1. Comparison of Serum Human Epididymis Protein 4 with Cancer Antigen 125 as a Tumor Marker in Patients with Malignant and Nonmalignant Diseases
J.M. Escudero, J.M. Auge, X. Filella, A. Torne,
J. Pahisa, and R. Molina
November 2011
© Copyright 2011 by the American Association for Clinical Chemistry

2. Introduction Ovarian cancer
Accounts for nearly 4% of all cancers among women
Fifth most common cause of cancer death in women
CA125 is the tumor marker of choice in ovarian cancer
Diagnostic sensitivity is related to tumor stage (50% stage I and 80-90% stages III-IV)
Low diagnostic specificity with high concentrations in:
Benign gynecological diseases (endometriosis, myomas and ovarian cysts)
Effusions, liver and renal failure

3. Introduction (cont’d)
HE4 (human epididymis protein 4)
Encoded by a gene located in chromosome 20q12–13.1
Overexpressed in ovarian cancer, but also in pulmonary, endometrial, and breast cancers and mesotheliomas
Previous studies have suggested that HE4 has diagnostic sensitivity similar to that of CA 125, but an increased diagnostic specificity in patients with gynecologic malignancies compared with those with benign gynecologic disease
Little is known about HE4 specificity in other benign and malignant conditions

4. Questions Is HE4 a specific tumor marker?
What are the sources of false positive HE4 serum concentrations?
Are HE4 diagnostic specificity and sensitivity better than CA 125 in non gynecological diseases?
What are the advantages of using HE4 in relation to CA125 in patients with gynecological diseases?

5. Methods Patient population: 552 BENIGNANT DISEASES
101
HEALTHY PEOPLE
552 BENIGNANT DISEASES
455 MALIGNANT DISEASES
22 RENAL FAILURE
17 RENAL FAILURE + OTHERS BENIGN DISEASES
15 HEPATIC FAILURE
66 CIRRHOSIS
17 DERMATOLOGICAL
17 CARDIOVASCULAR
57 LUNG INFECTIOUS AND NON-INFECTIOUS
28 GASTROINTESTINAL
21 AUTOINMUNE
180 EPITHELIAL CANCER:
32 LUNG ADENOCARCINOMA (9 I-III, 23 IV)
12 LUNG SQUAMOUS CELL CARCINOMA (2 I-III, 10 IV)
5 NSCLC
28 SCLC
18 GÁSTRIC ADENOCARCINOMA
10 PANCREAS ADENOCARCINOMA
28 COLON ADENOCARCINOMA
19 BREAST ADENOCARCINOMA
14 HEPATOCELULAR CARCINOMA
7 UROLÓGICAL CARCINOMA
7 PROSTATIC ADENOCARCINOMA
30 HEMATOLOGICAL TUMORS
5 MESENCHYMAL TUMORS
9 MALIGNANT MELANOMAS
66 ENDOMETRIOSIS
58 MYOMAS
144 OVARIAN CYSTS
13 ENDOMETRIAL POLYPS
11 OTHERS
199 GYNECOLOGICAL CANCERS:
127 OVARIAN CANCER (25 I-II, 53 III, 49 IV)
35 ENDOMETRIAL ADENOC. (14 I-II,21 III-IV
19 ENDOCERVICAL ADENOC. (9 I-II, 10 III-IV)
18 CERVICAL SQUAMOUS C. (4 I-II, 14 III-IV)

6. Methods (cont’d) Laboratory methods:
HE4 and CA125 were determined by use of a chemiluminescent enzyme immunoassay on an Architect® (Abbott Laboratories)
Creatinine was measured by use of an alkaline picrate kinetic method on an Advia® 2400 (Siemens Medical Solutions Diagnostics)
Statistical analysis:
Data reported herein as median (range). Tumor marker concentrations were compared by use of the Kruskall-Wallis and Mann-Whitney tests and ROC curves were compared by the DeLong mathematical model (SPSS 15.0, IBM-SPSS)

7. Questions Is HE4 a specific tumor marker?
What are the sources of false positive HE4 serum concentrations?

8. Results
Table 1. Serum concentrations of HE4 and CA125 in healthy people and patients with benign diseases.
a p=0.01; b p=0.005; c p=0.001; d p=0.023.
HE4 serum concentrations in healthy individuals were related to gender and age with significantly higher
concentrations in postmenopausal women (p<0.02).
Renal failure and effusions were the most important sources of false positive HE4 serum concentrations. HE4 must
be interpreted carefully in patients with renal failure.

9. Results (cont’d)
HE4 showed a higher specificity than CA 125 with a higher area under the curve in both situations, for diagnosis of cancer or ovarian cancer
Figure 1. ROC curves for (A), HE4 and CA125 for the diagnosis of malignancy (excluding renal failure), comparing active cancer and patients with benign diseases; (B), HE4 and CA125 for the diagnosis of ovarian cancer (excluding renal failure), comparing patients with ovarian cancer and other diseases (benign and malignant).

10. Questions
Are HE4 diagnostic specificity and sensitivity better than CA 125 in non gynecological diseases?

11. Results (cont’d)
Table 2. Serum concentrations of HE4 and CA125 in patients with active malignancy.
a p=0.001 with both markers; b p=0.001 with HE4.
The highest HE4 serum concentrations were found in patients with ovarian cancer but also
were found in other malignancies such lung and endometrial cancer. In contrast, CA125 was
widely distributed.

12. Questions
What are the advantages of using HE4 in relation to CA125 in patients with gynecological diseases?

13. Results (cont’d)
Both tumor markers were clearly related to stage and histology, with significantly
higher serum concentrations in advanced stage and in non-mucinous malignancies
CA 125 showed a higher sensitivity in advanced stages and slightly higher HE4
sensitivity was obtained in early stages
Combination of both tumor markers improved the detection of ovarian cancer
Table 3. Serum concentrations of HE4 and CA125 in patients with ovarian cancer [excluding patients with renal failure or creatinine >1.3 mg/dl (>115µmol/L)] subdivided according to tumor stage and histological type.

14. Results (cont’d)
HE4 showed a better area under the curve in both situations, in the diagnosis of gynecologic cancer vs. benign gynecologic diseases and in the diagnosis of ovarian cancer
Figure 2. ROC curves for (A), HE4 and CA125 for the diagnosis of gynecological cancer (excluding renal failure), comparing gynecological cancer and patients with benign gynecological diseases; (B), HE4 and CA125 for the diagnosis of ovarian cancer (excluding renal failure), comparing patients with ovarian cancer and other gynecological diseases (benign and malignant)

15. Conclusions
Renal failure and effusions were the most important sources of false positive HE4 serum concentrations. HE4 must be interpreted carefully in patients with renal failure.
HE4 diagnostic specificity was higher than CA125 in non-malignant diseases, both gynecological or non-gynecological.
The highest HE4 serum concentrations were found in patients with ovarian cancer but HE4 also may be found in patients with lung cancer or endometrial cancer. By contrast CA125 was widely distributed.
HE4 and CA125 were diagnostically sensitive tumor markers with a clear relationship to tumor stage and histology, with the lowest concentrations in mucinous malignancies.
HE4 diagnostic sensitivity was better than CA125 in early stages of ovarian cancer.

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