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Premenopausal women presenting with high level
tumour marker CA-125 and pelvic mass is not
necessarily bad news. Case reports and review of
literature Essam Hadoura, Magdy Moustafa Royal
Alexandra Hospital. Paisley. Scotland. UK,
Frimley Park Hospital. Surrey. England. UK
Abstract
Discussion
Conclusions
Introduction
In conclusion, the combination of ultrasound
characteristics and serum tumour marker CA125,
and possible other imaging modalities are
essential to diagnose the nature of ovarian mass.
CA-125 on its own has low specificity in
premenopausal women with an adnexal mass even at
a very high level.
CA125 and transvaginal ultrasound are the main
components of the risk malignancy index (RMI).
RMI is a way in triaging women with ovarian cysts
into low, moderate or high risk of malignancy and
accordingly patients can be managed by general
gynaecologist, in a cancer unit or in a cancer
institute 1. Recent observational diagnostic
study by Van Calster et al., shows that triaging
women using the International Ovarian Tumour
Analysis (IOTA) and logistic regression model
(LR2) was more accurate than the RMI-based
protocol 2.   Case (1) A 45 year old woman,
Para 2 was referred with six months history of
lower abdominal pain, progressively increasing
over the right iliac fossa region in the last
three months. Physical examination revealed
generalized pelvic tenderness and a mass palpated
at the right side. Trans-vaginal ultrasound scan
revealed unilocular 8cm right adnexal mass with
homogenous low level echogenicity, consistent
with endometrioma. Left ovary contains 3cm
haemorrhagic cyst. Pelvic computerized
tomography (CT) confirmed bilateral ovarian
masses with features in keeping with
endometriomas. CA125 measured 3102 IU/ml (Normal
0-35 IU/ml). At Laparotomy widespread haemosidren
deposition noted over the peritoneum and pelvic
organs with large right sided ovarian cyst. She
had total abdominal hysterectomy and bilateral
salpingoophrectomy and omentectomy.
Histolopathological examination confirmed
bilateral ovarian endometriomas. Case (2) A
thirty years old nulligravida was referred by the
urologist because of incidental ultrasound
finding of pelvic mass 10X6X10 cm. Her main
complaint was lower abdominal pain and urinary
frequency. MRI showed bilateral ovarian
endometrioma of 8x8 cm (right) 5x5 cm (left).
Examination revealed pelviabdominal mass of about
18 weeks size. CA125 was 1060 IU/ml. She had
Laparoscopic bilateral ovarian cystectomy.
Histolopathological examination confirmed
bilateral ovarian endometriomas with no malignant
changes. Repeat CA125 four weeks after surgery
was 214 IU/ml.
Serum Carbohydrate Antigen 125 (CA-125) is a
high molecular weight glycoprotein elevated in
80 of epithelial ovarian tumours. It is useful
for the detection of persistence, recurrence and
monitoring response to chemotherapeutic agents in
patients with epithelial ovarian cancers 3. It
is elevated in benign gynaecological conditions
like ovarian endometriomas, serous cystadenoma,
pelvic inflammatory disease, pregnancy,
menstruation and leiomyoma. CA125 is also
elevated in non-gynaecological conditions
including cancers of the colon, pancreas, breast
and lungs 4.   Since the serum CA-125 levels of
more than 1,000 IU/ml was rarely seen in the
patients with benign gynaecological diseases, it
could be used to differentiate malignant and
benign ovarian masses in combination with the
other diagnostic methods 5. Ghaemmaghami et
al., 2007 described their experience with CA125
serum level gt1,000 IU/ml with uterine leiomyoma
and endometrioma without any malignancy 6. It
is not clear the mechanism of significantly
raised serum CA125 level in benign ovarian
endometriomas, but it has been observed in cases
of ruptured endometrioma7 as evident in case 1.
Regression of serum CA125 level was shown after
resection of these benign conditions as noted in
case 2. Ovarian endometrioma occurs in 50 of
women with endometriosis. The typical ultrasound
features of endometriomas in premenopausal
patients have been described as a unilocular cyst
with homogeneous low-level echogenicity of the
cyst fluid (ground glass echogenicity) in 53 by
Van Holsbeke et al., and 83 Guerriero et al
8-9.   The International Ovarian Tumour
Analysis (IOTA) Group described ultrasound
characteristic rules for endometriomas. The use
of specific ultrasound morphological findings
without CA-125 has been shown to have high
sensitivity, specificity and likelihood ratios
10. Using these rules, the reported sensitivity
was 95, specificity 91, positive likelihood
ratio of 10.37 and negative likelihood ratio of
0.06.   There is no clear consensus regarding the
need for further imaging beyond transvaginal
ultrasound in the presence of apparently benign
disease. However, these additional imaging
modalities will have a place in the evaluation of
more complex lesions 11.  
Objective The clinical value of high level
tumour marker CA125 in premenopausal women
presenting with Lower abdominal pain and pelvic
mass. Methods Two clinical cases presented with
lower abdominal pain, pelvic mass and very high
level tumour marker CA125 Results Case I
treated with total abdominal hysterectomy and
bilateral salpingoophrectomy. Case II had
Laparoscopic bilateral ovarian cystectomy.
Histolopathological examination confirmed
bilateral ovarian endometriosis with no malignant
changes in both cases. Conclusion Although
high level tumour marker CA125 is commonly
associated with epithelial ovarian malignancy it
is also detected in non malignant gynaecological
conditions mainly ovarian endometrioma, stage 4
endometriosis and leiomyoma. Premenopausal women
presenting with high level of Tumour marker CA125
with acute pelvic pain and or abnormal vaginal
bleeding is not necessarily bad news.
References

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