1. Ovarian Cancer Tumour Markers Brig Dilshad Ahmed Khan MBBS, MCPS, FCPS, FRC Path, PhD Head of Chem Pathology & Endocrinology dept AFIP, Rawalpindi

2. Outlines  Introduction  Risk factors for development of ovarian cancer  Diagnosis of ovarian cancer  Clinical application of CA125  Clinical application of HE4  Algorithms for the estimation of the risk of ovarian cancer in women with pelvic mass ( ROMA)

3. Introduction Ovarian cancer are developed from three categories of cells  Epithelial Cells (65-70%)  Serous  Mucinous  Endometrioid  Transitional cell  Stromal cell– 15-20%  Germ cell – 5-10%:

4. Ovarian Cancer Epidemiology  Incidence is 2 to 15 cases per 100,000 women  The 2 nd most common gynecologic malignancy  4 th leading cause of cancer death in U.S. (after lung, breast and colon) American Cancer Society, 20013

5. Risk Factors Age Women over age 55 account for ~80% of all cases Reproductive history Early menarche or age >30 years at first child- bearing, and late menopause Hormone replacement therapy > 10 years May be associated with 30% increased risk American Cancer Society, 2013

6. Risk Factors: Age

7. Risk factors: Heredity  Up to 10% of epithelial ovarian cancer are familial  Familial breast-ovarian cancer and site-specific ovarian cancer syndromes are associated with mutations of the BRCA1 suppressor gene; account for 90% of familial ovarian cancers Rollins, G. Ann Int Med 2000;133:1021-1024.

8. Diagnosis of Ovarian Cancer  Early detection is not an easy task  Pelvic examination  Ultrasound  CT Scan & MRI  Laparoscopic biopsy  Histological examination  Ovarian cancer tumor markers

9. History : Symptoms of ovarian cancer  Asymptomatic  Lower abdominal pain/pressure  Pelvic mass  Abdominal enlargement  Vaginal bleeding  Urinary/bowel symptoms

10. Images: U/S MRI, CT Ultrasound  Relatively inexpensive  Delineates cystic vs solid structures CT Scan  Assesses other organs  Excellent for retroperitoneum (1-5 mm) MRI  Allows for ID of soft tissue lesions  Can differentiate normal from malignancy

11. Epithelial ovarian cancer, stage 1C ovarian capsule Histopathology

12. Ovarian Tumors: Classification 1.Surface epithelial – 65- 70%:  Serous (tubal)  Mucinous (endocx & intestinal)  Endometrioid  Transitional cell - Brenners.  Clear cell 2. Stromal – 15-20%:  Granulosa-cell tumor  Thecoma  Fibroma  Sertoli-Leydig cell tumors 3.Germ cell tumors – 5-10%:  Teratoma – Benign cystic (dermoid cysts) Solid immature Monodermal – struma ovarii, carcinoid  Dysgerminoma  Yolk sac tumor Choricarcinoma  Mixed germ cell tumor 4.Metastatic tumors – 5%

13. Ovarian Cancer : tumor stages  Because ovarian cancer cause few symptoms,  >75% of patients are diagnosed stage III-IV: 5 year survival rate up to 25%  25% are diagnosed with stage I: 5 year survival rate up to 90% Stage II: 5 year survival rate up to 70%  Early detection has great promise to improve clinical outcome

14. Ovarian Cancer Biomarkers  CA 125  HE4  CA 15-3  CA 72-4  B7-H4 (Ov-110)  Transthyretin  IGFBP-2  SMRP (Mesomark™)  HK6  Cytokeratin 19

15. CA-125 – Tumor Markers CA125 is the first tumor marker of ovarian cancer Discovered with a mouse monoclonal antibody (OC125) produced by immunizing a mouse with a serous ovarian cancer cell line Glycoprotein with a molecular weight (>200 kD) Reference range : Serum <35 U/mL

16. CA125 is a tiny part of a very large molecule called MUC16 Ovarian Cancer cell CA125 Blood CA-125 – Tumor Markers

17. Increased in most ovarian cancers especially 80% of epithelial ovarian cancers 1 Elevated in 50% of Stage I disease Longitudinal assessment improve sensitivity Marker to test the recurrence of cancer Clinical application of CA 125 1 NIH Consensus Development Conference Statement. Gynecol Oncol. 1994;55:S4-S14. 2 ACOG Practice Bulletin. Obstet Gynecol. 2007;110:201-213.

18. CA125 CA-125 – Serum CA125 Assay

19. Clinical application of CA 125

20.  Diagnostic sensitivity is related to tumor stage:  Stage I-II : 50%  Stages III-IV: 80-90% CA125 : Diagnostic Sensitivity Stage I Stage IV

21. CA125 : Diagnostic Specificity Limitations Poor specificity (elevated in many gynecologic & non-gynecologic malignancies as well as benign conditions – increased in 0.2 ‐ 5.9% healthy women – increased in 2.2 ‐ 27.8% of benign disease 1,2 1 NIH Consensus Development Conference Statement. Gynecol Oncol. 1994;55:S4-S14. 2 ACOG Practice Bulletin. Obstet Gynecol. 2007;110:201-213.

22. CA125 : Diagnostic Specificity Malignant conditions  Cervical CA  Fallopian tube CA  Endometrial CA  Pancreatic CA  Colon CA  Breast CA  Mesothelioma Benign conditions  Endometriosis  Uterine fibroids  ovarian cysts  PID  Pancreatitis  Liver disease  Renal failure

23. Monitoring Treatment Response G ynecological cancer group criterion: Complete responder: CA 125 concentrations fall within the reference range after treatment. At least 50% of CA 125 decrease compared with the pre treated sample

24. Tumor Canc er cell Time Diagnosis and treatment Monitoring Treatment Response

25. Monitoring Recurrence  Useful in detecting residual disease in the cancer patients  CA-125 can detect recurrence of the cancer up to 75% accuracy  CA-125 correlate with ovarian cancer progression or regression in 80-90 % of cases.

26. Monitoring Recurrence  Patients with normalized CA 125 level: Increase in CA 125 ≥ 2 times of the upper limit of reference on two occasions after treatment.  An absolute increase of CA 125 level ≥ 5U/mL compared with its nadir value was a strong predictor of recurrence Gynecological Cancer Intergroup criterion (2011)

27. Human epididymis protein 4 (HE 4)  HE4 is human epididymis protein 4  A new up-regulated biomarker for ovarian cancer  Gene located in chromosome 20q12–13.1

28.  HE4 has better diagnostic sensitivity in the early diagnosis of ovarian cancer  Overexpressed in 93% of serous, 100% of endometrioid and 50% of clear cell ovarian cancer  Not expressed in mucinous and germ ‐ cell ovarian cancers HE4 : Diagnostic Sensitivity 1 NIH Consensus Development Conference Statement. Gynecol Oncol. 1994;55:S4-S14. 2 ACOG Practice Bulletin. Obstet Gynecol. 2007;110:201-213.

29. HE4 : Diagnostic Sensitivity

30.  HE4 has an increased diagnostic specificity compared with CA 125, in the ovarian malignancies  Overexpressed in pulmonary, endometrial, and breast cancers and mesotheliomas  Renal failure and pleural effusions are the most important sources of false positive HE4. HE4 : Diagnostic Specificity

31. Monitoring the disease progression  HE4 correlated better with the PET/CT results as compared to CA 125  HE4 increased 5 ‐ 8 month before CA 125 in relapsed ovarian cancer

32. Combination of HE4 and CA125  Tumor markers CA 125 and HE4 are approved by FDA for monitoring the disease progression  The combination of HE4 and CA 125 are more sensitive than either marker alone  Both tumor markers relate to stage and histology of ovarian cancer

33. Combination of HE4 and CA125 Higher serum concentrations in advanced stage

34. Algorithms for the Estimation of risk of ovarian cancer in women with pelvic mass (ROMA)  To assess whether a woman who presents with an ovarian adnexal mass is at high or low likelihood of having malignancy  A quantitative test that combines serum HE4, CA 125 & menopausal status into a numerical score

35. ROMA (Risk of Ovarian Malignancy Algorithm :Calculation  ROMA = exp(PI) [1+exp(PI)]*10  Premenopausal: Predicative Index (PI) = cut off of ≥1.31  Postmenopausal: Predicative Index (PI) = cut off of ≥ 2.77  Provide a specificity level of 75%.

36. Conclusions  CA125 is the tumor marker of choice for monitoring ovarian cancer  HE4 diagnostic sensitivity is better than CA125 in early stages of ovarian cancer  Combination of both tumor markers improved the detection of ovarian cancer & specificity than either alone  Both correlated well with the tumour stage, histology and prognosis  ROMA estimate the risk of ovarian cancer in women with pelvic mass