Gynecologic Oncology 132 (2014) 159–165

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Serum HE4 as a prognostic marker in endometrial cancer — A population based study Donal J. Brennan a,1, Andreas Hackethal a,1, Alex M. Metcalf b, Jermaine Coward c, Kaltin Ferguson b, Martin K. Oehler d, Michael A. Quinn e, Monika Janda f, Yee Leung g, Michael Freemantle h, ANECS Group b, Penelope M. Webb b, Amanda B. Spurdle b, Andreas Obermair a,⁎ a

Queensland Centre for Gynaecological Oncology, University of Queensland, School of Medicine, Central Clinical Division, Brisbane, Australia Queensland Institute of Medical Research, Genetics and Computational Biology Division, 300 Herston Rd, Herston, Brisbane 4006, Australia c Mater Medical Research Institute, South Brisbane, QLD, Australia d Department of Gynaecological Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia e Women's Cancer Research Centre, Royal Women's Hospital, Victoria, Australia f School of Public Health, Queensland University of Technology, Brisbane, Australia g School of Women's and Infants' Health, University of Western Australia, Perth, Australia h Sullivan Nicolaides Pathology, Cnr Whitmore St & Seven Oaks St, Taringa, QLD 4068, Australia b

H I G H L I G H T S • HE4 can serve as a prognostic biomarker in endometrial cancer. • Better identification of high-risk patients with advanced endometrioid endometrial cancer

a r t i c l e

i n f o

Article history: Received 5 September 2013 Accepted 29 October 2013 Available online 6 November 2013 Keywords: Endometrial cancer HE4 Biomarker Prognostic marker

a b s t r a c t Objective. HE4 has emerged as a promising biomarker in gynaecological oncology. The purpose of this study was to evaluate serum HE4 as a biomarker for high-risk phenotypes in a population-based endometrial cancer cohort. Methods. Peri-operative serum HE4 and CA125 were measured in 373 patients identified from the prospective Australian National Endometrial Cancer Study (ANECS). HE4 and CA125 were quantified on the ARCHITECT instrument in a clinically accredited laboratory. Receiver operator curves (ROC), Spearman rank correlation coefficient, and chi-squared and Mann–Whitney tests were used for statistical analysis. Survival analysis was performed using Kaplan–Meier and Cox multivariate regression analyses. Results. Median CA125 and HE4 levels were higher in stage III and IV tumours (p b 0.001) and in tumours with outer-half myometrial invasion (p b 0.001). ROC analysis demonstrated that HE4 (area under the curve (AUC) = 0.76) was a better predictor of outer-half myometrial invasion than CA125 (AUC = 0.65), particularly in patients with low-grade endometrioid tumours (AUC 0.77 vs 0.64 for CA125). Cox multivariate analysis demonstrated that elevated HE4 was an independent predictor of recurrence-free survival (HR = 2.40, 95% CI 1.19–4.83, p = 0.014) after adjusting for stage and grade of disease, particularly in the endometrioid subtype (HR = 2.86, 95% CI 1.25–6.51, p = 0.012). Conclusion. These findings demonstrate the utility of serum HE4 as a prognostic biomarker in endometrial cancer in a large, population-based study. In particular they highlight the utility of HE4 for pre-operative risk stratification to identify high-risk patients within low-grade endometrioid endometrial cancer patients who might benefit from lymphadenectomy. © 2013 Elsevier Inc. All rights reserved.

Introduction

⁎ Corresponding author at: Queensland Centre for Gynaecological Oncology, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Herston, QLD 4006, Australia. Fax: +61 7 36465289. E-mail address: [email protected] (A. Obermair). 1 Equal contribution. 0090-8258/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ygyno.2013.10.036

Uterine cancer is the most common gynaecological cancer, and the fourth most common cancer overall among women in Western countries, with more than 280,000 cases occurring annually worldwide [1]. The age-standardised incidence of uterine cancer is rising throughout the developed world [1] and this trend is expected to continue mainly

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due to the increasing prevalence of obesity. Approximately 90% of uterine cancers arise from the endometrium and are classified as endometrial adenocarcinomas (EACs). Eighty percent of EAC patients present with early stage, low-grade endometrioid endometrial carcinoma, commonly referred to as type 1 EAC. Approximately 20% of patients are diagnosed with high-risk histological subtypes (serous, clear cell or high-grade endometrioid), commonly referred to as type II EAC. The vast majority of endometrial cancer patients require surgery (total hysterectomy, bilateral salpingo-oophorectomy). Although lymph node status is included in the current FIGO staging of EAC, there is a lack of consensus regarding the role of routine lymphadenectomy, particularly as it increases surgical complexity and has not been shown to have a therapeutic benefit [2,3]. Uterine pathological factors such as tumour grade and depth of myometrial invasion correlate with a patient's probability of node metastasis to a large extent. Patients with low-grade tumours and no or only inner-half myometrial invasion are at negligible risk of lymph node metastases. As a consequence, many groups advocate an approach where patients at negligible risk of lymph node metastases are spared lymphadenectomy [4]. However identification of these patients before surgery remains challenging, and thus the decision to perform a lymphadenectomy is often based on intra-operative frozen section to assess histological grade and depth of myometrial invasion. Frozen section is not available in all centres both nationally and internationally, and conflicting reports regarding its reliability in surgical staging of endometrial cancer [5–8] suggest significant inter- and intra-observer variability. The availability of a highly standardised and reliable pre-operative biomarker would enhance risk assessment greatly. Serum markers could predict the absence of high-risk uterine features even prior to surgery to identify which patients should be spared lymphadenectomy. However, despite active research in this area, no such biomarker is currently accepted for routine use in clinical practice. In addition although the majority of EACs have an inherently good prognosis, recurrence occurs in 13–17% of women, mostly within 3 years of primary treatment [9,10]. Prognostic biomarkers that could stratify patients by recurrence risk would allow for more personalized, and thus more cost effective post-operative care. Human epididymis protein 4 (HE4), initially identified as one of four cDNAs highly expressed in the human epididymis [11] is a secreted protein that is overexpressed in patients with serous and endometrioid epithelial ovarian [12,13] and uterine cancers [14–16]. Although the true functional role of HE4 in carcinogenesis has yet to be fully elucidated, it is generally agreed that HE4 plays a role in natural immunity [17]. Multiple studies have reported its utility as an ovarian cancer biomarker (reviewed in [18]) and in 2009, the United States Food and Drug Agency (FDA) approved HE4 as an aid in monitoring recurrence or progressive disease in patients with epithelial ovarian cancer. There is accumulating evidence that HE4 may also prove to be a useful marker for endometrial cancer. HE4 has been shown to be elevated in patients with EAC compared to healthy controls [14–16], and single institutional analyses of relatively small retrospective cohorts suggest that increased HE4 levels may be associated with myometrial invasion [15,19,20] and poor prognosis [15,16,21]. The aim of the present analysis was to assess peri-operative serum HE4 levels as a biomarker of disease severity in a large-population-based EAC cohort. Methods

proportion of these patients were recruited after they had had definitive surgery. The study was approved by the Human Research Ethics Committees at the Queensland Institute of Medical Research and all participating hospitals and cancer registries. Patients were included in this serum study if they had a peri-operative serum sample and complete pathological data: 343 patients (90%) had pre-operative samples taken, and the remaining 40 patients (10%) had blood taken on day 1 or 2 post-surgery. Median follow-up time for this cohort was 37 months. Ten patients had a follow-up less than 6 months in this study and 19 patients had a follow-up between 6 and 12 months. Standard treatment was total hysterectomy (laparoscopic or abdominal) and bilateral salpingo-oophorectomy. The proportion of patients who had formal surgical staging and adjuvant treatment is outlined in Table 1. Quantification of HE4 and CA125 in human serum Blood was taken at local sites and transported at room temperature prior to processing. The median time from blood drawing to processing for samples included in this study was 3 days (range 0–13 days). Serum was stored at −80 °C until analysis. Specimens were analysed in a clinically accredited laboratory by means of chemiluminescent microparticle immunoassays specific for HE4 (ARCHITECT HE4 assay; Abbott Diagnostics, Lane Cove, NSW, Australia) or CA125 (ARCHITECT CA125 II assay; Abbott Diagnostics, Lane Cove, NSW, Australia). The dynamic range of HE4 detection goes from 20 to 1500 pM with an automated 1:10 dilution protocol that extends the linear range up to 15,000 pM. The intra-assay and total imprecision (CV%) of the CMIA HE4 assay has previously been demonstrated to range from 2.11 to 2.93 and from 3.13 to 3.70 depending on the concentrations of the positive controls used [23]. The CA125 assay is linear up to 1000 U/mL and has a normality threshold at 35 U/mL. Statistics HE4 and CA125 protein levels were compared across groups using the Mann–Whitney test. The χ2 or Fisher's exact test was used for categorical data. Spearman's rank correlation coefficient was used to estimate the relationship between quantitative HE4 data and age and body-mass index (BMI, kg/m2). Receiver operator curves (ROC) were used to compare the ability of HE4 and CA125 to identify patients with outer-half myometrial invasion. Recurrence-free survival (RFS) was calculated from date of surgery to date of histological confirmation of recurrence or the date a woman was last known to be alive and recurrence-free. Overall survival (OS) was calculated from date of surgery to date of death or the date a woman was last known to be alive. Kaplan–Meier analysis and the log rank test were used to illustrate differences between OS and RFS according to HE4 and CA125 expression. Cox proportional hazard models were used to estimate the relationship between HE4 and CA125 and survival, controlling for other clinical variables. Variables that were significant in univariate analysis (grade, stage, histological subtype, lymphovascular space invasion (LVSI) and adjuvant treatment) were assessed for inclusion in the multivariate models. Age was not included as it was not a significant predictor of OS or RFS in univariate analysis. All calculations were performed using IBM SPSS Statistics version 20.0.0 (IBM Corporation, Armonk, New York, USA). A p value b0.05 was considered statistically significant. Statistical comparison of ROC (StAR) was used to compare AUC values for HE4 and CA125 as previously described [24].

Patients Results The Australian National Endometrial Cancer Study (ANECS) was a large, Australia-wide, population-based, case–control study of endometrial cancer conducted between 2005 and 2007 [22]. Women aged 18– 79 years, diagnosed with endometrial cancer during this period were recruited through treatment clinics and state-based cancer registries, the final sample comprised 1458 eligible women, however a significant

A total of 373 peri-operative serum samples were successfully analysed for HE4 and CA125. The distribution of HE4 and CA125 levels did not differ between samples taken pre- or post-operatively (Supplemental Fig. 1, Supplemental Table 1). Table 1 shows the characteristics of women included in the HE4 sub-study (n = 373) compared to the

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rest of the ANECS cohort (n = 1085), and demonstrates that, with the exception of LVSI and BMI, the cohort used for the HE4 sub-study was a representative sample of the ANECS cohort. Patients in the HE4 substudy sample had a mean age (SEM) of 61.2 (0.52) years, and the mean BMI (SEM) was 32.5 kg/m2 (0.44). During a median follow-up period of 37 months (range 1 to 63 months), 43 patients developed a recurrence and 20 of these patients died (16 confirmed cancer-specific deaths).

Table 1 Characteristics of ANECS women included in the HE4 study, compared to those not included. Inclusion in the HE4 sub-study Yes

No

(n = 373)

(n = 1085)

p value

Age (years) Mean (SEM)

61.2 (0.52)

61.4 (0.29)

0.70

BMI Mean (SEM)

32.5 (0.44)

30.7 (0.26)

b0.001

Grade 1 2 3 Missing

180 (49) 111 (31) 76 (20) 6

580 (54) 277 (26) 212 (20) 16

0.17

FIGO stage (2009) 1A 1B 2 3 4 Missing

263 (72) 48 (13) 29 (8) 24 (6) 5 (1) 4

739 (70) 147 (14) 60 (6) 83 (8) 23 (2) 33

0.32

LVSI Absent Present Missing

276 (83) 57 (17) 40

786 (90) 84 (10) 215

b0.001

Myometrial invasion ≤50% N50% Missing

289 (77) 84 (23)

818 (77) 245 (23) 22

0.83

Nodal status Negative Positive Not assessed Missing

183 (49) 22 (6) 168 (45)

482 (45) 65 (6) 525 (48) 13

0.38

Histological subtype Serous Mucinous Endometrioid Clear cell Mixed Malignant mixed mullerian tumour Undifferentiated/NOS/other

13 (3.7) 1 (0.3) 316 (85) 6 (1.6) 26 (7) 9 (2.4) 2 (0.6)

43 (4) 3 (0.2) 863 (80) 17 (1.6) 110 (10.1) 43 (4) 3 (0.3)

0.86

External beam radiotherapy No Yes Unknown

311 (84) 59 (16) 3

866 (82) 185 (18) 34

0.47

Brachytherapy No Yes Unknown

298(81) 69 (19) 6

892 (85) 158 (15) 35

0.09

Chemotherapy No Yes Unknown

326 (88) 43 (12) 4

922 (88) 127 (13) 36

0.82

Values in parenthesis are percentages unless otherwise stated. SEM — standard error of mean, BMI — body mass index, LVSI — lymphovascular space invasion, NOS — not otherwise specified. Statistical analysis excluded missing values.

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The association between serum HE4 and CA125 levels and clinicopathological characteristics is shown in Table 2. The median serum HE4 concentration of all patients was 75.5 pmol/L (range 21–1163 pmol/L) and the median CA125 was 15.4 U/mL (range 1–568 U/mL). CA125 was greater than 35 U/mL, the established clinical threshold used for the assay, in 50 (13%) patients. HE4 and CA125 demonstrated a moderate correlation (Spearman's rank r = 0.349; p b 0.001). Serum HE4 levels were associated with increasing age (r = 0.342, p b 0.001) and BMI (r = 0.147, p = 0.005). CA125 was not associated with age or BMI. Median HE4 levels were significantly higher in patients with advanced stage disease, outer-half myometrial invasion, patients who developed recurrent disease, and a history of diabetes or hypertension, but were not associated with cell type (endometrioid vs other), or LVSI (Table 2). Median CA125 levels were significantly higher in patients with advanced stage disease and outer-half myometrial invasion and those who subsequently developed recurrent disease (Table 2). Area-under-the-curve (AUC) analysis of HE4 vs CA125 in regards to the prediction of outer-half myometrial invasion in the evaluated cohort (n = 373) revealed a significantly higher AUC for HE4 compared to CA125 (p = 0.007) (Fig. 1A). The superiority of HE4 over CA125 was strengthened when the analysis was limited to endometrioid endometrial cancer patients (n = 316), and remained so even for grade I and II endometrioid endometrial cancer (n = 280) tumours (Fig. 1B and C). Due to the small number of non-endometrioid tumours we were unable to assess the ability of HE4 and CA125 to predict outerhalf myometrial invasion in this subset. A logistic regression model combining HE4 and CA125 (AUC for model 0.76, 95% CI 0.70–0.82) did not improve the predictive value of HE4 alone (AUC 0.76 (95% CI 0.70–0.81)) for assessing depth of myometrial invasion. The sensitivity and specificity of HE4 to predict myometrial invasion were assessed using a threshold of 70 pmol/L as previously published [19]. This value was close to the median level (75.5 pmol/L) in our study population (Table 3). A HE4 level of 70 pmol/L was associated with a sensitivity of 83%, a specificity of 53% and a negative predictive value of 92% when assessing depth of myometrial invasion in the evaluated cohort (n = 373). These figures remained very similar when the analysis was restricted to endometrioid histology alone (n = 316), low-grade endometrioid histology (n = 280) and early stage endometrioid histology (n = 295). Application of the 75th percentile, which was used for survival analysis (see below), demonstrated that HE4 had a sensitivity of 53%, a specificity of 83% and a negative predictive value of 86% when assessing myometrial invasion in the evaluated cohort (n = 373), suggesting that a lower threshold may be more effective in this setting. Kaplan–Meier analysis demonstrated that increased HE4 levels were associated with impaired RFS and OS; however, curves for the first 3 quartiles of HE4 overlapped and only patients with HE4 levels between the 75th and 100th percentiles differed significantly. Therefore data were dichotomized based on the 75th percentile (HE4 ≥ 113 pmol/L), which demonstrated that increased HE4 at this level was associated with a significantly reduced RFS and OS in the evaluated cohort (n = 373) (both p b 0.001 compared to women below the 75th percentile, Fig. 2A and B). A similar pattern was seen in the subset of women with endometrioid histology (n = 316) (Fig. 2C and D). Given the similarity between the results for RFS and OS, further analyses focused on RFS. Univariate analysis showed that stage, grade, histological subtype, LVSI, CA125 and HE4 were all significantly associated with RFS; however these variables were all highly correlated. Forward stepwise regression suggested that in multivariable models the only independent clinical predictors of RFS were stage and grade, thus further models were adjusted for these characteristics. After adjustment for stage and grade, CA125 was not significantly associated with RFS (HR = 1.94, 95% CI 0.88–4.25, p = 0.099). The association between RFS and HE4, however, remained strong and statistically significant even after adjustment (HR = 2.40, 95% CI 1.19–4.38, p = 0.014) (Table 4). Similar

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results were seen when the cohort was restricted to endometrioid endometrial cancer (HR = 2.86, 95% CI 1.25–6.51, p = 0.012) and to low-grade (G1/2) endometrioid endometrial cancer (HR = 2.99, 95% CI 1.16–7.71, p = 0.024). Discussion Additional biomarkers are urgently required for endometrial cancer to allow pre-operative stratification of patients based on their likely risk of recurrence, to inform the extent of surgery performed and planning of appropriate personalized therapeutic regimens. A pre-operative serum-based assay would be the least invasive and most cost-effective approach. Currently no marker has received universal approval. Although some units use preoperative serum CA125 its sensitivity and specificity are low and its main utility appears to predict extra-uterine disease, which is uncommon in EAC [25]. Several small single institutional studies have suggested that HE4 may be of value for EAC risk stratification [15,19–21]. In the present population-based study of 373 cases, we used a clinically accredited and highly standardised test to provide the first definitive description of HE4 as a prognostic biomarker in EAC. The findings demonstrate that the HE4 serum assay should be considered for future pre-operative triage of EAC cancer patients. The strengths of this study include the fact that it was a populationbased cohort. HE4 and CA125 analysis was performed in a clinically accredited laboratory and the median HE4 levels were similar to previous publications [15,19–21]. Weaknesses of the study include the fact

that there was no central pathology review and it is thus possible that minor components of high grade or aggressive subtypes could be identified by future review of individual low-grade endometrioid tumours. However this is unlikely to bias our results given that associations for HE4 with myometrial invasion are strongest for endometrioid tumours irrespective of grade. As a consequence of the national recruitment protocol, blood was not processed immediately after draw, however HE4 has been shown to remain stable across multiple freeze–thaw cycles and when stored at room temperature for over 72 h [18]. Finally, although renal failure is a well-recognized cause of elevated HE4 in benign disease [26,27], we were unable to control for this as baseline renal function was not available for patients in this study. An association between a serum marker and an aggressive EAC phenotype may have important clinical implications, as pre-operative serum HE4 testing may offer preliminary pre-operative risk stratification. Lymphadenectomy as part of the staging procedure remains the most controversial issue in the management of EAC. Nevertheless, the current lack of an appropriate pre-operative test to effectively estimate the likely extent of disease precludes the surgeon from identifying and counselling those patients who could potentially benefit from lymphadenectomy. MRI has been used to triage patients pre-operatively, however its sensitivity and cost effectiveness have been questioned. Reports on the accuracy of MRI in predicting depth of myometrial invasion vary widely from 46.6% to 93% with negative predictive values of 71– 92.3% [28]. Herein we present 70 pmol/L as a threshold for HE4 to predict outer-half myometrial invasion (Table 3). Moore et al. previously

Table 2 Median serum HE4 and CA125 levels by clinicopathological characteristics. All women

Median HE4 (IQR) [pmol/L]

p value

Median CA125 (IQR) [U/mL]

p value

FIGO stage (2009) Stages I & II (n = 340) Stages III & IV (n = 29)

72.7 (53.2–106.3) 134.6 (83–237.7)

b0.001

14.9 (11–23) 29.4 (15.1–76.5)

b0.001

Grade Grades I & II (n = 291) Grade III (n = 76)

73.1 (53.5–114.7) 82.7 (53.3–113.4)

0.572

15.4 (11.1–24.1) 15.5 (11.3–28.5)

0.431

Endometrioid histology Non-endometrioid (n = 56) Endometrioid (n = 316)

81.8 (56.0–110.7) 73.7 (53.6–113.4)

0.765

14.9 (11–30.5) 15.5 (11.2–24.2)

0.496

LVSI Absent (n = 276) Present (n = 57)

74.2 (53.1–111.2) 77.9 (51.8–114.3)

0.908

14.9 (11.2–24.8) 15.4 (9.9–25.9)

0.853

68.0 (52–93.6) 115.3 (81.7–178.9)

b0.001

14.6 (11.1–21.8) 25.1 (11.8–43.5)

b0.001

Age b62 (n = 184) ≥62 (n = 189)

64.0 (48.1–91.2) 85.2 (61.8–136.2)

b0.001

15.5 (11.6–26.1) 15.2 (10.5–26)

0.295

BMI (kg/m2) b30 (n = 184) ≥30 (n = 189)

68.4 (52.5–101.3) 81.6 (55.1–122)

0.024

15.0 (10.9–26.8) 15.6 (11.4–24.2)

0.723

Diabetes No (n = 309) Yes (n = 64)

73.1 (53.2–106.5) 91.1 (57.3–152.3)

0.023

15.4 (11.2–26) 15.9 (11.8–26.3)

0.781

Hypertension No (n = 231) Yes (n = 137)

69.8 (50–101.6) 82.7 (60–131.1)

0.001

15.2 (11.2–24.9) 15.8 (11.6–26.6)

0.653

Recurrence No (n = 330) Yes (n = 43)

73 (53–107.9) 90.7 (67.4–174.6)

0.001

15.1 (11–23.7) 20.4 (11.9–59.4)

0.011

Myometrial invasion ≤50% (n = 289) N50% (n = 84)

IQR, interquartile range; LVSI — lymphovascular space invasion.

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Fig. 1. HE4 is a superior predictor of outer-half myometrial invasion than CA125. Receiver operator curves (ROC) comparing HE4 to CA125 for differentiation of inner half and outer half myometrial invasion in all patients (A), endometrioid histology (B), low grade endometrioid histology (C). AUC = area under the curve. Values in parenthesis are 95% confidence intervals.

demonstrated that an HE4 threshold of 70 pmol/L had a sensitivity of 82% with a NPV of 82% in distinguishing stage 1A from all other endometrioid endometrial cancer [19]. We present similar figures for sensitivity but an improved NPV (Table 3). Taken together, these data suggest that HE4 can be used to effectively triage patients pre-operatively as a patient with a low grade tumour on curette and a low HE4 (b70 pmol/L) is extremely unlikely to be diagnosed with outer-half myometrial invasion, bears a low risk of lymph node metastases and could potentially avoid lymphadenectomy. By contrast, patients with low-grade tumours on curette but a high preoperative HE4 may indicate a high-risk EAC phenotype and may benefit

from a lymphadenectomy to ascertain the extent of the disease and inform decisions on adjuvant therapy. Yet another future use to be considered for HE4 serum assays may be for post-operative follow-up of patients with endometrial cancer. A proportion of patients with “low-risk” early stage disease will recur within the first 3 years, and to date no single approach has been shown to be effective for monitoring of patients for possible recurrence. Our finding that RFS at 3 years for patients with perioperative HE4 N 75th percentile was 78% versus 93% in patients with a HE4 b 75th percentile, suggests that the 25% of patients with such increased peri-operative HE4 may be suitable for more intense

Table 3 Sensitivity and specificity of HE4 in predicting myometrial invasion using a cut-off of 70 pmol/L.

Sensitivity Specificity PPV NPV Overall accuracy

All patients (n = 373)

Endometrioid histology (n = 316)

Grade 1/2 endometrioid histology (n = 280)

Stage 1/2 endometrioid histology (n = 295)

0.83 0.53 0.34 0.92 0.60

0.84 0.54 0.33 0.92 0.60

0.84 0.55 0.32 0.93 0.61

0.83 0.55 0.29 0.94 0.60

PPV — positive predictive value, NPV — negative predictive value.

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Fig. 2. HE4 is poor prognostic marker in EAC. Kaplan–Meier analysis of RFS based on HE4 using the 75th percentile as optimal threshold (A). Kaplan–Meier analysis of OS based on the 75th percentile (B) in evaluated cohort (n = 373). Kaplan–Meier analysis of RFS (C) and OS (D) in endometrioid endometrial carcinomas (n = 316).

follow-up. Future studies of the natural history of HE4 in recurrent endometrial cancer will, however, be required before it can be used in routine follow-up.

In summary, these data from a large, population-based cohort confirm previous smaller reports that elevated HE4 is associated with an aggressive EAC phenotype, even within the subset of low-grade

Table 4 Univariate and multivariate Cox models of recurrence free survival. All tumours

Endometrioid histology

(n = 373)

(n = 316)

HR

95% CI

p value

HR

95% CI

p value

Univariate Stage (III + IV vs I + II) Grade (III vs I + II) Histology (endometrioid vs non-endometrioid) LVSI (present vs absent) Adjuvant therapy (yes vs no) CA125 (≥35 U/mL vs b35 U/mL) HE4 (N75th percentile vs 0–75th percentile)

4.83 3.18 0.33 2.13 3.63 3.11 2.71

2.41–9.67 1.66–6.09 0.17–0.62 1.05–4.33 1.91–6.91 1.62–5.99 1.47–4.97

b0.001 b0.001 0.001 0.037 b0.001 0.001 0.001

6.97 2.82

2.93–16.62 1.20–6.63

b0.001 0.018

2.55 3.54 3.52 4.36

1.05–6.15 1.66–7.57 1.59–7.78 2.06–9.21

0.038 0.001 0.002 b0.001

Multivariatea Stage (III + IV vs I + II) Grade (III vs I + II) HE4 (N75th percentile vs 0–75th percentile)

3.13 2.66 2.40

1.42–6.94 1.32–5.38 1.19–4.38

0.005 0.006 0.014

3.87 2.45 2.86

1.50–9.96 1.01–5.97 1.25–6.51

0.005 0.048 0.012

LVSI — lymphovascular space invasion. a Adjusted for all other variables in the table.

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endometrioid endometrial cancer. HE4 is an independent poor prognostic marker and is superior to CA125 as a predictor of outer-half myometrial involvement. The NPV and sensitivity values presented here are comparable to those previously published for MRI and suggest that HE4 may be a more cost-effective approach in identifying patients who are low risk to avoid unnecessary lymphadenectomy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2013.10.036. Conflict of interest statement The authors have no conflicts of interest to declare. AH worked as a consultant for Ethicon Endosurgery, Terumo and Fisher & Paykel.

Acknowledgements Funding is acknowledged from Royal Brisbane and Women’s Hospital Foundation, Queensland Institute of Medical Research. ARCHITECT assays were provided by Abbott. National Health and Medical Research Council (NHMRC) Fellowship scheme (ABS and PMW), NHMRC project grant (ID #339435), the Cancer Council Queensland (ID #4196615), the Cancer Council Tasmania (ID #403031 and ID #457636), and Cancer Australia (ID #552468) are also acknowledged. The ANECS Group comprises: AB Spurdle, PM Webb, and J Young (Queensland Institute of Medical Research); Consumer representative: L McQuire; Clinical Collaborators: NSW: S Baron-Hay, D Bell, A Bonaventura, A Brand, S Braye, J Carter, F Chan, C Dalrymple, A Ferrier (deceased), G Gard, N Hacker, R Hogg, R Houghton, D Marsden, K McIlroy, G Otton, S Pather, A Proietto, G Robertson, J Scurry, R Sharma, G Wain, and F Wong; Qld: J Armes, A Crandon, M Cummings, R Land, J Nicklin, L Perrin, A Obermair, and B Ward; SA: M Davy, T Dodd, J Miller, M Oehler, S Paramasivum, J Pierides, and F Whitehead; Tas: P Blomfield and D Challis; Vic: D Neesham, J Pyman, M Quinn, R Rome, and M Weitzer; WA: B Brennan, I Hammond, Y Leung, A McCartney (deceased), C Stewart, and J Thompson; Project Managers: S O'Brien and S Moore; Laboratory Manager: K Ferguson; Pathology Support: M Walsh; Admin Support: R Cicero, L Green, J Griffith, L Jackman, and B Ranieri; Laboratory Assistants: M O'Brien and P Schultz; Research Nurses: B Alexander, C Baxter, H Croy, A Fitzgerald, E Herron, C Hill, M Jones, J Maidens, A Marshall, K Martin, J Mayhew, E Minehan, D Roffe, H Shirley, H Steane, A Stenlake, A Ward, S Webb, and J White. The authors thank the many individuals who participated in this study and the numerous institutions and their staff who have supported recruitment. ANECS thanks members of the Molecular Cancer Epidemiology and Cancer Genetic laboratories at QIMR for technical assistance, and the ANECS research team for assistance with the collection of risk factor information and blood samples. ANECS also gratefully acknowledges the cooperation of the following institutions: NSW: John Hunter Hospital, Liverpool Hospital, Mater Misericordiae Hospital (Sydney), Mater Misericordiae Hospital (Newcastle), Newcastle Private Hospital, North Shore Private Hospital, Royal Hospital for Women, Royal Prince Alfred Hospital, Royal North Shore Hospital, Royal Prince Alfred Hospital, St George Hospital, Westmead Hospital, and Westmead Private Hospital; Qld: Brisbane Private Hospital, Greenslopes Hospital, Mater Misericordiae Hospitals, Royal Brisbane and Women's Hospital, Wesley Hospital, and Queensland Cancer Registry; SA: Adelaide Pathology Partners, Burnside Hospital, Calvary Hospital, Flinders Medical Centre, Queen Elizabeth Hospital, Royal Adelaide Hospital, and South Australian Cancer Registry; Tas: Launceston Hospital, North West Regional Hospitals, and Royal Hobart Hospital; Vic: Freemasons Hospital, Melbourne Pathology Services, Mercy Hospital for Women, Royal Women's Hospital, and Victorian Cancer Registry; WA: King Edward Memorial Hospital, St John of God Hospitals Subiaco & Murdoch, and Western Australian Cancer Registry.

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Serum HE4 as a prognostic marker in endometrial cancer--a population based study.

HE4 has emerged as a promising biomarker in gynaecological oncology. The purpose of this study was to evaluate serum HE4 as a biomarker for high-risk ...
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