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Case report
Highly elevated levels of the antigen Ca-125 associated with inflammatory abdominal masses

Maciej Wilczak, Paweł Rzymski, Ksenia Stryjakowska, Robert Stanek, Tomasz Opala

Arch Med Sci 2007; 3, 3: 278-280
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Introduction

High levels of the CA-125 antigen are mostly associated with ovarian malignancies, although its effectiveness in detecting malignant changes, particularly in the early stage, is low [1-5]. According to literature the most statistically effective cut-off point for CA-125 concentrations in detecting malignancies, regardless of their level of staging, falls between 30-35 U/mL [5-7]. The significant growth of CA-125 has been associated with benign gynecological conditions such as: endometriosis, ovarian neoplastic cysts, adenomyosis, parasitic diseases and inflammatory processes [3, 5, 8-12]. But the lack of malignancies associated with the level of the CA-125 higher than 1000 U/mL is very rare, and only a few previously reported cases have been found in literature concerning this diagnostic problem [9, 13-16].


Case report

A 33-year-old patient with abdominal pain was referred to our clinic. The examination revealed a retroflexed uterus, deviated to the left side of pelvis. A palpable resistance was detected in the approximate location of the right adnexa, which stretched to the right anterior superior iliac spine. The volume of the left adnexa was slightly increased. The ultrasound examination (Aloka SSD5000, Japan) revealed a partially cystic, partially solid mass in the location of the right adnexa whose dimensions were 66×47 mm with similar mass adjoining to the left ovary of dimensions 39×19 mm. Laboratory examination showed CEA and AFP markers were within the normal range (CEA 2.1 ng/mL, AFP 1.91 ng/mL), CA-125 was highly elevated to 1259.85 U/mL and CRP 4.33 mg/L. Other laboratory test results (blood morphology, urine analysis, electrolyte levels) were all within the normal range (Axsym 2000, USA).
The patient underwent laparotomy, which revealed large inflammatory masses connecting the right adnexa and appendix, crossing over the iliac vessels and reaching to the promontorium. The adhesions were released and the inflammatory masses were removed along with the adherent right ovarian tube, ovary and the appendix. The final pathologic examination confirmed the result of the intraoperative sample examination: abscessus ovarii dextrii (M-41740), salpingitis et perisalpingitis dextrii, appendicitis et periappendicitis chronica (M-40000), omentitis (M-43000). The postoperative course was without any complications except for slightly elevated body temperature of 37°C. Thus, patient was administered Ceftriazone (2×1.0 g) and Metronidazolum (2×0.5 g). A repeat CA-125 drawn 2 weeks after the surgery showed a decline from the preoperative levels to 119.7 U/mL, and a decline to 34.4 U/mL a month after her surgery with CRP to 2.4 mg. After 2 months of monitoring, the symptoms totally regressed.


Discussion

Highly elevated levels of the CA-125 antigen correlated in addition with pelvic or abdominal masses typically suggest malignancies. Nevertheless, the result of the final pathologic examination can still be surprising, even with the use of a wide range of laboratory and imaging diagnostics. While ovarian cancer is most likely high on the list of differential diagnoses, atypical clinical presentation of fasciola may give rise to
a misdiagnosis of malignancy [12, 17].
In our report, the decline of the CA-125 marker from the initial value of 1259.85 U/mL to 34.4 U/mL after 4 weeks from the operation confirms a rare situation, when a benign condition mimics a malignant process. In comparison, Ghamande et al. describes a case of considerably high level of CA-125 associated with parasitic leiomyoma [16]. Postoperative monitoring of the antigen level showed a decrease to 35 U/mL (Table I). The equally high level of CA-125 1248.5 U/mL appeared to be tuberculosis peritonitis [15]. After the typical treatment, the level of CA-125 decreased to the normal values (Table I). Kammerer-Doak et al. described the case of a 37-year-old woman with adenomyosis and endometriosis, in which high values CA-125 were misleading, suggesting malignancy [14]. Similarly, as in the case of our patient, pathologic examination revealed the benign character of the process [14], and the postoperative monitoring confirmed the appropriateness of the undertaken treatment (Table I).


Conclusions

Apparently the benign gynecologic conditions can determine the high elevation of the CA-125 antigen. It seems that the postoperative and the adequate post-treatment monitoring is a valuable method in confirming the effectiveness of the undertaken treatment.

References

1. Bast RC Jr, Feeney M, Lazarus H, Nadler LM, Colvin RB, Knapp RC. Reactivity of a monoclonal antibody with human ovarian carcinoma. J Clin Invest 1981; 68: 1331-7.
2. Markowska J. Markery nowotworowe w diagnozowaniu i monitorowaniu raka jajnika [Polish]. In: Onkologia ginekologiczna. Markowska J (ed.), Urban & Partner Wrocław 2002; 782-8.
3. Sajdak S, Spaczyński M, Kędzia H, et al. Nowotwory jajnika [Polish]. In: Onkologia ginekologiczna. Markowska J (ed.), Urban & Partner, Wrocław 1997; 205-42.
4. Czekierdowski A, Źrubek H, Sikorski M, et al. Przydatność kliniczna oceny poziomu antygenu CA-125 i badania ultrasonograficznego z kolorowym Dopplerem w diagnostyce raka jajnika [Polish]. Gin Pol 1996; 67: 553-6.
5. Opala T, Rzymski P, Wilczak M, et al. Evaluation of CA-125, sICAM-1, soluble receptors TNFa p55 and p75 in prediction of optimal primary surgical treatment in patients with ovarian cancer [Polish]. Prz Ginekol Pol 2004; 4: 71-6.
6. Nowak-Markwitz E, Michalak M, Spaczynski M. Wartość predykcyjna stężenia Ca 125 w optymalnej wtórnej cytoredukcji u chorych na zaawansowanego raka jajnika [Polish]. Współcz Onkol 2003; 7: 662-7.
7. Wilczak M, Stanek R, Rzymski P, et al. The estimation of the CA-125 level at patients with the ovarian tumours. Prz Ginekol Poł – in press.
8. Bulsa M, Nowacki M, Perzanowski P. Elevated level of Ca 125 antigen in women in reproductive age without neoplastic diseases in pelvis minor [Polish]. Gin Pol 2002; 73: 517-22.
9. Nagata H, Takahashi K, Yamane Y, et al. Abnormally high values of CA-125 and CA19-9 in women with benign tumors. Gyneacol Obstet Invest 1989; 28: 165-8.
10. Kilic G, Blankstein J, Kadanoff R. Vertebral tuberculosis presenting with elevated Ca-125 and weight loss mimicking ovarian malignancy: case report. Eur J Gynaecol Oncol 2003; 24: 561-2.
11. Zeimat AG, Offner FA, Müller-Holzner E, et al. Peritoneum and tissues of the female reproductive tract as a physiological source of CA-125. Tumour Biol 1998; 19: 275-82.
12. Yazici G, Dilek UT, Karabacak T, Ertunc D, Korkmaz M, Dilek S. Adnexal fascioliasis masquerading as ovarian cancer. Gyn Oncol 2005; 99: 236-8.
13. Check JH, Coates TE, Nowroozi K. Extreme elevation of serum Ca-125 in two women with severe endometriosis: case report. Gynaecol Endocrinol 1991; 5: 217-20.
14. Kammerer-Doak DN, Magrina JF, Nemiro JS, Lidner TK. Benign gynecologic conditions associated with a CA-125 level >1,000 U/mL. Case report. J Reprod Med 1996; 41: 179-82.
15. Wu JF, Li HJ, Lee PI, Ni YH, Yu SC, Chang MH. Tuberculous peritonitis mimicking carcinomatosis: a case report. Eur J Pediatr 2003; 162: 853-5.
16. Ghamade SA, Eleonu B, Hamid AM. High levels of CA-125 in a case of parasitic leiomyoma presenting as an abdominal mass. Gyn Oncol 1996; 61: 297-8.
17. Rzymski P. Tumor Necrosis Factor alpha receptors p55 and p75 and ovarian cancer – state-of-the-art research and clinical implications. Arch Med Sci 2005; 1: 3-7.
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