- Email: [email protected]
Preoperative Evaluation of D-Dimer and CA 125 Levels in Differentiating Benign from Malignant Ovarian Masses
GYNECOLOGIC ONCOLOGY ARTICLE NO.
60, 197–202 (1996)
0025
Preoperative Evaluation of D-Dimer and CA 125 Levels in Differentiating Benign from Malignant Ovarian Masses ANGIOLO GADDUCCI,* UGO BAICCHI,† ROBERTO MARRAI,* MARCO FERDEGHINI,‡ ROMANO BIANCHI,‡ AND VIRGILIO FACCHINI* *Department of Gynecology and Obstetrics and ‡Institute of Nuclear Medicine, University of Pisa; and †Blood Bank, S. Chiara Hospital, Pisa, Italy Received September 21, 1994
Plasma levels of D-dimer (DD) and CA 125 were measured preoperatively in 121 patients with ovarian masses submitted to laparotomy. DD and CA 125 levels were higher in the 56 patients with epithelial ovarian cancer than in the 65 patients with benign ovarian disease (P õ 0.0001). The logistic regression procedure showed that both DD assay (cutoff 416 ng/ml) and CA 125 assay (cutoff 65 U/ml) were significant predictive variables for malignancy (P Å 0.0001). The concordance between predicted probabilities and observed responses was 75.7% for DD, 72.1% for CA 125, and 90.8% for DD and CA 125. It is worth noting that DD was increased (ú416 ng/ml) in 73% of FIGO stage I patients, whereas CA 125 was above 65 U/ml in only 33.3%. Sensitivity, specificity, positive predictive value, and negative predictive value of the tests in differentiating benign from malignant ovarian masses were as follows: 76.8, 93.8, 91.5, and 82.4%, respectively, for CA 125; 94.6, 76.9, 77.9, and 94.3%, respectively, for the combination CA 125 or DD; and 73.2, 100.0, 100.0, and 81.3%, respectively, for the combination CA 125 and DD. The combination CA 125 and DD seems to be a useful diagnostic tool to differentiate benign from malignant ovarian masses. Elevated preoperative levels of both antigens are invariably associated with a postsurgical diagnosis of epithelial ovarian cancer. q 1996 Academic Press, Inc.
INTRODUCTION
The preoperative assessment of ovarian masses is a controversial issue in gynecological practice. Ultrasound has a good diagnostic reliability in the preoperative assessment of ovarian masses, even if there is no general agreement about the sonographic characteristics considered predictive of malignancy [1 – 7]. Several clinical studies have shown that serum CA 125 assay can be used as a diagnostic tool to discriminate benign from malignant ovarian masses, especially in postmenopausal women [2, 5, 7 – 13]. Coagulation and fibrinolytic pathways are often altered in cancer patients. About 50% of all patients, and up to 95% of those with metastatic disease, present some abnormalities of the hemostatic pa-
rameters [14, 15]. Moreover, thromboembolism and hemorrhage represent the second largest cause of death in cancer patients. Furthermore, there is morphological and histochemical evidence of fibrin deposition in tumors [16]. Tumor fibrin results from extravasation and extravascular clotting of plasma fibrinogen. Fibrin can facilitate tumor angiogenesis and stroma generation and serve as a barrier between tumor cells and host inflammatory cells which could otherwise invade and destroy the tumor [16 – 18]. Evidence of tumor-associated activation of both coagulation and fibrinolysis can be provided by the measurement of fibrin split products, such as D-dimer (DD), in the patient’s plasma [19–21]. DD is a stable end product of cross-linked fibrin degradation by plasmin, which can be measured with an enzyme-linked immunosorbent sandwich assay using monoclonal antibodies [19]. In an earlier study we evaluated the reliability of plasma DD assay in the differential diagnosis of ovarian masses, using as a cutoff limit the sum of the mean value and the doubled standard deviation value of DD (416 ng/ml) in a group of 88 healthy nonpregnant females [22]. Sensitivity and specificity of the DD assay for epithelial ovarian cancer were 91 and 84%, respectively. DD levels were not related to patient age. The aim of this study is to compare the reliability of DD and CA 125 assay in differentiating benign from malignant ovarian masses. MATERIALS AND METHODS
This investigation was conducted on 124 consecutive patients with a clinical diagnosis of ovarian mass submitted to laparotomy at the Department of Gynecology and Obstetrics of the University of Pisa. Most of these patients had been included in a previous study [22]. Patients with cardiovascular disease, diabetes, acute or chronic inflammatory disease, previous malignancy, or previous 197
/ m4468$4130
01-19-96 23:06:24
goas
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
AP: Gyn Onc
198
GADDUCCI ET AL.
episodes of thrombophlebitis or thromboembolia were not included in this study. Three patients were excluded after primary operation because the clinically diagnosed ovarian mass was found to be a uterine leiomyoma in two cases and a leiomyosarcoma of the small bowel in one case.
FIG. 1.
Peripheral blood samples for the measurement of DD and CA 125 were drawn from all patients before surgery. Blood samples were collected early in the morning by venipuncture from the antecubital vein with minimal venous occlusion. Samples were excluded if venipuncture was traumatic or if the samples could not be quickly obtained. The plasma was
D-dimer and CA 125 preoperative plasma levels in patients with (a) benign ovarian disease or (b) epithelial ovarian cancer.
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
199
D-DIMER AND CA 125 IN OVARIAN MASSES
FIG. 2. ROC analysis curves plotted using the 65 patients with benign ovarian disease.
then separated by centrifugation and was stored at 0707C until assayed. DD was measured with an enzyme-linked immunosorbent sandwich assay using two monoclonal antibodies specific for two covalently bound D fragments (Boehringer-Mannheim GmbH, Germany). CA 125 was measured with a solid-phase immunoradiometric assay using monoclonal antibodies (International Cis, Gif-sur-Yvette, France). All determinations were carried out in duplicate. The values of 416 ng/ml and 65 U/ml were chosen as cutoff limits for DD [22] and CA 125 [13], respectively. The results were expressed as median value and range. The statistical analysis of the data was performed by Mann – Whitney U test, Spearman rank correlation test, the normal test of comparison of two proportions, and logistic regression analysis. Significance was assigned as P õ 0.05. RESULTS
The postsurgical diagnosis was epithelial ovarian cancer in 56 patients (median age, 62 years; range, 28 – 81
years) and benign ovarian disease in 65 patients (median age, 42 years; range, 17 – 73 years). Of the patients with epithelial ovarian cancer, 12 were in premenopause and 44 in postmenopause. Of the patients with benign ovarian disease, 45 were in premenopause and 20 in postmenopause. Of the cases with histologically ascertained cancer, 32 were serous, 12 undifferentiated, 8 mucinous, 3 endometrioid, and 1 case was a clear cell tumor. According to the FIGO classification, 15 patients had stage I and 41 had stage III – IV disease. Figure 1 illustrates the distribution of values of DD and CA 125 in benign (Fig. 1a) and malignant (Fig. 1b) ovarian masses, respectively. The receiver operator curve (ROC) for DD and CA 125 is shown in Fig. 2. Both DD and CA 125 levels were higher in patients with epithelial ovarian cancer than in those with benign ovarian disease (median 1895 ng/ml, range 162 – 3720 ng/ml vs median 218 ng/ml, range 11 – 2418 ng/ml, P õ 0.0001; and median 210 U/ml, range 12 – 6523 U/ml vs median 17 U/ml, range 4 – 267 U/ml, P õ 0.0001, respectively). In patients with epithelial ovarian cancer, DD levels correlated with CA 125 levels (Z Å 3.894, P õ 0.0001). The logistic regression procedure showed that both DD assay and CA 125 assay were significant predictive variables for malignancy (P Å 0.0001) (Table 1). The concordance between predicted probabilities and observed responses was 75.7% for DD, 72.1% for CA 125, and 90.8% for DD and CA 125. DD and CA 125 levels were related to FIGO stage (III–IV vs I, P Å 0.0001 and P õ 0.0001, respectively), but not to histologic type or menopausal status (Table 2). CA 125 values were higher in nonmucinous than in mucinous tumors, but the difference did not reach the statistical significance because of the small number of mucinous malignancies. It is worth noting that DD and CA 125 levels were greater in stage I epithelial ovarian cancer than in benign ovarian disease (median 589 ng/ml, range 164 – 3007 ng/ ml vs median 218 ng/ml, range 11 – 2418 ng/ml, P õ
TABLE 1 Logistic Regression Analysis of Preoperative DD, CA 125, and DD and CA 125 in Patients with Ovarian Masses
Variable
Parameter estimate
Standard error
Wald x2
P value
DD CA 125 DD CA 125
3.9135 3.9208 3.4441 3.4206
0.5736 0.6054 0.7123 0.7591
46.5470 41.9379 23.3766 20.3044
0.0001 0.0001 0.0001 0.0001
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
Concordance between predicted probabilities and observed responses (%) 75.7 72.1 90.8
200
GADDUCCI ET AL.
TABLE 2 Preoperative Levels of DD and CA 125 in Patients with Epithelial Ovarian Cancer: Relationship with FIGO Stage, Histologic Type, and Menopausal Status—Incidence of Elevated Preoperative Levels of DD and CA 125 in Patients with Epithelial Ovarian Cancer DD (ng/ml)
CA 125 (U/ml) ú416 ng/ml
na
Median
FIGO stage III–IV I
41 15
1984 589
Histologic type Nonmucinous Mucinous
48 8
Menopausal status Postmenopause Premenopause
44 12
a
Range
n
ú65 U/ml
(%)
Median
Range
n
(%)
162–3720 164–3007 P Å 0.0001
40 (97.6) 11 (73.3)
483 39
12–6523 12–1262 P õ 0.0001
38 (92.7) 5 (33.3)
1895 1445
162–3720 418–3100 P Å 0.6147
43 (89.6) 8 (100)
265 98
12–6523 15–550 P Å 0.0874
38 (79.2) 5 (62.5)
1896 1558
162–3720 418–3720 P Å 0.4073
39 (88.6) 12 (100)
210 213
12–6186 15–6523 P Å 0.6036
35 (79.5) 8 (66.7)
n, number of patients.
0.0001; and median 39 U/ml, range 12 – 1262 U/ml vs median 17 U/ml, range 4 – 267 U/ml, P õ 0.0001, respectively). DD levels ú416 ng/ml and CA 125 levels ú65 U/ml were found in 16.9 and 6.2%, respectively, of patients with benign ovarian masses (Table 3). Using these cutoff limits, elevated levels of DD and CA 125 were detected in 91.1 and 76.8%, respectively, of patients with epithelial ovarian cancer and in particular in 73.3 and 33.3%, respectively, of those with stage I disease and in 97.6 and 92.7%, respectively, of those with stage III – IV disease (Table 2). All eight patients with mucinous malignancy presented elevated DD levels, whereas only five had raised CA 125 values. Table 4 reports sensitivity, specificity, positive predictive value, and negative predictive value of DD and CA 125 in differentiating benign from TABLE 3 Incidence of Elevated Preoperative Levels of DD and CA 125 in Patients with Benign Ovarian Masses
Histology
Patients (n)
DD (ú416 ng/ml)
CA 125 (ú65 U/ml)
Serous cystoadenoma Mucinous cystoadenoma Endometriotic cyst Adult cystic teratoma Fibroma-thecoma Other
28
6 (21.4%)
1 (3.6%)
10 11 7 5 4
2 1 1 1 0
0 2 (18.2%) 1 (14.3%) 0 0
Total
65
/ m4468$4130
(20.0%) (9.1%) (14.3%) (20.0%)
11 (16.9%)
01-19-96 23:06:24
4 (6.2%)
goas
malignant ovarian masses using 416 ng/ml and 65 U/ml, respectively, as cutoff limits. The parameters of diagnostic evaluation of the two tests in pre- and postmenopausal women are shown in Table 5. DISCUSSION
Malignancy is frequently accompanied by evidence of systemic activation of hemostasis. This can be due either to nonspecific mechanisms, such as necrosis of tumor tissue or inflammatory response of the host, or to specific causes, such as synthesis of cancer cell procoagulants [14, 23, 24]. As far as epithelial ovarian cancer is concerned, following immunohistochemical studies on intact carcinomatous tissue, Zacharski et al. [25] suggested there is a dominant tumor cell-associated procoagulant pathway leading to thrombin generation. In fact, they found that fibrin was conspicuously present in the vicinity of viable tumor cells, but distant from areas of necrosis and areas containing inflammatory cells. The recent development of specific immunoenzymatic assays able to quantitate very low plasma levels of fibrin split products, such as DD, represents an important advance in the laboratory evaluation of fibrin formation and degradation [26]. Some authors have reported that plasma DD levels were elevated in patients with ovarian cancer [21, 27–29]. DD values were found to correlate with tumor stage, size, and activity and with CA 125 levels [21, 27]. In this study DD levels, as well as CA 125 levels, were significantly higher in patients with epithelial ovarian cancer, even in early stage,
AP: Gyn Onc
201
D-DIMER AND CA 125 IN OVARIAN MASSES
TABLE 4 Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, and Diagnostic Accuracy of DD and CA 125 Assays in Differentiating Benign from Malignant Ovarian Masses
CA 125 (ú65 U/ml) DD (ú416 ng/ml) CA 125 or DD Pa CA 125 and DD Pa
SE
SP
PPV
NPV
DA
76.8% 91.1% 94.6% 0.015 73.2% 0.897
93.8% 83.1% 76.9% 0.013 100.0% õ0.0001
91.5% 82.3% 77.9% 0.127 100.0% õ0.0001
82.4% 91.5% 94.3% 0.107 81.3% 0.943
86.0% 86.8% 85.1% 0.879 87.6% 0.890
Note. SE, sensitivity; SP, specificity; PPV, positive predictive value; NPV, negative predictive value; DA, diagnostic accuracy. a Versus CA 125 alone.
than in patients with benign ovarian disease. It is worth noting that DD was increased (ú416 ng/ml) in 73% of FIGO stage I patients, whereas CA 125 was greater than 65 U/ml in only 33.3%. DD assay was more sensitive but less specific than CA 125 assay for epithelial ovarian cancer. The combination CA 125 or DD had higher sensitivity (94.6% vs 76.8%, P Å 0.015) and lower specificity (76.9% vs 93.8%, P Å 0.013), while positive and negative predictive values were not significantly different when compared to CA 125 assay alone. It is worth noting that the association CA 125 and DD showed a 100% specificity and a 100% positive predictive value (P õ 0.0001 vs CA 125 alone), and that sensitivity and negative predictive value of this combination were similar to those of CA 125 assay alone. The benefit achieved by combining the two tests
seemed to be limited to premenopausal patients. In this group of patients the combination CA 125 or DD had higher sensitivity (100% vs 66.7%, P Å 0.031) and higher negative predictive value (100% vs 91.1%, P õ 0.0001), while the association CA 125 and DD had higher specificity (100% vs 91.1%, P õ 0.0001) when compared to CA 125 alone. In conclusion, the combination CA 125 and DD seems to be a useful diagnostic tool to discriminate benign from malignant ovarian masses particularly in premenopausal patients. Elevated preoperative levels of both antigens are invariably associated with postsurgical diagnosis of epithelial ovarian cancer. Therefore, the combined evaluation of DD and CA 125 could help to identify patients at increased risk for malignancy who should be referred to a specialistic oncologic center for adequate treatment.
TABLE 5 CA 125 and DD Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, and Diagnostic Accuracy in Patients with Ovarian Cancer by Menopausal Status SE
SP
PPV
NPV
DA
91.1% 100.0% 100.0% õ0.0001 91.8% 0.787
86.0% 93.0% 86.0% 0.771 93.0% 0.404
51.3% 72.2% 81.3% 0.169 64.5% 0.599
85.9% 81.3% 84.4% 0.961 82.8% 0.858
Premenopause CA 125 (ú65 U/ml) DD (ú416 ng/ml) CA 125 or DD Pa CA 125 and DD Pa
66.7% 100.0% 100.0% 0.031 66.7% 0.628
91.1% 91.1% 82.2% 0.408 100.0% õ0.0001
66.7% 75.0% 60.0% 0.866 100.0% 0.069
Postmenopause CA 125 DD CA 125 or DD Pa CA 125 and DD Pa
79.5% 88.6% 93.2% 0.155 75.0% 0.878
100.0% 65.0% 65.0% 0.003 100.0% 0.598
100.0% 84.8% 85.4% õ0.0001 100.0% 0.686
Note. SE, sensitivity; SP, specificity; PPV, positive predictive value; NPV, negative predictive value; DA, diagnostic accuracy. a Versus CA 125 alone.
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
202
GADDUCCI ET AL.
REFERENCES 1. Herrmann, U. J., Jr., Locher, G. W., and Goldhirsch, A. Sonographic patterns of ovarian tumors: Prediction of malignancy, Obstet. Gynecol. 69, 777–781 (1987). 2. Finkler, N. J., Benacerraf, B., Lavin, P. T., Wojciechowski, C., and Knapp, R. C. Comparison of serum CA 125, clinical impression and ultrasound in the preoperative evaluation of ovarian masses, Obstet. Gynecol. 72, 659–664 (1988). 3. Granberg, S., Wikland, M., and Jansson, I. Macroscopic characterization of ovarian tumors and the relation to histological diagnosis: Criteria to be used for ultrasound evaluation, Gynecol. Oncol. 35, 139–144 (1989). 4. Campbell, S., Bhan, V., Royston, P., Whitehead, M. I., and Collins, W. P. Transabdominal ultrasound screening for early ovarian cancer, Br. J. Med. 299, 1363–1367 (1989). 5. Gadducci, A., Capriello, P., Ferdeghini, M., Madrigali, A., Puccetti, A., Annichiarico, C., Prontera, C., Bianchi, R., and Fioretti, P. Pelvic ultrasound, serum CA 125 assay, CA 19.9 assay and serum CA 72.4 assay in the differential diagnosis of ovarian masses, Cancer J. 4, 249– 253 (1991). 6. Sassone, A. M., Timor-Tritsch, E., Artner, A., Westhoff, C., and Warren, W. B. Transvaginal sonographic characterization of ovarian disease: Evaluation of a new scoring system to predict ovarian malignancy, Obstet. Gynecol. 78, 70–76 (1991). 7. Maggino, T., Gadducci, A., D’Addario, V., Pecorelli, S., Lissoni, A., Stella, M., Romagnolo, C., Ferdeghini, M., Zucca, S., Trio, D., and Trovo, S. Prospective multicenter study on CA 125 in postmenopausal pelvic masses, Gynecol. Oncol. 54, 117–123 (1994). 8. O’Connel, G. J., Ryan, E., Murphy, K. J., and Prefontaine, M. Predictive value of CA 125 for ovarian carcinoma in patients presenting with pelvic masses, Obstet. Gynecol. 70, 930–932 (1987). 9. Einhorn, N., Bast, R. C., Jr., Knapp, R. C., Tjernberg, B., and Zurawski, V. R., Jr. Preoperative evaluation of serum CA 125 levels in patients with primary epithelial ovarian cancer, Obstet. Gynecol. 67, 414–416 (1986). 10. Malkasian, G. D., Jr., Knapp, R. C., Lavin, P. T., Zurawski, V. R., Jr., Podratz, K. C., Stanhope, R., Mortel, R., Berek, J. S., Bast, R. C., Jr., and Ritts, R. E. Preoperative evaluation of serum CA 125 levels in premenopausal and postmenopausal patients with pelvic masses: Discrimination of benign from malignant disease, Am. J. Obstet. Gynecol. 159, 341–346 (1988). 11. Vasilev, S. A., Schlaerth, J. B., Campeau, J., and Morrow, C. P. Serum CA 125 levels in preoperative evaluation of pelvic masses, Obstet. Gynecol. 71, 751–756 (1988). 12. Jacobs, I., and Bast, R. C., Jr. The CA 125 tumour-associated antigen: A review of the literature, Hum. Reprod. 4, 1–12 (1989). 13. Gadducci, A., Ferdeghini, M., Prontera, C., Moretti, L., Mariani, G., Bianchi, R., and Fioretti, P. The concomitant determination of different tumor markers in patients with epithelial ovarian cancer and benign ovarian masses: Relevance for differential diagnosis, Gynecol. Oncol. 44, 147–154 (1992).
/ m4468$4130
01-19-96 23:06:24
goas
14. Rickles, F. R., and Edwards, R. L. Activation of blood coagulation in cancer: Trousseau’s Syndrome revisited, Blood 62, 14–31 (1983). 15. Nand, S. Hemostasis and cancer, Cancer J. 6, 54–58 (1993). 16. Nagy, J. A., Brown, L. F., Senger, D. R., Lanir, N., Van De Water, L., Dvorak, A. M., and Dvorak, H. F. Pathogenesis of tumor stroma generation: A critical role for leaky blood vessels and fibrin deposition, Biochim. Biophys. Acta 948, 305–326 (1988). 17. Olander, J. V., Bremer, M. E., Marase, J. C., and Feder, J. Fibrin enhanced endothelial cell organization, J. Cell. Physiol. 125, 1–9 (1985). 18. Zacharski, L. R., Costantini, V., Wojtukiewicz, M. Z., Memoli, V. A., and Kudryk, B. J. Anticoagulants as cancer therapy, Semin. Oncol. 17, 217–227 (1990). 19. Rylatt, D. B., Blake, A. S., Cottes, L. E., Massingam, D. A., Fletcher, W. A., Masci, P. P., Whitaker, A. N., Elms, M., Bunce, I., Webber, A. J., Wyatt, D., and Bundensen, P. G. An immunoassay for human Ddimer using monoclonal antibodies, Thromb. Res. 31, 767–778 (1983). 20. Bick, R. L. Coagulation abnormalities in malignancy: A review, Semin. Thromb. Hemost. 18, 353–372 (1992). 21. Mirshahi, S. S., Pujade-Lauraine, E., Soria, C., Mirshahi, M., Fretault, J., Bernadou, A., and Soria, J. D-dimer and CA 125 levels in patients with ovarian cancer during antineoplastic therapy: Prognostic significance for the success of anticancer treatment, Cancer 69, 2289–2292 (1992). 22. Gadducci, A., Baicchi, U., Marrai, R., Del Bravo, B., Fosella, P. V., and Facchini, V. Pretreatment plasma levels of fibrinopeptide-A (FPA), D-dimer (DD), and von Willebrand factor (vWF) in patients with ovarian carcinoma, Gynecol. Oncol. 53, 352–356 (1994). 23. Wojtukiewicz, M. Z., Zacharski, L. R., Moritz, T. E., Hur, K., Edwards, R. L., and Rickles, F. R. Prognostic significance of blood coagulation tests in carcinoma of the lung and colon, Blood Coagulation Fibrinolysis 3, 429–437 (1992). 24. Zacharski, L. R., Wojtukiewicz, M. Z., Costantini, V., Ornstein, D. L., and Memoli, V. A. Pathways of coagulation/fibrinolysis activation in malignancy, Semin. Thromb. Hemostasis 18, 104–116 (1992). 25. Zacharski, L. R., Memoli, V. A., Ornstein, D. L., Rousseau, S. M., Kisiel, W., and Kudryk, B. J. Tumor cell procoagulant and urokinase expression in carcinoma of the ovary, J. Natl. Cancer Inst. 85, 1225– 1230 (1993). 26. Sagripanti, A., Carpi, A., Ferdeghini, M., Baicchi, U., and Grassi, B. Plasmatic markers of haemostatic system activation in patients with solid neoplasms, J. Nucl. Med. Allied Sci. 34, 321–332 (1990). 27. Hafter, R., Schrock, R., Von Hugo, R., and Graeff, H. Measurement of crosslinked fibrin derivatives in plasma and ascitic fluid with monoclonal antibodies against D dimer using EIA and Latex test, Scand. J. Clin. Lab. Invest. 45, 137–144 (1985). 28. Schrock, R., Hafter, R., Graeff, H., and Schmid, L. Die simultane bestimmung von CA 125 und D-dimer in plasma and aszites beim ovarialkarzinom, Gakologie 8, 260–262 (1985). 29. Khoo, S. K., Rylatt, D. B., Parsons, P., Wilson, K., Webb, M. J., Dickie, G., Kearsley, J., and Mackay, E. V. Serial D-dimer levels in the assessment of tumor mass and clinical outcome in ovarian cancer, Gynecol. Oncol. 29, 188–198 (1988).
AP: Gyn Onc
60, 197–202 (1996)
0025
Preoperative Evaluation of D-Dimer and CA 125 Levels in Differentiating Benign from Malignant Ovarian Masses ANGIOLO GADDUCCI,* UGO BAICCHI,† ROBERTO MARRAI,* MARCO FERDEGHINI,‡ ROMANO BIANCHI,‡ AND VIRGILIO FACCHINI* *Department of Gynecology and Obstetrics and ‡Institute of Nuclear Medicine, University of Pisa; and †Blood Bank, S. Chiara Hospital, Pisa, Italy Received September 21, 1994
Plasma levels of D-dimer (DD) and CA 125 were measured preoperatively in 121 patients with ovarian masses submitted to laparotomy. DD and CA 125 levels were higher in the 56 patients with epithelial ovarian cancer than in the 65 patients with benign ovarian disease (P õ 0.0001). The logistic regression procedure showed that both DD assay (cutoff 416 ng/ml) and CA 125 assay (cutoff 65 U/ml) were significant predictive variables for malignancy (P Å 0.0001). The concordance between predicted probabilities and observed responses was 75.7% for DD, 72.1% for CA 125, and 90.8% for DD and CA 125. It is worth noting that DD was increased (ú416 ng/ml) in 73% of FIGO stage I patients, whereas CA 125 was above 65 U/ml in only 33.3%. Sensitivity, specificity, positive predictive value, and negative predictive value of the tests in differentiating benign from malignant ovarian masses were as follows: 76.8, 93.8, 91.5, and 82.4%, respectively, for CA 125; 94.6, 76.9, 77.9, and 94.3%, respectively, for the combination CA 125 or DD; and 73.2, 100.0, 100.0, and 81.3%, respectively, for the combination CA 125 and DD. The combination CA 125 and DD seems to be a useful diagnostic tool to differentiate benign from malignant ovarian masses. Elevated preoperative levels of both antigens are invariably associated with a postsurgical diagnosis of epithelial ovarian cancer. q 1996 Academic Press, Inc.
INTRODUCTION
The preoperative assessment of ovarian masses is a controversial issue in gynecological practice. Ultrasound has a good diagnostic reliability in the preoperative assessment of ovarian masses, even if there is no general agreement about the sonographic characteristics considered predictive of malignancy [1 – 7]. Several clinical studies have shown that serum CA 125 assay can be used as a diagnostic tool to discriminate benign from malignant ovarian masses, especially in postmenopausal women [2, 5, 7 – 13]. Coagulation and fibrinolytic pathways are often altered in cancer patients. About 50% of all patients, and up to 95% of those with metastatic disease, present some abnormalities of the hemostatic pa-
rameters [14, 15]. Moreover, thromboembolism and hemorrhage represent the second largest cause of death in cancer patients. Furthermore, there is morphological and histochemical evidence of fibrin deposition in tumors [16]. Tumor fibrin results from extravasation and extravascular clotting of plasma fibrinogen. Fibrin can facilitate tumor angiogenesis and stroma generation and serve as a barrier between tumor cells and host inflammatory cells which could otherwise invade and destroy the tumor [16 – 18]. Evidence of tumor-associated activation of both coagulation and fibrinolysis can be provided by the measurement of fibrin split products, such as D-dimer (DD), in the patient’s plasma [19–21]. DD is a stable end product of cross-linked fibrin degradation by plasmin, which can be measured with an enzyme-linked immunosorbent sandwich assay using monoclonal antibodies [19]. In an earlier study we evaluated the reliability of plasma DD assay in the differential diagnosis of ovarian masses, using as a cutoff limit the sum of the mean value and the doubled standard deviation value of DD (416 ng/ml) in a group of 88 healthy nonpregnant females [22]. Sensitivity and specificity of the DD assay for epithelial ovarian cancer were 91 and 84%, respectively. DD levels were not related to patient age. The aim of this study is to compare the reliability of DD and CA 125 assay in differentiating benign from malignant ovarian masses. MATERIALS AND METHODS
This investigation was conducted on 124 consecutive patients with a clinical diagnosis of ovarian mass submitted to laparotomy at the Department of Gynecology and Obstetrics of the University of Pisa. Most of these patients had been included in a previous study [22]. Patients with cardiovascular disease, diabetes, acute or chronic inflammatory disease, previous malignancy, or previous 197
/ m4468$4130
01-19-96 23:06:24
goas
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
AP: Gyn Onc
198
GADDUCCI ET AL.
episodes of thrombophlebitis or thromboembolia were not included in this study. Three patients were excluded after primary operation because the clinically diagnosed ovarian mass was found to be a uterine leiomyoma in two cases and a leiomyosarcoma of the small bowel in one case.
FIG. 1.
Peripheral blood samples for the measurement of DD and CA 125 were drawn from all patients before surgery. Blood samples were collected early in the morning by venipuncture from the antecubital vein with minimal venous occlusion. Samples were excluded if venipuncture was traumatic or if the samples could not be quickly obtained. The plasma was
D-dimer and CA 125 preoperative plasma levels in patients with (a) benign ovarian disease or (b) epithelial ovarian cancer.
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
199
D-DIMER AND CA 125 IN OVARIAN MASSES
FIG. 2. ROC analysis curves plotted using the 65 patients with benign ovarian disease.
then separated by centrifugation and was stored at 0707C until assayed. DD was measured with an enzyme-linked immunosorbent sandwich assay using two monoclonal antibodies specific for two covalently bound D fragments (Boehringer-Mannheim GmbH, Germany). CA 125 was measured with a solid-phase immunoradiometric assay using monoclonal antibodies (International Cis, Gif-sur-Yvette, France). All determinations were carried out in duplicate. The values of 416 ng/ml and 65 U/ml were chosen as cutoff limits for DD [22] and CA 125 [13], respectively. The results were expressed as median value and range. The statistical analysis of the data was performed by Mann – Whitney U test, Spearman rank correlation test, the normal test of comparison of two proportions, and logistic regression analysis. Significance was assigned as P õ 0.05. RESULTS
The postsurgical diagnosis was epithelial ovarian cancer in 56 patients (median age, 62 years; range, 28 – 81
years) and benign ovarian disease in 65 patients (median age, 42 years; range, 17 – 73 years). Of the patients with epithelial ovarian cancer, 12 were in premenopause and 44 in postmenopause. Of the patients with benign ovarian disease, 45 were in premenopause and 20 in postmenopause. Of the cases with histologically ascertained cancer, 32 were serous, 12 undifferentiated, 8 mucinous, 3 endometrioid, and 1 case was a clear cell tumor. According to the FIGO classification, 15 patients had stage I and 41 had stage III – IV disease. Figure 1 illustrates the distribution of values of DD and CA 125 in benign (Fig. 1a) and malignant (Fig. 1b) ovarian masses, respectively. The receiver operator curve (ROC) for DD and CA 125 is shown in Fig. 2. Both DD and CA 125 levels were higher in patients with epithelial ovarian cancer than in those with benign ovarian disease (median 1895 ng/ml, range 162 – 3720 ng/ml vs median 218 ng/ml, range 11 – 2418 ng/ml, P õ 0.0001; and median 210 U/ml, range 12 – 6523 U/ml vs median 17 U/ml, range 4 – 267 U/ml, P õ 0.0001, respectively). In patients with epithelial ovarian cancer, DD levels correlated with CA 125 levels (Z Å 3.894, P õ 0.0001). The logistic regression procedure showed that both DD assay and CA 125 assay were significant predictive variables for malignancy (P Å 0.0001) (Table 1). The concordance between predicted probabilities and observed responses was 75.7% for DD, 72.1% for CA 125, and 90.8% for DD and CA 125. DD and CA 125 levels were related to FIGO stage (III–IV vs I, P Å 0.0001 and P õ 0.0001, respectively), but not to histologic type or menopausal status (Table 2). CA 125 values were higher in nonmucinous than in mucinous tumors, but the difference did not reach the statistical significance because of the small number of mucinous malignancies. It is worth noting that DD and CA 125 levels were greater in stage I epithelial ovarian cancer than in benign ovarian disease (median 589 ng/ml, range 164 – 3007 ng/ ml vs median 218 ng/ml, range 11 – 2418 ng/ml, P õ
TABLE 1 Logistic Regression Analysis of Preoperative DD, CA 125, and DD and CA 125 in Patients with Ovarian Masses
Variable
Parameter estimate
Standard error
Wald x2
P value
DD CA 125 DD CA 125
3.9135 3.9208 3.4441 3.4206
0.5736 0.6054 0.7123 0.7591
46.5470 41.9379 23.3766 20.3044
0.0001 0.0001 0.0001 0.0001
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
Concordance between predicted probabilities and observed responses (%) 75.7 72.1 90.8
200
GADDUCCI ET AL.
TABLE 2 Preoperative Levels of DD and CA 125 in Patients with Epithelial Ovarian Cancer: Relationship with FIGO Stage, Histologic Type, and Menopausal Status—Incidence of Elevated Preoperative Levels of DD and CA 125 in Patients with Epithelial Ovarian Cancer DD (ng/ml)
CA 125 (U/ml) ú416 ng/ml
na
Median
FIGO stage III–IV I
41 15
1984 589
Histologic type Nonmucinous Mucinous
48 8
Menopausal status Postmenopause Premenopause
44 12
a
Range
n
ú65 U/ml
(%)
Median
Range
n
(%)
162–3720 164–3007 P Å 0.0001
40 (97.6) 11 (73.3)
483 39
12–6523 12–1262 P õ 0.0001
38 (92.7) 5 (33.3)
1895 1445
162–3720 418–3100 P Å 0.6147
43 (89.6) 8 (100)
265 98
12–6523 15–550 P Å 0.0874
38 (79.2) 5 (62.5)
1896 1558
162–3720 418–3720 P Å 0.4073
39 (88.6) 12 (100)
210 213
12–6186 15–6523 P Å 0.6036
35 (79.5) 8 (66.7)
n, number of patients.
0.0001; and median 39 U/ml, range 12 – 1262 U/ml vs median 17 U/ml, range 4 – 267 U/ml, P õ 0.0001, respectively). DD levels ú416 ng/ml and CA 125 levels ú65 U/ml were found in 16.9 and 6.2%, respectively, of patients with benign ovarian masses (Table 3). Using these cutoff limits, elevated levels of DD and CA 125 were detected in 91.1 and 76.8%, respectively, of patients with epithelial ovarian cancer and in particular in 73.3 and 33.3%, respectively, of those with stage I disease and in 97.6 and 92.7%, respectively, of those with stage III – IV disease (Table 2). All eight patients with mucinous malignancy presented elevated DD levels, whereas only five had raised CA 125 values. Table 4 reports sensitivity, specificity, positive predictive value, and negative predictive value of DD and CA 125 in differentiating benign from TABLE 3 Incidence of Elevated Preoperative Levels of DD and CA 125 in Patients with Benign Ovarian Masses
Histology
Patients (n)
DD (ú416 ng/ml)
CA 125 (ú65 U/ml)
Serous cystoadenoma Mucinous cystoadenoma Endometriotic cyst Adult cystic teratoma Fibroma-thecoma Other
28
6 (21.4%)
1 (3.6%)
10 11 7 5 4
2 1 1 1 0
0 2 (18.2%) 1 (14.3%) 0 0
Total
65
/ m4468$4130
(20.0%) (9.1%) (14.3%) (20.0%)
11 (16.9%)
01-19-96 23:06:24
4 (6.2%)
goas
malignant ovarian masses using 416 ng/ml and 65 U/ml, respectively, as cutoff limits. The parameters of diagnostic evaluation of the two tests in pre- and postmenopausal women are shown in Table 5. DISCUSSION
Malignancy is frequently accompanied by evidence of systemic activation of hemostasis. This can be due either to nonspecific mechanisms, such as necrosis of tumor tissue or inflammatory response of the host, or to specific causes, such as synthesis of cancer cell procoagulants [14, 23, 24]. As far as epithelial ovarian cancer is concerned, following immunohistochemical studies on intact carcinomatous tissue, Zacharski et al. [25] suggested there is a dominant tumor cell-associated procoagulant pathway leading to thrombin generation. In fact, they found that fibrin was conspicuously present in the vicinity of viable tumor cells, but distant from areas of necrosis and areas containing inflammatory cells. The recent development of specific immunoenzymatic assays able to quantitate very low plasma levels of fibrin split products, such as DD, represents an important advance in the laboratory evaluation of fibrin formation and degradation [26]. Some authors have reported that plasma DD levels were elevated in patients with ovarian cancer [21, 27–29]. DD values were found to correlate with tumor stage, size, and activity and with CA 125 levels [21, 27]. In this study DD levels, as well as CA 125 levels, were significantly higher in patients with epithelial ovarian cancer, even in early stage,
AP: Gyn Onc
201
D-DIMER AND CA 125 IN OVARIAN MASSES
TABLE 4 Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, and Diagnostic Accuracy of DD and CA 125 Assays in Differentiating Benign from Malignant Ovarian Masses
CA 125 (ú65 U/ml) DD (ú416 ng/ml) CA 125 or DD Pa CA 125 and DD Pa
SE
SP
PPV
NPV
DA
76.8% 91.1% 94.6% 0.015 73.2% 0.897
93.8% 83.1% 76.9% 0.013 100.0% õ0.0001
91.5% 82.3% 77.9% 0.127 100.0% õ0.0001
82.4% 91.5% 94.3% 0.107 81.3% 0.943
86.0% 86.8% 85.1% 0.879 87.6% 0.890
Note. SE, sensitivity; SP, specificity; PPV, positive predictive value; NPV, negative predictive value; DA, diagnostic accuracy. a Versus CA 125 alone.
than in patients with benign ovarian disease. It is worth noting that DD was increased (ú416 ng/ml) in 73% of FIGO stage I patients, whereas CA 125 was greater than 65 U/ml in only 33.3%. DD assay was more sensitive but less specific than CA 125 assay for epithelial ovarian cancer. The combination CA 125 or DD had higher sensitivity (94.6% vs 76.8%, P Å 0.015) and lower specificity (76.9% vs 93.8%, P Å 0.013), while positive and negative predictive values were not significantly different when compared to CA 125 assay alone. It is worth noting that the association CA 125 and DD showed a 100% specificity and a 100% positive predictive value (P õ 0.0001 vs CA 125 alone), and that sensitivity and negative predictive value of this combination were similar to those of CA 125 assay alone. The benefit achieved by combining the two tests
seemed to be limited to premenopausal patients. In this group of patients the combination CA 125 or DD had higher sensitivity (100% vs 66.7%, P Å 0.031) and higher negative predictive value (100% vs 91.1%, P õ 0.0001), while the association CA 125 and DD had higher specificity (100% vs 91.1%, P õ 0.0001) when compared to CA 125 alone. In conclusion, the combination CA 125 and DD seems to be a useful diagnostic tool to discriminate benign from malignant ovarian masses particularly in premenopausal patients. Elevated preoperative levels of both antigens are invariably associated with postsurgical diagnosis of epithelial ovarian cancer. Therefore, the combined evaluation of DD and CA 125 could help to identify patients at increased risk for malignancy who should be referred to a specialistic oncologic center for adequate treatment.
TABLE 5 CA 125 and DD Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, and Diagnostic Accuracy in Patients with Ovarian Cancer by Menopausal Status SE
SP
PPV
NPV
DA
91.1% 100.0% 100.0% õ0.0001 91.8% 0.787
86.0% 93.0% 86.0% 0.771 93.0% 0.404
51.3% 72.2% 81.3% 0.169 64.5% 0.599
85.9% 81.3% 84.4% 0.961 82.8% 0.858
Premenopause CA 125 (ú65 U/ml) DD (ú416 ng/ml) CA 125 or DD Pa CA 125 and DD Pa
66.7% 100.0% 100.0% 0.031 66.7% 0.628
91.1% 91.1% 82.2% 0.408 100.0% õ0.0001
66.7% 75.0% 60.0% 0.866 100.0% 0.069
Postmenopause CA 125 DD CA 125 or DD Pa CA 125 and DD Pa
79.5% 88.6% 93.2% 0.155 75.0% 0.878
100.0% 65.0% 65.0% 0.003 100.0% 0.598
100.0% 84.8% 85.4% õ0.0001 100.0% 0.686
Note. SE, sensitivity; SP, specificity; PPV, positive predictive value; NPV, negative predictive value; DA, diagnostic accuracy. a Versus CA 125 alone.
/ m4468$4130
01-19-96 23:06:24
goas
AP: Gyn Onc
202
GADDUCCI ET AL.
REFERENCES 1. Herrmann, U. J., Jr., Locher, G. W., and Goldhirsch, A. Sonographic patterns of ovarian tumors: Prediction of malignancy, Obstet. Gynecol. 69, 777–781 (1987). 2. Finkler, N. J., Benacerraf, B., Lavin, P. T., Wojciechowski, C., and Knapp, R. C. Comparison of serum CA 125, clinical impression and ultrasound in the preoperative evaluation of ovarian masses, Obstet. Gynecol. 72, 659–664 (1988). 3. Granberg, S., Wikland, M., and Jansson, I. Macroscopic characterization of ovarian tumors and the relation to histological diagnosis: Criteria to be used for ultrasound evaluation, Gynecol. Oncol. 35, 139–144 (1989). 4. Campbell, S., Bhan, V., Royston, P., Whitehead, M. I., and Collins, W. P. Transabdominal ultrasound screening for early ovarian cancer, Br. J. Med. 299, 1363–1367 (1989). 5. Gadducci, A., Capriello, P., Ferdeghini, M., Madrigali, A., Puccetti, A., Annichiarico, C., Prontera, C., Bianchi, R., and Fioretti, P. Pelvic ultrasound, serum CA 125 assay, CA 19.9 assay and serum CA 72.4 assay in the differential diagnosis of ovarian masses, Cancer J. 4, 249– 253 (1991). 6. Sassone, A. M., Timor-Tritsch, E., Artner, A., Westhoff, C., and Warren, W. B. Transvaginal sonographic characterization of ovarian disease: Evaluation of a new scoring system to predict ovarian malignancy, Obstet. Gynecol. 78, 70–76 (1991). 7. Maggino, T., Gadducci, A., D’Addario, V., Pecorelli, S., Lissoni, A., Stella, M., Romagnolo, C., Ferdeghini, M., Zucca, S., Trio, D., and Trovo, S. Prospective multicenter study on CA 125 in postmenopausal pelvic masses, Gynecol. Oncol. 54, 117–123 (1994). 8. O’Connel, G. J., Ryan, E., Murphy, K. J., and Prefontaine, M. Predictive value of CA 125 for ovarian carcinoma in patients presenting with pelvic masses, Obstet. Gynecol. 70, 930–932 (1987). 9. Einhorn, N., Bast, R. C., Jr., Knapp, R. C., Tjernberg, B., and Zurawski, V. R., Jr. Preoperative evaluation of serum CA 125 levels in patients with primary epithelial ovarian cancer, Obstet. Gynecol. 67, 414–416 (1986). 10. Malkasian, G. D., Jr., Knapp, R. C., Lavin, P. T., Zurawski, V. R., Jr., Podratz, K. C., Stanhope, R., Mortel, R., Berek, J. S., Bast, R. C., Jr., and Ritts, R. E. Preoperative evaluation of serum CA 125 levels in premenopausal and postmenopausal patients with pelvic masses: Discrimination of benign from malignant disease, Am. J. Obstet. Gynecol. 159, 341–346 (1988). 11. Vasilev, S. A., Schlaerth, J. B., Campeau, J., and Morrow, C. P. Serum CA 125 levels in preoperative evaluation of pelvic masses, Obstet. Gynecol. 71, 751–756 (1988). 12. Jacobs, I., and Bast, R. C., Jr. The CA 125 tumour-associated antigen: A review of the literature, Hum. Reprod. 4, 1–12 (1989). 13. Gadducci, A., Ferdeghini, M., Prontera, C., Moretti, L., Mariani, G., Bianchi, R., and Fioretti, P. The concomitant determination of different tumor markers in patients with epithelial ovarian cancer and benign ovarian masses: Relevance for differential diagnosis, Gynecol. Oncol. 44, 147–154 (1992).
/ m4468$4130
01-19-96 23:06:24
goas
14. Rickles, F. R., and Edwards, R. L. Activation of blood coagulation in cancer: Trousseau’s Syndrome revisited, Blood 62, 14–31 (1983). 15. Nand, S. Hemostasis and cancer, Cancer J. 6, 54–58 (1993). 16. Nagy, J. A., Brown, L. F., Senger, D. R., Lanir, N., Van De Water, L., Dvorak, A. M., and Dvorak, H. F. Pathogenesis of tumor stroma generation: A critical role for leaky blood vessels and fibrin deposition, Biochim. Biophys. Acta 948, 305–326 (1988). 17. Olander, J. V., Bremer, M. E., Marase, J. C., and Feder, J. Fibrin enhanced endothelial cell organization, J. Cell. Physiol. 125, 1–9 (1985). 18. Zacharski, L. R., Costantini, V., Wojtukiewicz, M. Z., Memoli, V. A., and Kudryk, B. J. Anticoagulants as cancer therapy, Semin. Oncol. 17, 217–227 (1990). 19. Rylatt, D. B., Blake, A. S., Cottes, L. E., Massingam, D. A., Fletcher, W. A., Masci, P. P., Whitaker, A. N., Elms, M., Bunce, I., Webber, A. J., Wyatt, D., and Bundensen, P. G. An immunoassay for human Ddimer using monoclonal antibodies, Thromb. Res. 31, 767–778 (1983). 20. Bick, R. L. Coagulation abnormalities in malignancy: A review, Semin. Thromb. Hemost. 18, 353–372 (1992). 21. Mirshahi, S. S., Pujade-Lauraine, E., Soria, C., Mirshahi, M., Fretault, J., Bernadou, A., and Soria, J. D-dimer and CA 125 levels in patients with ovarian cancer during antineoplastic therapy: Prognostic significance for the success of anticancer treatment, Cancer 69, 2289–2292 (1992). 22. Gadducci, A., Baicchi, U., Marrai, R., Del Bravo, B., Fosella, P. V., and Facchini, V. Pretreatment plasma levels of fibrinopeptide-A (FPA), D-dimer (DD), and von Willebrand factor (vWF) in patients with ovarian carcinoma, Gynecol. Oncol. 53, 352–356 (1994). 23. Wojtukiewicz, M. Z., Zacharski, L. R., Moritz, T. E., Hur, K., Edwards, R. L., and Rickles, F. R. Prognostic significance of blood coagulation tests in carcinoma of the lung and colon, Blood Coagulation Fibrinolysis 3, 429–437 (1992). 24. Zacharski, L. R., Wojtukiewicz, M. Z., Costantini, V., Ornstein, D. L., and Memoli, V. A. Pathways of coagulation/fibrinolysis activation in malignancy, Semin. Thromb. Hemostasis 18, 104–116 (1992). 25. Zacharski, L. R., Memoli, V. A., Ornstein, D. L., Rousseau, S. M., Kisiel, W., and Kudryk, B. J. Tumor cell procoagulant and urokinase expression in carcinoma of the ovary, J. Natl. Cancer Inst. 85, 1225– 1230 (1993). 26. Sagripanti, A., Carpi, A., Ferdeghini, M., Baicchi, U., and Grassi, B. Plasmatic markers of haemostatic system activation in patients with solid neoplasms, J. Nucl. Med. Allied Sci. 34, 321–332 (1990). 27. Hafter, R., Schrock, R., Von Hugo, R., and Graeff, H. Measurement of crosslinked fibrin derivatives in plasma and ascitic fluid with monoclonal antibodies against D dimer using EIA and Latex test, Scand. J. Clin. Lab. Invest. 45, 137–144 (1985). 28. Schrock, R., Hafter, R., Graeff, H., and Schmid, L. Die simultane bestimmung von CA 125 und D-dimer in plasma and aszites beim ovarialkarzinom, Gakologie 8, 260–262 (1985). 29. Khoo, S. K., Rylatt, D. B., Parsons, P., Wilson, K., Webb, M. J., Dickie, G., Kearsley, J., and Mackay, E. V. Serial D-dimer levels in the assessment of tumor mass and clinical outcome in ovarian cancer, Gynecol. Oncol. 29, 188–198 (1988).
AP: Gyn Onc