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Pitfalls of CA-125 Levels in the Preoperative Work-Up of Ovarian Masses

Institut Claudius Regaud, Toulouse, France

To the Editor:

We have read with interest the article by Timmerman et al¹ and the corresponding Editorial² in the September 20 issue of the Journal of Clinical Oncology addressing the issue of the diagnostic value of CA-125 levels in the preoperative diagnosis of ovarian cancer. Timmerman et al conclude that CA-125 levels are of limited value in the context of ovarian masses. This letter stresses the fact that, occasionally, they can be dangerously misleading.

We would like to draw the attention of the readers on the uncommon but clinically relevant occurrence of markedly elevated CA-125 levels in patients with benign ovarian tumors. A 62-year-old female was referred to our institution for the management of a large pelvic and abdominal mass. Neither ascites nor other anomalies were identified at abdominal examination. Ultrasonographic evaluation revealed a homogeneous, solid pelvic mass with calcifications. Computed tomography imaging of the abdomen and pelvis revealed a solid ovarian mass measuring 19 x 14 x 13 cm without ascites or adenomegalies. Thoracic computed tomography was normal. The CA-125 serum level was elevated at 9,739 U/mL (reference range, 0 to 35 U/mL). After multidisciplinary evaluation, the decision was made to proceed with laparotomy assessment. At laparotomy, a left ovarian tumor without any other pelvic or abdominal growth was found. Frozen section examination of the ovarian mass revealed a double contingent tumor, epithelial and conjunctive, without any sign of malignancy. Bilateral salpingo-oophorectomy was performed. A final pathologic diagnosis of benign clear-cell adenofibroma of the ovary was rendered. This unusual case, along with clinical experience with the association of elevated CA-125 levels to a variety of benign conditions, including endometriosis, demonstrates the need of frozen section before deciding a comprehensive staging and surgery in patients with ovarian masses and elevated CA-125 levels.

Another patient with a history of lobular breast cancer was referred with a diagnosis of ascites associated with a 3-cm solid mass of the left ovary. CA-125 level was 511 U/mL, and CA-15.3 level was 33 U/mL, suggesting a new primary ovarian tumor rather than a secondary site of the breast cancer. The final pathologic diagnosis was ovarian and peritoneal metastasis of the lobular breast cancer. This additional case again emphasizes the need for frozen section even when the pattern of serum markers seems to clearly orientate the clinician in the differential diagnosis between primary and secondary ovarian tumors.

Finally, the main role for CA-125 levels in the work-up of clinical masses is to select those patients who definitely need to be managed by a gynecologic oncologist who is able to perform a comprehensive staging operation in the case of malignancy, working in a center where frozen section can be examined by experienced gynecopathologists.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Moore RG, Bast RC Jr: How do you distinguish a malignant pelvic mass from a benign pelvic mass: Imaging, biomarkers, or none of the above? J Clin Oncol 25:4159-4161, 2007[Free Full Text]

2. Timmerman D, Van Claster B, Jurkovic D, et al: Inclusion of CA-125 does not improve mathematical models developed to distinguish between benign and malignant adnexal tumors. J Clin Oncol 25:4194-4200, 2007[Abstract/Free Full Text]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Querleu, D. Articles by Gladieff, L. Search for Related Content PubMed Articles by Querleu, D. Articles by Gladieff, L. Social Bookmarking                            What's this?