Diagnostic and Prognostic Markers
Clinical Significance of Serum HE4, CA125, CA724, and CA19-9 in Patients With Endometrial Cancer
Technology in Cancer Research & Treatment 2017, Vol. 16(4) 435–439 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533034616666644 journals.sagepub.com/home/tct
Jing Bian, PhD1,2, Xiaoxu Sun1,2, Bo Li, PhD3, and Liang Ming, PhD1,2
Abstract Purpose: Serum markers with increased sensitivity and specificity for endometrial cancer are required. To date, no good marker has met this standard. The aims of our study were to evaluate the utility of tumor markers HE4, CA125, CA724, and CA19-9 as potential markers in patients diagnosed with endometrial cancer. Methods: Blood samples from 105 patients with endometrial cancer and 87 healthy women were analyzed by Roche electrochemiluminescent immunoassay, and serum values were measured for the following biomarkers: HE4, CA125, CA724, and CA19-9. Results: Serum HE4, CA125, CA724, and CA19-9 concentrations were significantly higher in patients with endometrial cancer, compared with controls (P < .001). In the receiver operating characteristic analysis, the area under the curve value for combination of HE4, CA125, CA724, and CA19-9 was 82.1% (95% confidence interval: 75.3%-86.2%), the maximum area of the test groups. For all stages of patients with endometrial cancer, HE4 had higher sensitivity (58%), positive predictive value (60%), and negative predictive value (67%) than any other single tumor marker, and in the combination of HE4, CA125, CA724, and CA19-9, the sensitivity and positive predictive values reached 59.1% and 88%, respectively. Meanwhile, the receiver operating characteristic area under the curve of the combination of the 4 markers was significantly increased than any other group, either in stage I or in stage II to IV cases. HE4 and CA125 both correlate with advanced age; in addition, HE4 was related to pathology subtypes and positive adnexal involvement, CA125 was related to International Federation of Gynecology and Obstetrics stage, CA19-9 was related to International Federation of Gynecology and Obstetrics stage, and CA724 was correlated with positive lymph node. Conclusion: Combination of HE4, CA125, CA724, and CA19-9 has the highest value in diagnosing endometrial cancer, and they can be a useful tissue immune marker for patients with endometrial cancer. Keywords HE4, CA125, CA724, CA19-9, endometrial cancer Abbreviations AUCs, areas under the curve; CI, confidence interval; EC, endometrial cancer; FIGO, International Federation of Gynecology and Obstetrics; NPVs, negative predictive values; PPVs, positive predictive values; ROC curves, receiver operating characteristic curves Received: March 02, 2016; Revised: May 16, 2016; Accepted: July 28, 2016.
Endometrial cancer (EC) is the most common gynecological malignant tumor in Western countries, and its incidence has risen rapidly in Asia.1,2 Most patients with EC exhibit symptoms such as postmenopausal bleeding and vaginal discharge uterine and have well-differentiated endometrioid in histology that leads to the diagnosis of the malignancy in the early stages of the disease (type I ECs). However, people at high risk, including women with systemic and advanced stage disease, may benefit from a serum marker for early detection. In
Corresponding Authors: Jing Bian, PhD and Liang Ming, PhD, Department of Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, People’s Republic of China. Emails: [email protected]
; [email protected]
Department of Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China 2 Key Clinical Laboratory of Henan province, Zhengzhou, Henan, People’s Republic of China 3 The Stem Cells Research Center, Medical College of Zhengzhou University, Zhengzhou, Henan, People’s Republic of China
Technology in Cancer Research & Treatment 16(4)
Table 1. Patient Population Characteristics. Group Healthy Endometrial cancer type Endometrioid adenocarcinoma Serous papillary adenocarcinoma Clear cell carcinoma Mixed adenocarcinoma FIGO stage Stage I Stage II Stage III Stage IV
Average Age 53 (28-74) 54 (33-71)
n (%) 87 105 85 6 6 8
(100) (100) (81) (5.7) (5.7) (7.6)
74 13 16 5
(70) (13) (15) (5)
Abbreviation: FIGO, The International Federation of Gynecology and Obstetrics.
addition, sensitive and specific serum markers could help to monitor the effect of treatment and screen recurrence or metastasis of EC. Unfortunately, to date, no serum marker is universally utilized for patients with EC.3,4 In the present report, we have analyzed the serum level of HE4, CA125, CA724, and CA19-9 in single and combined, in order to evaluate their clinical value in EC.
experiment was strictly operated according to the instruction and operation manual. Critical values of HE4, CA125, CA724, and CA19-9 separated were 140 pmol/L, 35 U/mL, 6.9 U/mL, and 37 U/mL, respectively.
Statistical Analysis Data analysis was performed by SPSS 13.0 statistical analysis software. Median method (quartiles) was used to present quantitative data of skew distribution. Mann-Whitney test was used to assess difference between the 2 groups. Relationship between categorical variables was assessed using w2 test. Logistic regression models were estimated for each marker separately and for all combination of markers to differentiate between patients with EC and healthy controls. Receiver operating characteristic (ROC) curves were constructed, and the areas under the curve (AUCs) with binomial exact 95% confidence intervals (95% CIs) were calculated.9 The diagnostic performance of tumor markers was also performed by sensitivity, positive predictive values (PPVs), and negative predictive values (NPVs). A level of P < .05 was accepted as statistically significant for all comparisons.
Results Materials and Methods Preoperative serum samples from 105 patients with EC were collected at First Affiliated Hospital of Zhengzhou University between February 2013 and March 2014. Moreover, serum samples of 87 controls (women without gynecological pathologies) were collected. The study was approved by the institutional review board, and all enrolled patients provided written informed consent. The International Federation of Gynecology and Obstetrics (FIGO) stage, histologic type, pathologic grade, myometrial invasion, and pelvic lymph nodes metastasis that were based on the criteria of the FIGO and the World Health Organization were established in all cases.5-8 A total of 105 cases with EC including 85 cases with endometrioid adenocarcinoma, 6 cases with serous papillary adenocarcinoma, 6 cases with clear cell carcinoma, and 8 cases with mixed adenocarcinoma were included. Of the 105 patients with EC, 74 (70%) were diagnosed with stage I disease, 10 (10%) with stage II disease, 16 (15%) with stage III disease, and 5 (5%) with stage IV disease. The average age of patients with EC is 54 years (range: 33-71 years). Eighty-seven healthy controls are selected from physical examination in our hospital by women staff members, whose average age is 53 years (range: 28-74 years). Patient population characteristics are shown in Table 1. All blood samples were collected in the preoperative period, then centrifuged for 5 minutes with the serum withdrawn, and frozen at 80 C until analysis. Serum levels of HE4, CA125, CA724, and CA19-9 were detected by electrochemiluminescence. Reagents were provided by Roche Group. Serum samples were detected by Roche cobas e601 modules. The
The serum marker levels of HE4, CA125, CA724, and CA19-9 were evaluated in the 2 groups (Table 2). There was a significant difference between EC and healthy control. Serum levels of HE4 and CA125 were significantly elevated between EC and healthy control. We used ROC analysis to evaluate diagnostic performance of the markers in distinguishing malignant from normal conditions. The areas under the ROC (ROC-AUCs) curves for a single marker and combinations of biomarkers for all stages of EC are presented in the first column in Table 3. In the single detection, HE4 has a greater ROCAUC (76.3%) than the other markers. Combination of HE4, CA125, CA724, and CA19-9 has the highest ROC-AUCs (82.1%) in all groups. Sensitivity, PPV, and NPV for the detection of single and combined tumor markers for all stages of EC are shown in Table 3. Sensitivity of combined CA19-9, CA125, and CA724 (40.6%) is lower than HE4 alone (58%) but has higher PPV (0.65 vs 0.6) and NPV (0.8 vs 0.67). Combined HE4, CA125, CA724, and CA19-9 has higher sensitivity, PPV, and NPV than combined HE4, CA125, and CA724, but this difference was not statistically significant (P > .05). The ROC-AUCs for single markers and marker combination assays for stage I and stage II to IV cases are presented in Table 4. Detection of the ROC-AUCs for single tumor marker revealed that HE4 had a significantly higher ROC-AUC when compared with CA125, CA724, or CA19-9, both in stage I and stage II to IV patients (74.9% and 84.4%, respectively). The combination of HE4, CA125, CA724, and CA19-9 had the largest ROC-AUC for any triplet combination of markers, no
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Table 2. Serum Markers in 2 Groups. Group Endometrial cancer Healthy control Mann-Whitney U test P
88.1 (13.8-356.7) 29.1 (6.9-122.0) 9 .5
54.9 (39/71) 91.2 (31/34) .001b
47.9 (34/71) 47.1 (16/34) .175
31.0 (22/71) 35.3 (12/34) .827
31.0 (22/71) 29.4 (10/34) >.5
55.6 (5/9) 67.7 (65/96) >.5
44.4 (4/9) 47.9 (46/96) >.5
33.3 (3/9) 32.3 (31/96) >.5
33.3 (3/9) 30.2 (29/96) >.5
Abbreviation: FIGO, The International Federation of Gynecology and Obstetrics. a Positive rate %. b Statistically significant when comparing every 2 groups (P < .05).
According to 2011 NCCN (National Comprehensive Cancer Network) guidelines for revision of EC clinical stage, age status, pathology subtypes, FIGO stage, histologic type, lymph node status, and cervical stroma invasion, adnexal involvement and menopause are important factors for EC prognosis. In our research, we found that HE4 and CA125 were both related to advanced age; furthermore, HE4 was also associated with pathology subtypes and positive adnexal involvement; CA125 was related to FIGO stage but not relevant with pathology subtypes. The serum CA19-9 was related to FIGO stage, and CA724 was associated with positive lymph node. Besides this, the worse histologic classes, the later clinical stage, and the metastatic lymph node were associated with the higher rate of HE4, CA125, CA19-9, and CA724. So combined detection could help clinicians for prognosis evaluation and rational treatment exploration. In conclusion, HE4, CA125, CA19-9, and CA724 all have good early diagnostic value. For patients with all stages of EC, combined detection of HE4, CA125, CA19-9, and CA724 has
the equal sensitivity but higher PPV and NPV compared with combined HE4, CA19-9, and CA724. As a single marker, HE4 performed the best effective feature in both stage I and stage II to IV cases. The ROC-AUC of the combination of HE4, CA125, CA724, and CA19-9 was obviously higher compared to any other group, especially in stage II to IV group. According to relationship between the 4 markers and EC-related prognostic factors, patients can be classified and appropriately treated. Combined detection of the 4 markers should be promoted for EC biochemical properties, diagnosis, and treatment. Moreover, the 4 markers have different relationships with EC clinical and pathological characteristics, and combined detection has more advantages than single detection in improving the prognosis of patients with EC. Acknowledgments The authors thank Xuna Wang, Weitao Zhu, and Peiguo Zheng (Department of Tumor Immunity, The First Affiliated Hospital of Zhengzhou University) for technical assistance.
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Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Medical science and technology research projects, Henan, People’s Republic of China (No. 201303075, 201403035) and Scientific research key project fund of Henan province education department, Henan, People’s Republic of China (project No.13A310622).
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