INTRODUCTION
While over 80% of advanced stage ovarian epithelial cancer patients attain clinical remission with standard platinum/paclitaxel-based chemotherapy [1], the vast majority of them will relapse within two to five years [2,3]. It has become standard clinical practice to include CA125 testing in patient surveillance. Elevation in CA125 often precedes clinical evidence of relapse by imaging or physical exam [4-8]. Data from a large randomized clinical trial, however, demonstrate no survival advantage from CA125 screening [9]. These results are controversial, in part because the trial did not control for treatment after recurrence [10] or the role of more active drugs and regimens [11]. Recently, it has been shown that each week delay of intervention after first CA125 elevation correlated with a 3% increased chance of suboptimal resection at secondary cytoreductive surgery (SCS) [12]. HE4 has been shown to be effective for ovarian cancer detection [13,14] and received approval by the Food and Drug Administration as a recurrence monitoring marker. Limited information suggests that rising HE4 could detect a recurrence earlier than CA125 [14-16]. Mesothelin and MMP7 have been suggested as a marker for ovarian cancer diagnosis [17,18] or remission monitoring [14]. The goal of this study is to evaluate if any of the recently identified ovarian cancer tumor markers HE4, MMP7 and Mesothelin complements CA125 in monitoring disease status.
METHODS
Patients and serum specimens
Twenty-three patients were recruited from the offices of Pacific Gynecology Specialists (PGS), a private practice consisting of 6 gynecologic oncologist located on the Swedish Medical Center campus. Eligible patients included all women with ovarian and fallopian cancer who received both primary surgery and chemotherapy at Swedish Medical Center under the direction of PGS physicians during the years 2001-2008. Patients were approached by their treating physician or research nurse at their initial clinical visit. All but one patient entered clinical remission following surgery and chemotherapy. Clinical follow-up information (treatment regimen, response to treatment, clinical CA125 values, physical exam results, imaging results, date and type of recurrence, and date of death) as well as personal and family history were available through medical chart abstraction and a questionnaire completed at enrollment. Sixteen of the 23 women participated in the POCRC Surgical Donation Protocol at the time of their initial surgery, and they donated blood to the repository just prior to their surgery. These pre-treatment samples were available for marker measurement. At the time of a blood draw, each patient was required to have hemoglobin levels above 9 mg/dl, and platelet counts above 100,000 and no severe anemia or thrombocytopenia per her most recent clinical laboratory results. In some cases, this requirement reduced the number of blood draws. Characteristics of the 23 patients are listed in Table 1 and a timeline deputizing each patient’s marker levels and clinical data is shown in Table S1. A total of 182 serum samples (mean samples per patient: 8, range: 3-24) were tested for each of the markers. Blood was processed and placed at −80°C within 4 hours of the collection time.
Table 1.
Patient Characteristics.
Age is age at surgery, women below 50 are considered pre-menopausal; Residual disease of 2 cm or less is considered an optimal resection; First clinical recurrence: Imaging includes CT, MRI and PET, PE: physical examination; PFI - Progression-free interval. All patients received 6 cycles of a Taxane/Platin, patient 14 received 4 cycles; Diagnostic draw indicates that a pre-surgical blood draw was available.
| Pt | Age | Histology | Stage | Grade | Other initial treatment |
Chemo- therapy Response |
Residual Disease |
1st clinical Recurrence through |
Deceased | PFI (months) |
Survival (months) |
Total # of Draws |
Diagnostic Draw |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 35 | Serous Ovarian Cancer | IVA | B | Radiation | Recurrent | < 1 cm | Imaging | • | 48 | 108 | 6 | • |
| 2 | 66 | Serous Ovarian Carcinoma, primary looks endometrioid |
IIIC | C | Gemcitabine | Recurrent | none | PE | • | 23 | 84 | 9 | • |
| 3 | 60 | Occult Fallopian Tube Cancer | IIC | C | none | 46 | 24 | • | |||||
| 4 | 63 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | ≥ 2 cm | Imaging | • | 19 | 40 | 6 | • | |
| 5 | 60 | Serous Ovarian Carcinoma | IVA | B | Recurrent | < 1 cm | Imaging | 24 | 91 | 9 | |||
| 6 | 86 | Serous Ovarian Carcinoma | IIIC | B | Recurrent | < 1 cm | CA125 | • | 28 | 96 | 13 | • | |
| 7 | 51 | Serous Ovarian Carcinoma | IIIC | C | CTI 2103 | < 1 cm | 83 | 15 | • | ||||
| 8 | 76 | Serous Ovarian Carcinoma | IIIB | C | Gemcitabine | Recurrent | none | Imaging | • | 34 | 72 | 11 | • |
| 9 | 70 | Serous Ovarian Carcinoma | IIIC | B | Recurrent | < 1 cm | Imaging | • | 29 | 50 | 10 | • | |
| 10 | 48 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | 1-2 cm | Imaging | • | 16 | 44 | 7 | • | |
| 11 | 51 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | < 1 cm | Imaging | • | 9 | 11 | 4 | • | |
| 12 | 60 | Serous Ovarian Carcinoma | IVA | C | Recurrent | < 1 cm | Imaging | • | 11 | 25 | 4 | • | |
| 13 | 63 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | < 1 cm | Imaging | • | 21 | 63 | 11 | • | |
| 14 | 61 | Serous Ovarian Carcinoma | IIIC | C | Progressive | < 1 cm | 64 | 8 | • | ||||
| 15 | 70 | Serous Ovarian Carcinoma | IIIA | C | Recurrent | < 1 cm | Imaging | • | 9 | 16 | 4 | • | |
| 16 | 52 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | < 1 cm | Imaging | • | 17 | 28 | 4 | ||
| 17 | 56 | Ovarian Cancer | IIIC | C | Recurrent | none | Imaging | 39 | 68 | 9 | |||
| 18 | 37 | Serous Ovarian Carcinoma | IIIC | A | Recurrent | none | Imaging | 18 | 66 | 5 | |||
| 19 | 41 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | < 1 cm | Imaging | • | 14 | 37 | 5 | • | |
| 20 | 51 | Serous Ovarian Carcinoma | IIIC | C | Recurrent | ≥ 2 cm | Imaging | 17 | 48 | 6 | • | ||
| 21 | 56 | Serous Ovarian Carcinoma | IIIC | C | Avastin | Recurrent | < 1 cm | Imaging | 17 | 47 | 4 | ||
| 22 | 57 | Serous Ovarian Carcinoma | IIIC | C | Avastin | Recurrent | < 1 cm | Imaging | 18 | 42 | 3 | ||
| 23 | 48 | Serous Ovarian Cancer, complex adnexal mass |
IIIC | C | Avastin | Recurrent | < 1 cm | Imaging | 17 | 39 | 5 |
Evaluation of protein marker levels in serum samples
CA125 was measured using an in-house clinical assay based on Bio-Plex technology running on a Luminex platform using antibodies from Research Diagnostics (RDI-TRK4C29-X306 for capture and RDI-TRK4C29-X52 for detection) [19]. The assay is certified for clinical use in the State of Washington through the Clinical Laboratory Improvement Amendments (CLIA). Its performance is comparable to that of other clinical assays [19-21]. HE4 was measured on the Abbott ARCHITECT i1000SR platform using previously described antibodies [13]. Mesothelin was measured using a bead-based Luminex assay developed in-house with previously described antibodies (4H3 for capture and OV569 for detection) [22-25]. MMP7 was measured using a bead-based Luminex assay (R&D Systems; Cat. # LMP907). The mean fluorescence units measured in the Mesothelin and MMP7 assays were normalized by the averaged expression in four replicates of a normal human serum sample, resulting in relative fluorescence units (RFU). The sample consisted of a pool of 73 sera from high-risk participants without cancer [18,26].
Definition of marker elevation
Marker elevation was defined by two methods that are commonly used for disease monitoring with CA125: (1) Marker rises above a standard population threshold. (2) Marker rises above 2 x the lowest value (nadir) measured during the remission period. The definitions of disease progression by both methods are based on GCIG recommendations for disease monitoring using CA125 [27]. Due to the relative infrequency of blood draws, conditions were relaxed to require a single measurement above threshold to count as a positive marker increase.
Definition of response to chemotherapy
For all four markers, response to chemotherapy was measured as defined by the Gynecologic Cancer Intergroup (GCIG) for CA125: a 50% reduction in marker levels confirmed and maintained for at least 28 days [27].
RESULTS
In this study, marker behavior during remission and before recurrence was evaluated independently from whether the marker had dropped with surgery. A marker was required to have remission levels below threshold before a pre-recurrence rise was considered valid. All results are summarized in Supplemental Table S2 and charted in Supplemental Figure S1.
Determination of marker threshold
Relevant thresholds for using these markers for remission monitoring have not been established. There is an established threshold range for various commercial CA125 assays [27], however, no threshold has been determined yet for the CA125 assay used in this study. Thresholds for HE4 have been reported only recently but remain uncertain [28-31]. Given that HE4 serum values increase with age [32], separate HE4 thresholds were established for women below 50 years of age and women equal or above. The thresholds for all four markers were determined as the 95th percentile of expression in healthy controls. Control sera were obtained from 646 participants enrolled in an ongoing POCRC trial who were recruited from the general population and thus assumed to be healthy. Further sera were obtained from 122 POCRC participants who were either perceived healthy (73) or had benign ovarian and non-ovarian disease (49). The thresholds were established as follows (number of women in parentheses): CA125: 38 U/ml (637), HE4: premenopausal: 44 pmol/l (241), postmenopausal: 62 pmol/l (289), MMP7: 24 RFU/50 μl (635), Mesothelin: 20 RFU/50 μl (122).
Marker behavior
Of the 23 patients in the study, one was resistant to treatment (Table 1, #14). The remaining 22 patients achieved remission determined by normalization of CA125 levels, physical examination and/or imaging by computerized tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI) or ultrasound. Of those, 20 patients developed recurring disease with a median progression-free interval (PFI) of 18 months (range: 9-48 months). Two patients stayed in remission (Table 1, #3 and #7) and had all four markers below their threshold values during the remission period.
In the patient with persistent disease following chemotherapy and the presence of tumor confirmed by imaging results, CA125, HE4 and MMP7 dropped with surgery but remained above their respective thresholds thereafter. In this patient, Mesothelin dropped with initial treatment but remained below threshold, suggesting that it might not be associated with disease burden.
In the 20 cases with recurrence, 18 had a rise in CA125 resulting in physical examination and/or imaging (CT, PET or MRI) and the subsequent detection of a recurring mass. Patient #b had CA125 serum levels that were consistently in the normal range. Her disease progression was instead followed with the serum marker CA27-29. Patient #2’s recurrence was detected by physical exam alone (see Table S1). Pre-surgical samples were available for 13 of the 20 cases. CA125 dropped with surgery in 10 of the 13 patients with available pre-surgical blood draw. An example graph is shown in Figure 1 where patient #13 shows a CA125 drop and the other three patients don’t. CA125 was below threshold during remission and rose in 12 patients (Table 2). HE4 levels dropped with surgery in all 13 patients. HE4 levels were below threshold during remission and rose before or at recurrence in 10 patients (e.g. patient #13 in Figure 1). In a further four patients, HE4 remission levels oscillated around threshold (patient #8 in Figure 1) or remained above threshold during remission (patient #9 shown in Figure 1 and patients #6 and #15 shown in Figure S1) before elevating further before recurrence (shaded cells in Table 2). Mesothelin levels dropped in five of the 13 patients. They were below threshold and elevated before recurrence in five patients (two with a drop and three without) but their rise was also detected by CA125 and/or HE4 (#9, #10, #12, #13 and #15, Table 2). Mesothelin levels had a smaller amplitude than the other markers (e.g. patient #9 in Figure 1), a steep pre-recurrence elevation being observed only in patients #8 and #9. Patient #8 saw Mesothelin rise only one month after recurrence (Figure 1). MMP7 levels dropped in four of the 13 patients. In four patients (one with a drop and three without), the marker was below threshold during remission and rose before recurrence. Three of these events were also detected by CA125 and/or HE4 (patients #9, #16 and #17). In patient #4, MMP7 was the only maker to elevate before recurrence. Marker graphs are shown in Figure 1 for four exemplary patients and in Figure S1 for all patients.
Figure 1.
Graphs from four patients representing the range of CA125 and HE4 marker behavior from surgery to recurrence. The graphs focus on the clinically relevant expression range of 0-200 U/ml of CA125. HE4 expression units were in the same numeric range. Patient #8 had consistently normal CA125 levels. HE4 dropped with surgery, was above threshold during remission and further rose two months before recurrence. During remission, HE4 hovered around threshold. Patient #9 had no rising CA125 before recurrence but HE4 was above threshold during remission, dropped midway and rose eight months before recurrence. Patient #13’s recurrence was detected by HE4 with a 4½ month lead time but not by CA125. In Patient #20 neither marker was above 2x threshold before surgery but CA125 and HE4 dropped to 50%, remained below threshold during remission and finally elevated, however three months after recurrence. Figure S1 shows the graphs of all 23 patients.
Table 2.
Marker elevation prior to recurrence and lead time in days, by patient.
Numbers indicate lead time in days for marker elevation (doubling the remission nadir or above threshold) before first clinical recurrence in 20 patients with complete clinical remission. No values mean no elevation prior to recurrence. Shaded cells indicate that HE4 was consistently at or above threshold during remission.
| Patient | CA125 | HE4 | Meso. | MMP7 |
|---|---|---|---|---|
| 1 | 12 | 12 | ||
| 2 | 25 | |||
| 4 | 20 | |||
| 5 | 35 | |||
| 6 | 28 | 572 | ||
| 8 | 682 | |||
| 9 | 631 | 631 | 36 | |
| 10 | 2 | 2 | 2 | |
| 11 | 44 | |||
| 12 | 0 | 0 | 0 | |
| 13 | 137 | 38 | ||
| 15 | 0 | 178 | 0 | |
| 16 | 95 | 95 | 95 | |
| 17 | 227 | 0 | 0 | |
| 18 | 97 | |||
| 19 | 10 | 10 | ||
| 20 | ||||
| 21 | 69 | |||
| 22 | ||||
| 23 | 84 | 84 |
Advantage of HE4 over CA125 in the prediction of a clinical recurrence
Table 3 shows that five recurrences were detected by HE4 alone. This includes three patients with HE4 lead times of 4½ months (#13 shown in Figure 1) and around one month (#2 and #11 shown in Figure S1). This also includes two patients with HE4 at or above threshold during the entire remission period (#8 and #9 shown in Figure 1). A further two recurrences were detected earlier by HE4 than by CA125. These two patients also had HE4 levels consistently above threshold during remission. In six patients, the recurrence was detected by both markers at the same time. However in one of these six (#16), imaging was negative at the time of elevation of both markers resulting in the recurrence to be called three months later (Figure S1).
Table 3.
Number of patients with ovarian cancer recurrence first detected by elevation of either HE4 or CA125 or both and percent of recurrences detected by each marker. HE4 detects 14 recurrences and CA125 detects 11. Neither marker elevates in 3 patients.
| HE4 alone |
HE4 earlie r than CA12 5 |
Both at same time |
CA125 earlier than HE4 |
CA125 alone |
None |
|---|---|---|---|---|---|
| 5 | 2 | 6 | 1 | 3 | 3 |
| 25% | 10% | 30% | 5% | 15% | 15% |
| 60% | |||||
| 70% | |||||
| 85% | |||||
DISCUSSION
Elevation in CA125 expression levels often precedes clinical evidence of relapse by imaging or physical exam in roughly 80% of patients with ovarian cancer [4-8]. Ovarian cancer remission monitoring using CA125 is part of standard care as it is generally accepted that earlier detection of relapse leads to improve outcomes. This assumption has been challenged as a recent, large randomized study demonstrated no survival advantage and reduced quality of life with CA125 monitoring [9] although endpoint [10], altered drugs and regimens [11] or a more contemporary definition of CA125 elevation [35] could have changed this study’s outcome. Despite the controversy, CA125 monitoring remains a part of standard clinical practice. The purpose of this study is investigate the ability of HE4, Mesothelin and MMP7 marker levels to complement CA125 in monitoring disease status in patients with ovarian cancer, remission and first recurrence.
Of the three markers in this study, HE4, and to a limited extent MMP7, have been previously investigated for the same purpose. In a study of 80 ovarian cancer patients, Allard et al. found HE4 to compare well to CA125 for recurrence detection, including patients where CA125 is not of utility [37]. Havrilesky et al. measured HE4 and MMP7 as part of a marker panel and found increased lead time of 1-15 months over CA125 [14]. In a study of 31 ovarian cancer patients, Anastasi et al. found HE4 to rise 5-8 months before CA125 [15]. Mesothelin has been previously associated with ovarian cancer [17,18,38] but has not been tested for disease monitoring.
In this study, a Mesothelin elevation before recurrence was seen in in four patients but this elevation was also detected by CA125 and/or HE4. This and the relatively low amplitude of expression makes Mesothelin less suited as a marker for ovarian cancer monitoring.
MMP7 displayed pre-recurrence elevation in one patient with a lead time of three weeks. This recurrence was neither preceded by CA125 nor HE4. There was also an association of elevated MMP7 at first clinical recurrence with shorter survival. Although patient numbers were too small for statistical significance, the behavior of MMP7 in ovarian cancer monitoring warrants evaluation in a larger patient population.
HE4 displayed several advantages over CA125 for predicting a recurrence. Confirming similar results cited above, we observed greater lead time than for CA125 (Table 2) and in five cases HE4 was the only marker which was elevated before recurrence (Table 3). In addition, HE4 proved to be valuable even in cases where CA125 was elevating at the same time. Patient #16, for example, showed simultaneous elevation of CA125 and HE4. However, at the time of marker elevation the patient’s CT results were negative and clinical recurrence was therefore called only three months later at a positive imaging result. Results from this patient suggest HE4 may be more sensitive than imaging for confirming elevated CA125 elevations in some patients. Compared with imaging additional benefits for measuring HE4 levels as a confirmatory test include low cost, convenience and lack of ionizing radiation. Another patient’s recurrence was detected not by rising CA125 but by physical exam. Her CA125 level rose only after the physician called the recurrence. However, HE4 was already elevated at that time. An unexpected observation in patient #3 was a steady rise of HE4 to and above threshold in the last year of the study period during which both, imaging results and CA125 remained negative. This could indicate tumor recurrence and will need to be confirmed or ruled out by future medical data abstraction.
A very different behavior of HE4 was seen in four patients where marker levels during remission were consistently at or above threshold (Patients #8 and #9 in Figure 1, Patients #6, 8, 9 and 15 in Figure S1) and further rose before recurrence. This finding was unexpected. HE4 serum levels are related to progression of disease stage [39] and hence to tumor burden. A failure of HE4 levels to normalize at the completion of primary therapy could be related to persistent disease not detected by CA125 nor by physical exam or CT imaging. These patients may represent a high risk group who could potentially benefit from additional treatment or more intensive monitoring. Confirmation of this HE4 behavior in a larger number of patients is therefore warranted.
These and previous findings demonstrate the usefulness of HE4 in supporting or surpassing CA215 as a remission monitoring marker and speak in favor of adding HE4 alongside CA125 in settings where biochemical monitoring of ovarian cancer disease status is deemed clinically appropriate.
Supplementary Material
Table S1 - Clinical and marker data over observation period for all 23 patients. Spreadsheet holding the data for Figure S1, also covering the period after recurrence that is not displayed in Figure S1.
Table S2 - Comparison of CA125 to HE4, MMP7 and Mesothelin using four methods of threshold determination. Comparison of clinical parameters (imaging, biopsy, recurrence) with marker levels of CA125, HE4, MSLN and MMP7. Shown are (a) marker drop during first line treatment, (b) whether the marker is below threshold during remission (2 thresholds) and (c) days before marker elevation before 1st clinical recurrence (4 thresholds). Positive results in each category are indicated by cell shading. Empty cells mean that a value could not be calculated. Four methods were used for assessment of the markers at the time of first recurrence: (1) Marker rises by ≥25% observed on two occasions; (2) Marker rises at or above 2 x the threshold (3) Marker rises at or above the threshold; (4) Marker rises at or above 2 x the nadir of the remission period calculated on 2 occasions at least 1 week apart. The last two methods were used for marker comparison, the first two methods are shown for comparison.
Figure S1 - Individual patient graphs covering the observation period. Extension of Figure 1 showing the graphs of all 23 patients.
ACKNOWLEDGEMENTS
The project described was supported by Award Numbers P50 CA083636 and U01 CA152637 from the National Cancer Institute. This research was also supported by a grant of no-charge study materials from Abbott Laboratories. The Hellström Laboratory is supported by R01 134487 from National Cancer Institute and by a grant from Fujirebio Diagnostics, Inc. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National Institute of Health or Abbott Laboratories. We would like to thank Marta Janer and Beth A. Schodin for critical review of the manuscript.
Footnotes
CONFLICT OF INTEREST The authors have no conflict of interest.
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BIBLIOGRAPHY
- 1.Chemotherapy for advanced ovarian cancer. Advanced Ovarian Cancer Trialists Group. Cochrane Database of Systematic Reviews. 2000;(Issue 1) doi: 10.1002/14651858.CD001418. [No authors listed] Art No: CD001418. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2003;21:3194–3200. doi: 10.1200/JCO.2003.02.153. [DOI] [PubMed] [Google Scholar]
- 3.Cannistra SA. Cancer of the ovary. N Engl J Med. 2004;351:2519–2529. doi: 10.1056/NEJMra041842. [DOI] [PubMed] [Google Scholar]
- 4.Rustin GJ, Marples M, Nelstrop AE, Mahmoudi M, Meyer T. Use of CA-125 to define progression of ovarian cancer in patients with persistently elevated levels. J Clin Oncol. 2001;19:4054–4057. doi: 10.1200/JCO.2001.19.20.4054. [DOI] [PubMed] [Google Scholar]
- 5.Tuxen MK, Soletormos G, Rustin GJ, Nelstrop AE, Dombernowsky P. Biological variation and analytical imprecision of CA 125 in patients with ovarian cancer. Scand J Clin Lab Invest. 2000;60:713–721. doi: 10.1080/00365510050216448. [DOI] [PubMed] [Google Scholar]
- 6.Bridgewater JA, Nelstrop AE, Rustin GJ, Gore ME, McGuire WP, et al. Comparison of standard and CA-125 response criteria in patients with epithelial ovarian cancer treated with platinum or paclitaxel. J Clin Oncol. 1999;17:501–508. doi: 10.1200/JCO.1999.17.2.501. [DOI] [PubMed] [Google Scholar]
- 7.Rustin GJ, Nelstrop AE, Tuxen MK, Lambert HE. Defining progression of ovarian carcinoma during follow-up according to CA 125: a North Thames Ovary Group Study. Ann Oncol. 1996;7:361–364. doi: 10.1093/oxfordjournals.annonc.a010602. [DOI] [PubMed] [Google Scholar]
- 8.Tuxen MK, Soletormos G, Dombernowsky P. Serum tumor marker CA 125 for monitoring ovarian cancer during follow-up. Scand J Clin Lab Invest. 2002;62:177–188. doi: 10.1080/003655102317475434. [DOI] [PubMed] [Google Scholar]
- 9.Rustin GJ, van der Burg ME, Griffin CL, Guthrie D, Lamont A, et al. Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial. Lancet. 2010;376:1155–1163. doi: 10.1016/S0140-6736(10)61268-8. [DOI] [PubMed] [Google Scholar]
- 10.Morris RT, Monk BJ. Ovarian cancer: relevant therapy, not timing, is paramount. Lancet. 2010;376:1120–1122. doi: 10.1016/S0140-6736(10)61515-2. [DOI] [PubMed] [Google Scholar]
- 11.Guarneri V, Barbieri E, Dieci MV, Piacentini F, Conte P. Timing for starting second-line therapy in recurrent ovarian cancer. Expert Rev Anticancer Ther. 2011;11:49–55. doi: 10.1586/era.10.204. [DOI] [PubMed] [Google Scholar]
- 12.Fleming ND, Cass I, Walsh CS, Karlan BY, Li AJ. CA125 surveillance increases optimal resectability at secondary cytoreductive surgery for recurrent epithelial ovarian cancer. Gynecol Oncol. 2011;5:5. doi: 10.1016/j.ygyno.2011.01.014. [DOI] [PubMed] [Google Scholar]
- 13.Hellström I, Raycraft J, Hayden-Ledbetter M, Ledbetter J, Schummer M, et al. The HE4 (WFDC2) protein is a biomarker for ovarian carcinoma. Cancer Res. 2003;63:3695–3700. [PubMed] [Google Scholar]
- 14.Havrilesky LJ, Whitehead CM, Rubatt JM, Cheek RL, Groelke J, et al. Evaluation of biomarker panels for early stage ovarian cancer detection and monitoring for disease recurrence. Gynecol Oncol. 2008;110:374–382. doi: 10.1016/j.ygyno.2008.04.041. [DOI] [PubMed] [Google Scholar]
- 15.Anastasi E, Marchei GG, Viggiani V, Gennarini G, Frati L, et al. HE4: a new potential early biomarker for the recurrence of ovarian cancer. Tumour Biol. 2010;31:113–119. doi: 10.1007/s13277-009-0015-y. [DOI] [PubMed] [Google Scholar]
- 16.Allard J, Somers E, Theil R, Moore RG. Use of a novel biomarker HE4 for monitoring patients with epithelial ovarian cancer. J Clin Oncol (Meeting Abstracts) 2008;26:5535. [Google Scholar]
- 17.Hellström I, Hellström KE. Two novel biomarkers, mesothelin and HE4, for diagnosis of ovarian carcinoma. Expert Opin Med Diagn. 2011;5:227–240. doi: 10.1517/17530059.2011.559459. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Palmer C, Duan X, Hawley S, Scholler N, Thorpe JD, et al. Systematic evaluation of candidate blood markers for detecting ovarian cancer. PLoS ONE. 2008;3:e2633. doi: 10.1371/journal.pone.0002633. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Scholler N, Crawford M, Sato A, Drescher C, O’Briant K, et al. Bead-Based ELISA for Validation of Ovarian Cancer Early Detection Markers. Clin Cancer Res. 2006;12:2117–2124. doi: 10.1158/1078-0432.CCR-05-2007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Cramer DW, Bast RC, Jr., Berg CD, Diamandis EP, Godwin AK, et al. Ovarian cancer biomarker performance in prostate, lung, colorectal, and ovarian cancer screening trial specimens. Cancer Prev Res (Phila) 2011;4:365–374. doi: 10.1158/1940-6207.CAPR-10-0195. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Zhu CS, Pinsky PF, Cramer DW, Ransohoff DF, Hartge P, et al. A framework for evaluating biomarkers for early detection: validation of biomarker panels for ovarian cancer. Cancer Prev Res (Phila) 2011;4:375–383. doi: 10.1158/1940-6207.CAPR-10-0193. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Scholler N, Garvik B, Hayden-Ledbetter M, Kline T, Urban N. Development of a CA125-mesothelin cell adhesion assay as a screening tool for biologics discovery. Cancer Lett. 2007;247:130–136. doi: 10.1016/j.canlet.2006.03.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Scholler N, Fu N, Yang Y, Ye Z, Goodman G, et al. Soluble member(s) of the mesothelin/megakaryocyte potentiating factor family are detectable in sera from patients with ovarian carcinoma. Proc Natl Acad Sci U S A. 1999;96:11531–11536. doi: 10.1073/pnas.96.20.11531. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Hellström I, Friedman E, Verch T, Yang Y, Korach J, et al. Anti-mesothelin antibodies and circulating mesothelin relate to the clinical state in ovarian cancer patients. Cancer Epidemiol Biomarkers Prev. 2008;17:1520–1526. doi: 10.1158/1055-9965.EPI-08-0039. [DOI] [PubMed] [Google Scholar]
- 25.McIntosh M, Drescher C, Karlan B, Scholler N, Urban N, et al. Combining CA 125 and SMR serum markers for diagnosis and early detection of ovarian carcinoma. Gynecol Oncol. 2004;95:9–15. doi: 10.1016/j.ygyno.2004.07.039. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Scholler N, Lowe KA, Bergan LA, Kampani AV, Ng V, et al. Use of Yeast-Secreted In vivo Biotinylated Recombinant Antibodies (Biobodies) in Bead-Based ELISA. Clin Cancer Res. 2008;14:2647–2655. doi: 10.1158/1078-0432.CCR-07-1442. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Rustin GJ, Vergote I, Eisenhauer E, Pujade-Lauraine E, Quinn M, et al. Definitions for Response and Progression in Ovarian Cancer Clinical Trials Incorporating RECIST 1.1 and CA 125 Agreed by the Gynecological Cancer Intergroup (GCIG) Int J Gynecol Cancer. 2011;21:419–423. doi: 10.1097/IGC.0b013e3182070f17. [DOI] [PubMed] [Google Scholar]
- 28.Park Y, Kim Y, Lee EY, Lee JH, Kim HS. Reference ranges for HE4 and CA125 in a large Asian population by automated assays and diagnostic performances for ovarian cancer. Int J Cancer. 2011 doi: 10.1002/ijc.26129. [DOI] [PubMed] [Google Scholar]
- 29.Park Y, Lee JH, Hong DJ, Lee EY, Kim HS. Diagnostic performances of HE4 and CA125 for the detection of ovarian cancer from patients with various gynecologic and non-gynecologic diseases. Clin Biochem. 2011;44:884–888. doi: 10.1016/j.clinbiochem.2011.04.011. [DOI] [PubMed] [Google Scholar]
- 30.Jacob F, Meier M, Caduff R, Goldstein D, Pochechueva T, et al. No benefit from combining HE4 and CA125 as ovarian tumor markers in a clinical setting. Gynecol Oncol. 2011;121:487–491. doi: 10.1016/j.ygyno.2011.02.022. [DOI] [PubMed] [Google Scholar]
- 31.Chang X, Ye X, Dong L, Cheng H, Cheng Y, et al. Human Epididymis Protein 4 (HE4) as a Serum Tumor Biomarker in Patients With Ovarian Carcinoma. Int J Gynecol Cancer. 2011 doi: 10.1097/IGC.0b013e31821a3726. [DOI] [PubMed] [Google Scholar]
- 32.Lowe KA, Shah C, Wallace E, Anderson G, Paley P, et al. Effects of Personal Characteristics on Serum CA125, Mesothelin, and HE4 Levels in Healthy Postmenopausal Women at High-Risk for Ovarian Cancer. Cancer Epidemiol Biomarkers Prev. 2008;17:2480–2487. doi: 10.1158/1055-9965.EPI-08-0150. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Crum CP, Drapkin R, Miron A, Ince TA, Muto M, et al. The distal fallopian tube: a new model for pelvic serous carcinogenesis. Curr Opin Obstet Gynecol. 2007;19:3–9. doi: 10.1097/GCO.0b013e328011a21f. [DOI] [PubMed] [Google Scholar]
- 34.Kurman RJ, Ie M Shih. Molecular pathogenesis and extraovarian origin of epithelial ovarian cancer-Shifting the paradigm. Hum Pathol. 2011;42:918–931. doi: 10.1016/j.humpath.2011.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Bast RC., Jr. CA 125 and the detection of recurrent ovarian cancer: a reasonably accurate biomarker for a difficult disease. Cancer. 2010;116:2850–2853. doi: 10.1002/cncr.25203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Goto T, Takano M, Watanabe A, Miyamoto M, Kato M, et al. Potential survival benefit of secondary cytoreductive surgery for recurrent epithelial ovarian, tubal, and peritoneal cancers. Int J Gynecol Cancer. 2011;21:263–268. doi: 10.1097/IGC.0b013e3182098002. [DOI] [PubMed] [Google Scholar]
- 37.Allard J, Somers E, Theil R, Moore RG. Use of a novel biomarker HE4 for monitoring patients with epithelial ovarian cancer. J Clin Oncol (Meeting Abstracts) 2008;26:5535–5535. [Google Scholar]
- 38.Shah CA, Lowe KA, Paley P, Wallace E, Anderson GL, et al. Influence of Ovarian Cancer Risk Status on the Diagnostic Performance of the Serum Biomarkers Mesothelin, HE4, and CA125. Cancer Epidemiol Biomarkers Prev. 2009;18:1365–1372. doi: 10.1158/1055-9965.EPI-08-1034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Paek J, Lee SH, Yim GW, Lee M, Kim YJ, et al. Prognostic significance of human epididymis protein 4 in epithelial ovarian cancer. Eur J Obstet Gynecol Reprod Biol. 2011 doi: 10.1016/j.ejogrb.2011.05.021. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1 - Clinical and marker data over observation period for all 23 patients. Spreadsheet holding the data for Figure S1, also covering the period after recurrence that is not displayed in Figure S1.
Table S2 - Comparison of CA125 to HE4, MMP7 and Mesothelin using four methods of threshold determination. Comparison of clinical parameters (imaging, biopsy, recurrence) with marker levels of CA125, HE4, MSLN and MMP7. Shown are (a) marker drop during first line treatment, (b) whether the marker is below threshold during remission (2 thresholds) and (c) days before marker elevation before 1st clinical recurrence (4 thresholds). Positive results in each category are indicated by cell shading. Empty cells mean that a value could not be calculated. Four methods were used for assessment of the markers at the time of first recurrence: (1) Marker rises by ≥25% observed on two occasions; (2) Marker rises at or above 2 x the threshold (3) Marker rises at or above the threshold; (4) Marker rises at or above 2 x the nadir of the remission period calculated on 2 occasions at least 1 week apart. The last two methods were used for marker comparison, the first two methods are shown for comparison.
Figure S1 - Individual patient graphs covering the observation period. Extension of Figure 1 showing the graphs of all 23 patients.