Tumor Markers in Ovarian Malignancies

R. Abdominal Wall Reconstruction After Extirpation of a 140-Pound Primary Ovarian Mucinous Adenocarcinoma

Ovarian cancer is a feared diagnosis for women and clinicians alike. Ovarian mucinous adenocarcinoma is a unique subset of ovarian cancer. As a primary tumor, massive ovarian masses, and more specifically mucinous adenocarcinomas, have been infrequently reported in the medical literature. Team approaches to massive tumor extirpations are essential, as patients often require the expertise of various subspecialists including, but not limited to, gynecologic-oncologists, general surgeons, and plastic and reconstructive surgeons. Here we present a case of a 71-year-old woman with a massive, incapacitating pelvic mass, later found to be a primary ovarian mucinous adenocarcinoma. Once medically optimized, a multi-service team approach was utilized for tumor extirpation and abdominal wall reconstruction. Involved surgical services included Gynecologic-Oncology, General Surgery, and Plastic and Reconstructive Surgery. Exploratory laparotomy for tumor extirpation, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal stripping, bilateral inguinal lymphadenectomy, and appendectomy was performed. Extensively thin, devascularized, and attenuated abdominal wall fascia that was adherent to the tumor was removed. The abdominal wall defect was reconstructed and reinforced with inlay and overlays of biologic monofilament mesh. Inverted-T of the vertical and horizontal skin components was performed in a tailor-tacking fashion, assuring the maintenance and protection of the abdominal skin flap vascularity through utilizing the Huger Zones of perfusion. Pathology revealed a stage IA grade 2 mucinous adenocarcinoma of the ovary without evidence of metastasis. No adjuvant therapies were required. The tumor's weight was 140 pounds, and its dimensions were 63 x 41 x 40 cm. It is our hope that presenting this experience will raise awareness of this spectrum of diseases and allow for earlier diagnoses and treatments, as well as exemplify the virtues of a team-based approach in the successful extirpation and subsequent reconstruction of the abdominal wall and skin.

Exosome-related protein CRABP2 is upregulated in ovarian carcinoma and enhances cell proliferation

Ovarian cancer is the most lethal cancer among women worldwide. Early diagnosis of ovarian cancer is a considerable challenge for gynecological oncologists. The exosome is a new emerging biomarker pool for cancer. Herein, we apply integrative transcriptome analysis to discover a new exosome biomarker for the diagnosis of ovarian carcinoma. We found 2316 differentially expressed genes (DEGs), among which were 431 DEGs that coded exosome proteins. We demonstrated three potential biomarkers-CRABP2, SPP1, and TNFAIP6, which are higher in ovarian cancer and associated with poor prognosis. According to receiver operating characteristic (ROC) curve analysis, CRABP2 performs better than the currently used biomarker CA125 in the diagnosis of ovarian cancer. CRABP2 level significantly elevates as the malignant property increases. We further confirmed that CRABP2 is upregulated in clinical tumor tissues of ovarian cancer patients as the malignant levels increase. CRABP2 can be detected and upregulated in the exosome in ovarian cancer patient serum samples rather than in healthy controls. GSEA revealed that high expression of CRABP2 was positively correlated with mitochondria oxidative phosphorylation pathway. At the same time, overexpression of CRABP2 can upregulate oxidative metabolism-related genes such as CYP4A11 and promote cell proliferation. Our findings based on CRABP2 could advance current practice in diagnosing and treating ovarian cancer.

ASCITIC AND SERUM LEVELS OF TUMOR BIOMARKERS (CA 72-4, CA 19-9, CEA AND CA 125) IN DISCRIMINATION OF CAUSE OF ASCITES: A PROSPECTIVE STUDY

BACKGROUND

The role of ascitic and serum levels of various tumour biomarkers in the discrimination of cause of ascites is not well established.

OBJECTIVE

To evaluate the role of serum and ascitic levels of tumor biomarkers (CA 72-4, CA 19-9, CEA and CA 125) in discrimination of cause of ascites.

METHODS

A prospective study was conducted in consecutive patients presenting with ascites. Serum and ascitic levels of CA 19-9, CA 125, CA 72-4 and carcinoembryonic antigen (CEA) were determined at the presentation. The patients with cirrhotic ascites, tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC) were eventually included in analysis.

RESULTS

Of the 93 patients (58 males, mean age 47 years) included, the underlying cause was cirrhosis in 31, PC in 42 and peritoneal tuberculosis in 20. The best cutoff for discriminating benign and malignant ascites for serum CEA, CA 19-9 and CA 72-4 were 6.7 ng/mL, 108 IU/mL and 8.9 IU/mL, respectively. The best cutoff for discriminating benign and malignant ascites for ascitic CA 125, CEA, CA 19-9 and CA 72-4 were 623 IU/mL, 8.7 ng/mL, 33.2 IU/mL and 7 IU/mL, respectively.

CONCLUSION

The performance of single biomarker for the prediction of underlying PC is low but a combination of serum CA 19-9 and CA 72-4 best predicted the presence of peritoneal carcinomatosis.

MicroRNAs in ovarian cancer and recent advances in the development of microRNA-based biosensors

Ovarian cancer is the most aggressive of all gynaecological malignancies and is the leading cause of cancer-associated mortality worldwide.

Study of oxidative stress in ovarian cancer

Background: Ovarian cancer is the fifth most common form of cancer in the world and is often asymptomatic in its early stages. Development of ovarian cancer-specific biomarkers for the early detection of disease could improve the current dismal survival rate. Evaluation of serum carbohydrate antigen 125 (CA125), alkaline phosphatase (ALP) and oxidative stress in ovarian carcinoma patients may improve the prognosis of the disease through earlier detection. Aim of the study: The aim of this study was to find the relative risk of ovarian cancer in patients screened for CA125, ALP, Nitric oxide (NO) and Malondialdehyde (MDA) as a marker for lipid peroxidation. Material and methods: 451 subjects with ovarian cancer were screened for serum CA125 levels using a chemiluminescence analyser, out of which 164 showed values above 21 U/ml. 80 subjects with higher values were further analysed for MDA and NO using spectrophotometry and ALP by fully automated chemistry analyser. Results: The selected 80 subjects with CA125 values above 74 U/ml had increased ALP, NO and MDA, also showing positive correlation amongst these parameters. Conclusions: Benefits of CA125 screening vary with age group according to blood CA125 levels. Enzyme ALP levels are elevated with higher values of CA125. MDA and NO indicate oxidative stress and increase as the ovarian marker values increase. Positive correlation amongst the parameters indicates a significant increase in oxidative stress in ovarian cancer. For women with various CA125 levels in different age groups, screening and treatment depends upon individual decision and clinical examination.

Diagnostic value of the gynecology imaging reporting and data system (GI-RADS) with the ovarian malignancy marker CA-125 in preoperative adnexal tumor assessment

Objectives

The purpose of this study is to assess the preoperative evaluation of an adnexal mass using the GI-RADS classification and to verify whether CA-125 measurement can offer any additional benefits to the GI-RADS-based prediction of ovarian tumor malignancy.

Material and methods

In this study, we assessed a total of 215 women with an adnexal tumor using the GI-RADS classification combined with CA-125 measurement. All adnexal masses underwent histological verification.

Results

Of a total of 215 lesions, we classified 2 lesions as GI-RADS 2 (0.9%), 118 lesions as GI-RADS 3 (54.9%), 86 lesions as GI-RADS 4 (40.0%) and 9 lesions as GI-RADS 5 (4.2%). For GI-RADS 4–5 lesions, the sensitivity, specificity, PPV, NPV, ACC and OR were as follows: 94.3, 72.2, 52.6, 97.5, 77.7%, and 43.3 (CI 12.0–146), respectively. The corresponding parameters resulting from combining the GI-RADS classification with the CA-125 marker were as follows: 66.0, 93.8, 77.8, 89.4, 87.0%, and 29.6 (CI 12.6–69.6), respectively, with p < 0.001. For Ca-125 > 30 IU/mL alone, the results were as follows: 70.0, 80.3, 53.8, 89.1, 77.7%, and 9.5 (4.6–19.6), respectively, with p < 0.0001.

Additionally, 47.8% of the patients had no symptoms, 36.5% had back pain, 5.2% had an increased abdominal size, 4.3% had menstrual irregularities and 2.6% had constipation. There were 152 benign and 18 malignant cases in the low risk group (GIRADS 1–3 and GIRADS 4 + CA-125 < 30 IU/mL) and 10 benign and 35 malignant tumors in the high-risk group (GIRADS 4 + CA125 > 30 IU/mL and GIRADS 5).

Conclusions

GI-RADS classification had good performance in discriminating ovarian tumors. The additional measurement of CA-125 improves the system specificity, PPV and ACC for preoperative adnexal tumor assessment.

Giant ovarian cyst masquerading as a massive ascites: a case report

BACKGROUND

Giant ovarian cysts are tumours of the ovary presenting with diameters greater than 10 cm. Giant ovarian cysts have become rare in recent days as they are diagnosed and managed early due to the availability of good imaging modalities. The aim of this case report is to show how a huge cystic ovarian mass can mislead the diagnosis of ascites in a postmenopausal woman. Factors associated with late presentation of giant ovarian cysts in sub-Saharan Africa have also been discussed.

CASE PRESENTATION

We present the case of a 65-year-old grand multiparous woman who was referred to our centre with a grossly distended abdomen misdiagnosed as a massive ascites. Abdominopelvic ultrasound scan revealed a right giant multiloculated ovarian cyst. She benefited from a cystectomy with an uneventful postoperative stay. Histopathology revealed mucinous cystadenoma.

CONCLUSION

Large cystic ovarian tumours can present masquerading as massive ascites and misleading diagnosis as in this case report. We report this case to increase the suspicion index of a large ovarian cyst in all women presenting with massive ascites.

Toxin-based therapeutic approaches

Protein toxins confer a defense against predation/grazing or a superior pathogenic competence upon the producing organism. Such toxins have been perfected through evolution in poisonous animals/plants and pathogenic bacteria. Over the past five decades, a lot of effort has been invested in studying their mechanism of action, the way they contribute to pathogenicity and in the development of antidotes that neutralize their action. In parallel, many research groups turned to explore the pharmaceutical potential of such toxins when they are used to efficiently impair essential cellular processes and/or damage the integrity of their target cells. The following review summarizes major advances in the field of toxin based therapeutics and offers a comprehensive description of the mode of action of each applied toxin.

CA125 in ovarian cancer

A quarter of a century since its discovery, circulating CA125 antigen is recommended for clinical use in the USA for ovarian cancer screening of high-risk women with ovaries, despite its limited sensitivity and specificity. Recent findings suggest that CA125 might also serve as a predictive marker for pre-invasive ovarian carcinoma. Methods to quantify circulating CA125 evolved toward sensitive and reliable double-determinant ELISA assays. The CA125 gene, MUC16, was cloned 20 years after the protein discovery and revealed a very complex and unusual glycoprotein structure, suggesting an immunological role. Recent evidence points toward CA125 function in the induction of materno-fetal tolerance through the alteration of natural killer phenotype. Two receptors for CA125 have been described: mesothelin and galectin-1. The specific location and functional proprieties of CA125 make it a therapeutic target of choice; clinical trials have demonstrated that anti-CA125 injections are well tolerated and suggest a potential survival benefit.

Prediction of progressive disease using tumor markers in metastatic breast cancer patients without target lesions in first-line chemotherapy

BACKGROUND

The aim of this study was to develop a prediction model of progressive disease (PD) in breast cancer patients without measurable disease in first-line chemotherapy.

METHODS

We developed a model to predict PD using carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 15-3 in metastatic breast cancer patients who were enrolled in a phase III trial. The model was determined using the area under the receiver operating characteristic curve (AUC) calculated by the bootstrap method as internal validation. We verified the model for those who received first-line chemotherapy in a clinical setting as external validation. We categorized patients without measurable disease into PD and non-PD groups and compared the time to progression (TTP).

RESULTS

The model consisted of percent changes in CEA and CA 15-3 levels from second to third chemotherapy course and baseline abnormality of them. The AUC after external validation was 0.90. Patients without measurable disease were categorized into PD (N = 10) and non-PD groups (N = 53) by the model. The difference in TTP between the two groups was statistically significant (hazard ratio, 0.437; P = 0.021).

CONCLUSION

The model may be useful to determine PD in metastatic breast cancer patients without measurable disease.

IgE myeloma with elevated level of serum CA125

OBJECTIVE

To explore clinical and laboratory features and significance of detecting serum carbohydrate antigen 125 (CA125) in immunoglobulin E (IgE) multiple myeloma.

METHODS

We reported the clinical findings of a male patient with IgE myeloma and elevated level of serum CA125 and reviewed the literature.

RESULTS

Laboratory tests of this patient on admission showed extremely high serum IgE and CA125, a bone marrow aspirate revealed abnormal plasma cells (38.4% of nucleated cells: 16.4% mature and 22% atypical), and in bone marrow biopsy, immunoperoxidase staining showed positive cytoplasmic staining for IgE and kappa light chain within the vast majority of plasma cells. Computed tomography (CT) bone scans indicated wedge shape change and compressive fracture of thoracic vertebrae, and emission computed tomography (ECT) discovered multiple punctiform aggregation of radiation in both cervical ribs and spine. The serum IgE and CA125 gradually decreased to normal limits after eight cycles of chemotherapy. This patient is alive well with an 18-month complete remission.

CONCLUSION

We reported the first case of IgE myeloma with elevated level of serum CA125. To further evaluate clinical characteristics and significance of CA125 in IgE myeloma, more cases are needed.

Development and in vitro validation of anti-mesothelin biobodies that prevent CA125/Mesothelin-dependent cell attachment

Preventing peritoneal implantation of carcinoma cells could prolong ovarian cancer patient remission and survival. Peritoneal cells constitutively express mesothelin, a ligand for CA125 that is expressed by tumor cells. Thus blocking CA125/mesothelin-dependent cell attachment may prevent or delay peritoneal metastatic recurrence. We developed a high-throughput screening system for reagents able to block CA125/mesothelin-dependent cell attachment with a sensitive quantitative readout. Using a novel yeast-expression system to produce secreted, in vivo biotinylated proteins and biobodies (Bbs), we generated anti-mesothelin Bbs. Anti-mesothelin Bbs derived from high affinity yeast-display scFv detected both membrane-bound and soluble mesothelins and inhibited CA125/mesothelin-dependent cell attachment.

Bead-based ELISA for validation of ovarian cancer early detection markers

PURPOSE

Efforts to validate ovarian cancer early detection biomarkers with immunoassays are challenged by the limited specimen volumes available. We sought to develop a specimen-efficient assay to measure CA125 in serum, assess its reproducibility, validity, and performance, and test its potential for multiplexing and combining with human epididymis protein 4 (HE4), a promising novel ovarian cancer marker.

EXPERIMENTAL DESIGN

Four pairs of commercially available anti-CA125 antibodies and one pair of anti-HE4 antibodies were evaluated for accuracy in measuring known concentrations of antigen on a bead-based platform. The two best pairs were further assessed for reproducibility, validity, and the ability to discriminate between blinded serum samples obtained from ovarian cancer cases (n = 66) and women without ovarian cancer (n = 125).

RESULTS

Suitability for use in a bead-based assay varied across CA125 antibody pairs. Two CA125 bead-based assays were highly reproducible (overall correlations between replicates >/= 0.95; coefficients of variation < 0.2) and strongly correlated with the research standard CA125II RIA (correlations >/= 0.9). Their ability to distinguish ovarian cancer cases from non-cases based on receiver operating characteristic analyses (area under the curve, AUC, of 0.85 and 0.84) was close to that of the CA125II RIA (AUC, 0.87). The HE4 bead-based assay showed lower reproducibility but yielded an AUC of 0.89 in receiver operating characteristics analysis. Multiplexing was not possible but a composite marker including CA125 and HE4 achieved an AUC of 0.91.

CONCLUSION

Optimization procedures yielded two bead-based assays for CA125 that perform comparably to the standard CA125II RIA, which could be combined with an HE4 bead-based assay to improve diagnostic performance, and requires only 15 muL of sample each.

Development of a CA125-mesothelin cell adhesion assay as a screening tool for biologics discovery

Preventing peritoneal implantation of ovarian carcinoma cells could prolong patient remission and survival. CA125 is expressed on most ovarian cancer cells and was reported to be a ligand of mesothelin, a peritoneal protein. We developed a cell adhesion assay with CA125-expresser ovarian cancer cells and human mesothelin-transfected cells and we confirmed that CA125 and mesothelin mediate cell attachment. We also showed that this assay supplies a high-throughput screening system for reagents able to block CA125/mesothelin-dependent cell attachment with a sensitive quantitative readout. We finally demonstrated that a mesothelin chimeric protein and anti-CA125 antibodies block CA125/mesothelin-dependent cell attachment.

CA-125 response in patients with recurrent ovarian or primary peritoneal cancer treated with pegylated liposomal doxorubicin or topotecan

OBJECTIVE

Recent additions of novel chemotherapeutics, such as pegylated liposomal doxorubicin (PLD) and topotecan (TPT), have provided clinicians with multiple options for treating recurrent ovarian cancer. Evaluating treatment response in patients without radiographic or physically measurable disease is problematic, thereby CA-125 values may be the only available objective criteria. It has been advocated that several cycles of novel agents are required prior to an observed CA-125 response. In this study, we sought to gain insight into response patterns regarding CA-125 in responders vs. non-responders and to determine whether specific "cut-off" values could help predict ultimate clinical response.

METHODS

Patients with recurrent ovarian cancer who received either single agent PLD, TPT, or both were included. CA-125 levels were evaluated prior to initiation of chemotherapy and thereafter for each additional cycle. The Rustin criteria were utilized to evaluate CA-125 response.

RESULTS

Fifty-four of 120 patients were judged to be responders. When comparing responders to non-responders, as expected, the majority of responders demonstrated a decrease after each of the first 4 cycles. However, nearly 50% of responders who received PLD demonstrated an increase in CA-125 after cycle 1. There were no responders who demonstrated two successive rises in CA-125.

CONCLUSION

The majority of patients with recurrent ovarian cancer who will ultimately manifest a CA-125 response to novel agents, such as TPT or PLD, will demonstrate a decrease following each cycle. An initial increase in CA-125 should not mandate discontinuation of current therapy, but a successive rise over two or more cycles reliably predicts that a treatment response ultimately is unlikely.

A study to evaluate the use of CA125 in ovarian cancer follow-up: A change in practice led by patient preference

OBJECTIVES

To evaluate the use of CA125 in the follow-up of women with epithelial ovarian cancer in the Cambridge Gynaecologic Oncology Centre. To institute changes depending on patients' preferences.

METHODS

A patient questionnaire was developed on follow-up, CA125 estimation and patient education in epithelial ovarian cancer and CA125. Initially, 100 patients were evaluated, and a change in practice was instituted. This was re-evaluated using the same patient population.

RESULTS

22/22 patients in clinic, and 68/78 patients who received the questionnaire by post, completed and returned it (n = 90). 81% wanted CA125 results available at clinic follow-up visits, with 82% willing to have the blood test done at their GP surgery before attending outpatients. CA125 follow-up practice was changed accordingly. This change was re-evaluated. A second questionnaire was sent to 35 surviving patients from the first cohort. 31/35 (90%) responses were received. Five patients were either no longer on follow-up, being > or =5 years from completing their original treatment or were being monitored elsewhere, leaving an 87% response rate (26/30). 92.3% felt that having CA125 results available in clinic had enhanced the quality of their follow-up. Patient education and basic understanding of CA125 also improved, with 88.5% aware of its role.

CONCLUSIONS

The availability of CA125 results when patients attend for routine follow-up has improved their overall management in our clinics. It has reduced patient and physician anxiety and unsatisfactory out-of-clinic telephone communication. We recommend this change of practice to all Gynaecologic Oncology Centres engaged in active routine follow-up of their patients with epithelial ovarian cancer.

Marked ascites and serum carbohydrate antigen (CA) 125 elevation in a patient with anorexia nervosa

These findings suggest, for psychiatrically hospitalized adolescent females, that different patterns of factors may contribute to the maintenance of eating and body image disturbances across ethnic groups. Future research testing models of the etiology or maintenance of these disturbances needs to include ethnicity to ascertain whether the hypothesized components operate differently by ethnicity.

Ovarian teratoma with diffused peritoneal reactions mimicking advanced ovarian malignancy

BACKGROUND

Benign cystic teratomas are one of the most common benign ovarian neoplasms. Although its rupture is rare, once occurred it can cause complications such as granulomatous peritonitis, mimicking metastatic ovarian malignancy.

CASE

A 39-year-old woman, Para 0-0-0-0, presented to the hospital with rapid abdominal distention for 3 months. Her physical examination and ultrasonographic findings led to a diagnosis of advanced stage ovarian carcinoma. An exploratory laparotomy was performed and the operative impression was that of stage III ovarian carcinoma. Total hysterectomy with bilateral salpingo-oophorectomy and surgical staging were done. The postoperative pathology revealed a benign cystic teratoma of right ovary with chronic granulomatous peritonitis. She was well at discharge and at her 1-year follow-up.

CONCLUSION

Although ruptured a benign cystic teratoma is rare, it can cause granulomatous peritonitis, the clinical findings of which mimic advanced stage ovarian carcinoma. This warrants physicians to be aware of and intraoperative frozen section should be used, its correct management will provide a good outcome with less complication.

Tissue microarrays for miniaturized high-throughput molecular profiling of tumors

New high-throughput screening technologies such as complementary (cDNA) microarrays allow identification of hundreds of candidate genes in one experiment. To prioritize the leads obtained in such studies, it is necessary to analyze a large number of tissues for candidate gene expression. Tissue microarray (TMA) technology greatly facilitates such analyses. In this method, hundreds of minute tissue samples (0.6-mm diameter) can be placed on one microscope glass slide. The TMA approach allows simultaneous analysis of all tissues with in situ methods (immunohistochemistry, fluorescence in situ hybridization, RNA in situ hybridization) of all tumors in one experiment under highly standardized conditions. TMAs are not restricted to solid tumors but can be manufactured from a variety of other sources, including cell lines, xenografts, and hematologic tissues. In addition to tumor type-specific applications that comprise large numbers of one particular tumor type with extensive histopathologic and clinical data, TMAs are well suited for large-scale molecular epidemiologic studies. For example, genes of interest can be analyzed in multitissue TMAs containing a variety of different human normal tissues and tumor entities. Once tumor types are identified, where a given molecular alteration plays a role, the clinical significance of this molecular alteration can be investigated on tumor-specific TMAs. Thus, TMA technology allows miniaturized high-throughput molecular epidemiologic studies. The TMA technique will markedly accelerate the transition from basic research to clinical applications.