-up studies. Research on how to approach systematically in this case is very limited. The purpose of this study was to analyze the clinical features and the causes of CA 19-9 elevation without evidence of malignant or pancreatobiliary diseases. We retrospectively reviewed the medical records of patients who had CA 19-9 elevation (≥80 U/mL) and were found to be unrelated to cancer after follow-up. After exclusion, 192 patients were included in this study. The median level of CA 19-9 was 136.5 U/mL. The causes of CA 19-9 elevation were determined in 147 (76.6%) patients, and that was unknown in 45 (23.4%). The estimated causative diseases were hepatic diseases in 63 patients, pulmonary diseases in 32, gynecologic diseases in 38, endocrine diseases in 13, and spleen disease in 1. Of 45 patients with unknown cause, 35 had normalization of CA 19-9 and 10 had persistently elevated CA 19-9. In conclusion, CA 19-9 elevation without malignancies or pancreatobiliary diseases should be systematically evaluated and followed up. We suggest an algorithm to investigate the causes and follow up these patients.

CA 19-9 levels in patients with acute pancreatitis due to gallstone and metabolic/toxic reasons

OBJECTIVE

Acute pancreatitis (AP) is an important clinical event with an increased frequency due to increased life expectancy, obesity, and alcohol use. There are some data about the elevation of carbohydrate antigen (CA) 19-9 levels in benign and malignant pancreaticobiliary events in the literature, but in AP they are limited. The aim of this study was to evaluate the CA 19-9 level in patients with AP and determine its relationship according to the cause.

METHODS

Between 2010-2018, 173 patients evaluated with CA 19-9 levels as well as by standard laboratory tests were included in the study. CA 1 9-9 levels and laboratory findings were compared in patients with pancreatitis due to gallstone (group 1) and metabolic/toxic reasons such as hyperlipidemia, alcohol, or drug use (group 2).

RESULTS

There were 114 (66%) patients in the group 1 and 59 (34%) patients in the group 2. The majority of patients with high CA 19-9 level were in group 1 (92.1% vs 6.8%). CA 19-9 level, as well as amylase, lipase, AST, ALT and bilirubin levels were found to be statistically higher in patients with AP due to gallstone compared to patients with metabolic/toxic AP.

CONCLUSIONS

Patients with AP due to gallstone, were found to have a high level of CA 19-9 at admission. Early stage CA 19-9 levels may contribute to standard laboratory tests in the etiology of the disease in patients diagnosed with AP.

Dilemma of elevated CA 19-9 in biliary pathology

Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker which has been extensively evaluated and widely utilized primarily in diagnosing and prognosticating pancreaticobiliary malignancies. Levels may be significantly influenced and elevated in cases of benign biliary conditions however, especially in obstructive jaundice, thereby posing difficulty in distinguishing between benign and malignant cholestasis. A myriad of studies have focused on elucidating proper use and interpretation of CA 19-9 in pancreatic cancer as well as in the setting of cholestasis. These studies have demonstrated that many factors influence CA 19-9 values and various methods for interpreting CA 19-9 in obstructive jaundice have been proposed. With improvements in diagnostic imaging, advancements in endoscopic modalities, and likelihood that management will not change based on the results of the test, clinicians should be cautious when ordering CA 19-9 and consider the reasons for measuring the tumor marker.

Clinical Interpretation of Elevated CA 19-9 Levels in Obstructive Jaundice Following Benign and Malignant Pancreatobiliary Disease

Background/Aims

Elevated carbohydrate antigen (CA) 19-9 level may be unable to differentiate between benign and malignant pancreatobiliary disease with obstructive jaundice. The study aims to determine the clinical interpretation and the diagnostic value of CA 19-9 level in pancreatobiliary diseases with coexistent obstructive jaundice.

Methods

We retrospectively reviewed the data of 981 patients who underwent biliary drainage due to obstructive jaundice following pancreatobiliary disease at Sanggye Paik Hospital for 5 years. 114 patients with serial follow-up data for CA 19-9 level were included in this study (80 patients with malignancy and 34 patients with benign diseases). We compared the levels of CA 19-9 levels and the biochemical value before and after biliary drainage.

Results

The rate of CA 19-9 elevation (>37 U/mL) was significantly different between the benign group and the malignant group (59% vs. 90%, p=0.001). Despite the decrease in serum bilirubin after biliary drainage, CA 19-9 levels remained elevated in 12% of patients in the benign group and in 63% of patients in the malignant group (p<0.001). Finally, 12% of patients in the benign group turned out to have malignant disease. A receiver operating characteristic analysis provided a cut-off value of 38 U/mL for differentiating benign disease from malignant disease after biliary drainage (area under curve, 0.787; 95% confidence interval, 0.703 to 0.871; sensitivity, 62%; specificity, 88%).

Conclusions

This study suggested that we should consider the possibility of malignant causes if the CA 19-9 levels remain high or are more than 38 U/mL after resolution of biliary obstruction.

Serum carbohydrate antigen 19-9 in pancreatic adenocarcinoma: a mini review for surgeons

The optimal management of oncological conditions is reflected by the careful interpretation of investigations for screening, diagnosis, staging, prognostication and surveillance. Serum tumour markers are examples of commonly requested tests in conjunction with other imaging and endoscopic tests that are used to help clinicians to stratify therapeutic decisions. Serum carbohydrate antigen 19-9 (CA19-9) is a key biomarker for pancreatic cancers. Although this biomarker is considered clinically useful and informative, clinicians are often challenged by the accurate interpretation of elevated serum CA19-9 levels. Recognizing the pitfalls of normal and abnormal serum CA19-9 concentrations will facilitate its appropriate use. In this review, we appraised the biomarker, serum CA19-9, and highlighted the clinical utility and limitations of serum CA19-9 in the investigation and management of pancreatic cancers.

Prognostic Value of Preoperative Serum Carcinoembryonic Antigen and Carbohydrate Antigen 19-9 After Resection of Ampullary Cancer

BACKGROUND

The purpose of this study is to investigate the prognostic value of pre-resection serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 after resection of ampullary cancer (AC) in consideration of intestinal (IT) and pancreatobiliary (PT) subtypes.

METHODS

Overall survival (OS) analysis of patients undergoing curative resection of ampullary cancer.

RESULTS

Elevated preoperative CEA (P = 0.013) and CA 19-9 levels (P = 0.030) were significant prognostic factors. Subgroup analysis, however, showed both markers having prognostic value only for the IT subgroup. Pre-resection CEA within normal range identified a subgroup of IT patients with an excellent median survival of 145 months. Compared to other AC patients, this low-risk IT_CEA^- subpopulation was characterized by less frequent advanced pT stages (pT3/pT4, 41 vs. 62%; P = 0.047) and lymph node involvement (pN+, 30 vs. 65%; P = 0.001). OS of this subgroup was significantly better compared to other AC patients (145 vs. 25 months; HR = 3.8; P < 0.001). By multivariate survival analysis, the patient age, the PT subtype, and an elevated pre-resection serum CEA value were identified as independent prognostic variables.

CONCLUSIONS

In AC, the histomorphologic subclassification is highly relevant regarding the prognostic value of preoperative serum CEA and CA 19-9. IT-patients with normal preoperative CEA represent a favorable subgroup with excellent long-term survival.

Congenital choledochal malformation: search for a marker of epithelial instability

PURPOSE

There is a predisposition to the development of malignancy in congenital choledochal malformation (CCM) although the degree of risk is unknown. We investigated the role of CA19-9 in bile and the MIB-1 (Ki-67) epithelial proliferation index as markers of an at risk choledochal epithelium at the time of definitive surgery.

METHODS

Bile collected at surgery was analyzed for levels of amylase (as a surrogate of pancreatic reflux) and CA19-9. Immunohistochemical staining for CA19-9 and MIB-1 index (expressed as %) was performed on resected specimens. Data are quoted as median (IQR) and differences assessed using non-parametric statistics. A P value of 0.05 was regarded as significant.

RESULTS

Our study group consisted of 78 children with CCM (Type 1 fusiform, n=34; Type 1 cystic, n=30 and Type 4, n=14). Median bile CA19-9 was 159,400 (6-1×10(6)) kU/L. There was no correlation with bile amylase (P=0.49) or biliary pressure (P=0.17) but modest correlation with bilirubin (rs=0.24; P=0.02). In contrast, bile amylase was correlated with plasma γ-glutamyl transpeptidase (P=0.02), alkaline phosphatase (P=0.05) and aspartate aminotransferase (P=0.02); and inversely correlated with biliary pressure (rs=-0.38; P<0.0008). Epithelial expression of CA19-9 and MIB-1 was assessed in 43 specimens. CA19-9 was diffusely expressed on all choledochal epithelium. MIB-1 expression was divided into: high expression (>40%) n=3; moderate (20-40%) n=5, low (6-20%) n=7 and very low (≤5%) n=28. There was no correlation with choledochal pressure (P=0.87), CA19-9 (P=0.51) or bile amylase (P=0.55).

CONCLUSION

Biliary CA19-9 levels were grossly (and unexpectedly) raised in choledochal malformation and appear to arise from biliary rather than pancreatic epithelium. MIB-1 confirms that a small proportion (19%) has marked epithelial proliferation but no clinical correlates could be identified.

Benign Hydronephrosis and Elevated of Serum Levels of Carbohydrate Antigen CA 19-9: A Case Report

Patient: Male, 58

Final Diagnosis: Hydronephrosis

Symptoms: Blunt abdominal pain • constipation • constipation

Medication: —

Clinical Procedure: Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy

Specialty: Gastroenterology and Hepatology

The diagnostic value of brush cytology alone and in combination with tumor markers in pancreaticobiliary strictures

Aim. Differentiation of malignant and benign strictures constitutes a problem despite the increasing experience of the endoscopists, radiologists, and pathologists. The aim of our study is to determine the factors that affect the efficacy of the ERCP guided brush cytology in PBS and to evaluate its diagnostic success when used alone and together with tumor markers. Method. The data from brush cytologies of 301 PBS patients were collected retrospectively and analyzed. The final diagnosis was approved based on the histological examination of the tissue taken surgically or by other methods. In the absence of a histological diagnosis, the final diagnosis was based on radiological studies or the results of a 12-month clinical follow up. Results. A total of 28 patients were excluded from the study. From the remaining 273 patients 299 samples were analyzed. The sensitivity and the specificity of brush cytology in diagnosing malignancy are 62.4% and 97.7, respectively. The sensitivity of brush cytology increased to 94.1% when combined with CA-19.9 and CA-125. Conclusion. Brush cytology is a useful method in diagnosing pancreaticobiliary strictures. Advanced age, stricture dilatation before sampling, the presence of a mass identified by radiological studies, high levels of CA-19.9, ALT, and total bilirubin increase the sensitivity of brush cytology.

Elevated serum CA 19-9 at screening tests: underlying conditions and role of abdominopelvic CT

OBJECTIVES

To investigate underlying conditions of patients with elevated CA 19-9 at screening tests and to evaluate diagnostic performance of abdominopelvic CT.

METHODS

One hundred and thirteen patients with elevated CA 19-9 (>37 U/ml) who underwent abdominopelvic CT in a screening program were selected. Underlying conditions were determined by reviewing all available data and follow-up records. Patients were categorized into malignancy, benign, and normal/non-related disease groups. Their mean CA 19-9 and percent of patients with CA 19-9 ≥ 100 U/ml were compared. Diagnostic sensitivity of CT for detecting underlying conditions of elevated CA 19-9 was analysed.

RESULTS

Seventeen patients (17/113, 15 %) had 17 elevated CA 19-9-related malignancies, and 55 patients (55/113, 48.7 %) had 70 benign diseases. Mean CA 19-9 and percent of patients with CA 19-9 ≥ 100 U/ml in the malignancy group were significantly higher than in the two other groups. CT detected all except one malignant lesion with a detection sensitivity of 94.1 % (16/17). Of 70 CA 19-9-related benign diseases, CT detected 34 benign diseases (48.6 %) providing an alternative diagnosis for elevated CA 19-9.

CONCLUSION

Abdominopelvic CT is not only useful in detecting malignancies, but can also diagnose alternative benign causes of elevated CA 19-9 in asymptomatic screening tests.

KEY POINTS

• Fifteen percent of asymptomatic patients with elevated CA19-9 may have intra-abdominal malignancies. • Mean value of CA19-9 is different among malignant, benign, and non-related groups. • CT shows excellent sensitivity for intra-abdominal malignancies as causatives of elevated CA19-9. • CT provides alternative benign diagnoses as causatives of elevated CA19-9. • Detection of causatives of elevated CA19-9 using CT alleviates concerns and uncertainty.

CA19-9 serum levels in obstructive jaundice: clinical value in benign and malignant conditions

BACKGROUND

Obstructive jaundice is frequently associated with false CA19-9 elevation in benign conditions. The diagnostic accuracy of this tumor marker was evaluated in the present longitudinal study.

METHODS

In 128 patients admitted for obstructive jaundice (87 with pancreato-biliary malignancy and 41 benign disease) serum CA19-9 was measured. Statistical analysis of marker levels obtained before and after endoscopic biliary drainage was performed in 60 patients.

RESULTS

Elevated CA19-9 levels (>37 U/mL) were found in 61% of benign cases and 86% of malignancies. After biliary drainage, decrease of serum CA19-9 was observed in 19 of 38 malignant cases and in almost all benign cases (Wilcoxon matched pairs test: P = .207 and P <.001, respectively). Receiver operating characteristic (ROC) analysis identified a cut-off value of 90 U/mL to be associated with improved diagnostic accuracy after biliary drainage (sensitivity 61%, specificity 95%).

CONCLUSIONS

In the presence of successfully drained obstructive jaundice, CA19-9 serum levels that remain unchanged or measure more than 90 U/mL are strongly indicative of a malignant cause of obstruction. However, the real clinical utility of this marker remains controversial.

Mirizzi's syndrome: a diagnostic dilemma

A 62-year-old male presented with a history of upper abdominal discomfort. Past history included asymptomatic gallstones. Abdominal ultrasound and CT demonstrated gallstones within a thick-walled gallbladder, and intra and extrahepatic duct dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture within the mid-portion of the common bile duct. At laparotomy, a single large stone was found causing external compression of the common bile duct causing a Mirizzi's-type stricture. At repeat ERCP, cholangiogram showed no evidence of stricture. Clinicians should be aware that no definite clinical signs distinguish Mirizzi's syndrome and surgical exploration is often required for diagnosis.

Hemobilia as the initial manifestation of cholangiocarcinoma in a hemophilia B patient

Hemobilia is a rare manifestation of hemophilia and is usually iatrogenic following liver biopsy. There are only few reports of spontaneous hemobilia in hemophilia patients. Cholangiocarcinoma is a well-established cause of hemobilia. We describe a case of a 70-year-old male, with known haemophilia B and a past history of papillotomy, who presented with classical symptoms of hemobilia. The initial diagnostic work-up failed to demonstrate a potential cause of bleeding other than the coagulopathy. Three months later, he was readmitted to our hospital with a second episode of hemobilia. During the second work-up, a cholangiocarcinoma was diagnosed both by imaging studies and by a significant elevation of cancer antigen 19-9. Although hemobilia could be attributed to hemophilia, especially in a patient with previous papillotomy, an underlying malignancy of the biliary tree should be suspected.

Elevation of serum and urinary carbohydrate antigen 19-9 in benign hydronephrosis

OBJECTIVE

The aim of this study was to find out the predictive role of serum and urinary carbohydrate antigen 19-9 levels in benign hydronephrosis and whether these levels are helpful for differentiation of complete or partial urinary obstruction.

MATERIALS AND METHODS

Fifty-four patients with, and 23 without, benign hydronephrosis were enrolled in this study. Serum and urinary carbohydrate antigen 19-9 were determined by the chemiluminescence enzyme immunometric assay method and these levels were correlated with clinical factors.

RESULTS

The mean serum (P < 0.0001) and urinary (P < 0.0001) carbohydrate antigen 19-9 and serum creatinine (P < 0.008) levels were significantly higher in the hydronephrosis group than the control group. There was significant correlation between serum and urinary carbohydrate antigen 19-9 levels in the hydronephrosis group (r = 0.639, P < 0.0001). In the hydronephrosis group, there were no significant differences between the serum creatinine, serum or urinary carbohydrate antigen 19-9 levels and the clinical features except symptom duration. The best cut-off value for the serum and urinary carbohydrate antigen 19-9 were found to be 4.84 U/mL and 29.35 U/mL, respectively.

CONCLUSION

Serum and urinary carbohydrate antigen 19-9 levels correlated with each other, were significantly elevated in patients with hydronephrosis and did not predict complete urinary obstruction. Benign hydronephrosis should be considered in the differential diagnosis of carbohydrate antigen 19-9 increments, as this is what is of most importance in clinical practice.

Normalisation of high CA 19-9 values in autoimmune hepatitis after steroidal treatment

Carbohydrate 19-9 antigen (CA 19-9) is considered a specific marker of pancreatobiliary adenocarcinomas, but slight increase of its levels can be found in several non-malignant diseases of the liver, such as autoimmune hepatitis. We describe a case of marked CA 19-9 elevation (up to 898.0 U/ml) in a patient with autoimmune hepatitis. Laboratory and instrumental examinations excluded malignant diseases. Immunohistochemical analysis for CA 19-9 and MIB-1, performed on liver biopsy, showed reactivity in inflammatory areas, in particular in bile ductule cells and hepatocytes in ductular metaplasia, suggesting that these cells could be involved in CA 19-9 serum levels increase. After steroids, the clinical picture improved and all the laboratory parameters normalised.

Alpha1-and beta2-adrenoceptors in the human liver with mass-forming intrahepatic cholangiocarcinoma: density and coupling to adenylate cyclase and phospholipase C

Besides the regulation of hepatic metabolic pathways in which adrenoceptors are mainly involved, their effect on the second messenger cAMP is thought to be related to the growth and differentiation of neoplastic cells. However, few studies have been done on the status of these structures in the human liver affected by cholangiocarcinoma (CC). Thus, in this study, changes in densities of alpha1- and beta2-adrenoceptors (alpha1-and beta2-ARs) were investigated in membranes of human liver with cholangiocarcinoma, and for comparison, in membranes of non-adjacent non-tumour liver using the potent antagonists [3H]-prazosin and [1I]-iodocyanopindolol (ICYP) respectively. In addition, the activity of membrane-bound phospholipase C (PLC) and adenylate cyclase (AC) was also studied. In CC liver, the density of alpha1-and beta2-ARs was significantly reduced, compared with non-tumour liver tissues (alpha1-ARs: 23.38+/-4.69 vs 80.35+/-10.52, P=0.0002 beta2-ARs: 14.27+/-2.93 vs 33.22+/-4.32 fmol/mg protein, P=0.03), whereas the ligand affinities (KD) remained unchanged. The beta2-selective antagonist ICI 118,551 was about 100 times more potent in inhibiting ICYP binding than the beta1-selective antagonist CGP 20712A; thus, more than 98% of the beta-ARs were of the beta2-subtypes. The AC activity upon stimulants acting on beta-AR (isoprenaline), G-protein (GTP, NaF) and AC (forskolin) was decreased in CC liver. Similarly, noradrenaline-stimulated PLC activity was significantly reduced in tumour tissues. In conclusion, in CC liver the alpha1- and beta2-ARs density was down-regulated and the neoplastic invasion blunted AC and PLC activity. These quantitative changes may help to elucidate not fully understood pathogenetic mechanisms of disturbed hepatic metabolic processes, such as hypoglycemia during cancer in human liver.