Abstract
Context:
Pelvic masses are a prevalent cause for referral to gynecologic oncology departments to evaluate the possibility of benign or malignant conditions. Pelvic mass often was found in pelvic examinations among females with ovarian. Tumor markers are advantageous biomarker in tumor diagnosis.Evidence Acquisition:
We performed a computerized search in Medline/PubMed databases and Google Scholar with key words: “Cancer antigen 125 (CA125), Human epididymis protein 4 (HE4), risk of ovarian malignancy algorithm (ROMA), Risk of malignancy index (RMI), and Pelvic mass”.Results:
The usage of tumor marker CA125 alone is associated with serious limitations like low sensitivity for early or stage I disease and lack of specificity especially in pre-menopausal women. Serum HE4 is a good biomarker for discriminating ovarian cancer from benign pelvic disease, but could be affected by several factors including pregnancy, age, and smoking. ROMA has a high sensitivity, specificity, and negative predictive value to predict the presence of ovarian cancer in women with a pelvic mass. RMI could differentiate between benign and malignant pelvic masses, but RMI expression was higher in women with 55 years or more.Conclusions:
According to the results of this study, combination of these biomarkers or at least 2 or 3 biomarkers are suggested for early stage diagnosis of pelvic mass with high sensitivity and specificity.Keywords
1. Context
A pelvic mass is an enlargement or swelling in the pelvic region (1-5). The most common type of pelvic masses is ovarian masses which included cysts and tumors (1). Pelvic masses are a prevalent cause of referral to gynecologic oncology (2) departments to evaluate the possibility of benign or malignant conditions (3). Pelvic mass often was found in pelvic examinations among females with ovarian cancer. Annually, more than 200 000 women were admitted (4) by pelvic mass or ovarian cancer in United State (5). Ovarian cancer is a disease with 20% to 30% survival rate because of lack of trustful screening tools and non-specific early symptoms (6), so that more than 70% of patients are detected in progressive stage of ovarian cancer (7, 8). Therefore, early stage diagnosis is important, which needs a high sensitivity and specificity (6). Mass size, mobility, consistency, shape, possible internal aqueous component, and associated pain are beneficial characteristic to diagnose of mass nature (1). Moreover, tumor markers are advantageous instrument in tumor diagnosis (9). This paper evaluated biomarkers, including cancer antigen 125 (CA125), human epididymis protein 4 (HE4), risk of ovarian malignancy algorithm (ROMA), and risk of malignancy index (RMI) in pelvic mass.
2. Evidence Acquisition
In order to collect data about the role of CA125, HE4, ROMA and RMI in management of pelvic mass, we performed a computerized search in Medline/PubMed databases and Google Scholar with key words CA125, HE4, ROMA, RMI, and pelvic mass.
2.1. CA125
Cancer antigen 125 (CA125) is a glycoprotein (10, 11). It was identified by the OC125 monoclonal antibody (10). Studies following molecular cloning reported that CA125 has many features of mucin. Therefore, due to these features, CA125 was considered a mucin and determined MUC16 (12). CA125 assay is interesting because it is largely noninvasive, relatively cheap, and widely available (10). CA125 is created by ovarian cancer cells or normal cells from coelomic epithelium (13, 14). The serum tumor marker CA125 is used for predicting pelvic mass, but the usage of CA125 alone is associated with serious limitations. First; low sensitivity for stage I disease, Second; its lack of specificity particularly in pre-menopausal women with pelvic mass (10). This causes that CA125 had a low positive predictive value to detect ovarian cancer (10). Moreover, most clinicians apply composition of biomarker to distinguish pelvic mass type due to confined specificity and sensitivity (6). Moreover, CA125 in combination of CA724, CA211, CA199, and CA153 can screen ovarian neoplasm of patients (6). Another study reported that the addition of CA72-4 to Ca125, ultra sound, and pelvic investigation leads to the discrimination of malignant and benign pelvic mass (9).
2.2. HE4
Human epididymis protein 4 or HE4 as an acidic protein was detected by Kirchhoff et al. in 1991 (15). It was the first biomarker after CA125 approved by FDA for ovarian cancer (16). HE4 was discovered as a result of the WFDC2 gene transcript (17). HE4 as an 11-kDa protein (18) pertains to family of four-disulfide core protein (15) and acts as proteinase inhibitors (reducing the serine proteases activity) (19), which degrades collagen (14). HE4 was expressed in many normal and malignant tissues (14). It was also overexpressed in epithelial ovarian cancer (6), particularly serous (93%) and endometrioid tumors (100%) (15). Therefore, the highest level of HE4 was observed in ovarian cancer for women and moderate level of HE4 was seen in lung adenocarcinoma (15) Moreover, the lowest level of HE4 was found in breast, transitional cell, gastric, and pancreatic carcinomas (15, 20-22). But, in no mucinous tumors, HE4 was seen (15). Therefore, HE4 as a new marker in the assessment of ovarian cancer (6) can be considered as one of the most hopeful biomarkers in gynecology oncology (17). Moreover, several factors other than malignancy may affect the level of serum HE4. HE4 level is influenced by pregnancy, so that pregnant women have lower level of HE4 in comparison to non-pregnant women (15). Moreover, older women, smokers, and women with later menarche had significantly higher level of HE4 in comparison to control group (15). Furthermore, factors like menstrual cycle, endometriosis, and estrogen and progestin contraceptive usage did not change HE4 serum (15).
2.3. Risk of Ovarian Malignancy Algorithm (ROMA)
ROMA was applied for differentiating malignant from pelvic tumor (15). As a logistic regression algorithm, it uses HE4 and CA125 biomarker along menopause to evaluate benign or malignant ovarian mass (5). It is detected that ROMA has sensitivity 100%, specificity 47.7%, and negative predictive value 100% to predict ovarian cancer (5). Several studies have reported that ROMA has a pleasant efficacy to distinguish benign and malignant pelvic mass. But, another study reported that ROMA algorithm is better than in pre-menopausal women in comparison to post-menopausal population (23).
2.4. Risk of Malignancy Index (RMI)
Risk of malignancy index (RMI) was created in 1995 by Jacobas ultrasound findings × serum CA125 level × menstrual situation (1). RMI is an easy, simple, and convenient method to evaluate pelvic mass before surgery and affirms prior studies indicated RMI recovers differentiation between non-malignant and malignant pelvic masses. Extended index was reported as RMI1 and RMI2 in 1996 (1). Moreover, further extended indices including RM1, RM2 and RM3 were considered in 1999 (1). Yamamoto et al. reported a new index as RMI4 in 2009, which augments tumor size. The difference between these indices is due to U and M score allocation. For RMI1, if abnormal something is not observed in the ultrasonographic report, U is considered zero (U = 0); if abnormal something is observed, it will be U = 1; and if two or more abnormal findings was observed, it will be U = 2. Menopausal situation (M) is either post-menopausal (more than 1 year since the last menstruation or age > 50 if hysterectomy for any reason) (M = 3) or pre-menopausal (M = 1) (1). CA125 concentration is also considered in the formula. For RMI1, a cut-off value of 200 was considered as the best discrimination point with high sensitivity and specificity levels for benign and malignant pelvic masses diagnosis (1). For RMI 2, if there is 0 - 1 abnormal findings, U will be 1 and if 2 or more abnormal findings are existed, U will be 4. Moreover, M will be 1 and 4 for pre-menopausal and post-menopausal women, respectively. The serum concentration of CA125 is directly entered in the formula again (1). For RMI3, U = 1 in the presence of 0 - 1 abnormal findings and U = 1 in the presence of two or more abnormal findings. M is 1 and 3 for pre-menopausal and post-menopausal, respectively. The serum level of CA125 is directly considered in the formula again. For RMI4, the formula is considered as U × CA125 × M × S. When 0 - 1 and 2 or more abnormal findings is existed, U will be 1 and 4, respectively. In pre-menopausal and post-menopausal women, M will be 1 and 4, respectively. The serum level of CA125 is directly entered in the formula. S shows the largest diameter of the mass, which is 1 if < 7 cm, and 2 if ≥ 7 cm (24). Any of 4 malignancy risk indices (RMI1, RMI2, RMI3, and RMI4) can be used for election of cases for optimal therapy (25). Akturk et al. reported that no significant difference was seen in the efficiency of these 4 different malignancy risk indices (RMI1, RMI2, RMI3, and RMI4) in discriminating malignancy (25). Manjunath et al. in 2001 compared RMI1, RMI2, and RMI3 with each other. They reported that for benign malignancy discrimination, there is no difference between these indices (26). Another study reported that RMI2 was more trustful for discriminating benign and malignant disease. Morgante et al. also obtained similar result and reported that RMI2 performance was better than RMI1 (27). Moreover, RMI was significantly higher in women aged 55 or above comparing to younger women (2).
3. Results
3.1. CA125 and HE4
Studies about the role of CA125 in pelvic mass were shown in Table 1.
Studies About the Role of CA125 in Pelvic Mass
| Study | Result | Country | Number |
|---|---|---|---|
| Moore et al., 2008 (28) | Serum tumor marker CA125 with prediction of malignancy has low sensitivity and specificity in both pre- and post-menopausal women. | USA | 259 |
| Park et al., 2012 (8) | Results of this study demonstrated 4 RMIs and serum CA125 can correctly identify benign and malignant pelvic masses. | Korea | 547 |
| Cho et al., 2014 (29) | Serum CA125 is frequently increased in benign situation like pelvic inflammatory disease and in malignant disorders. | Korea | 27 |
| Karimi-Zarchi et al., 2014 (30) | CA125 is a prognostic and diagnostic biomarker in patients with newly-discovered pelvic mass, however, it cannot predict complication of malignant pelvic mass after surgery. | Iran | 203 |
| Lokich et al., 2015 (5) | Serum level of CA125 is elevated in multiple benign gynecologic tumors. | USA | 498 |
| Chen et al., 2015 (6) | Marker CA125 can be used for predicting pelvic masses. | China | 232 |
| Zhang et al., 2015 (31) | Serum cancer antigen (CA125) discriminate neoplasm tumors from benign tumors. | China | 2481 |
Studies about HE4 in pelvic mass were shown in Table 2.
Studies about HE4 in Pelvic Mass
| Study | Result | Country | Number |
|---|---|---|---|
| Montagnana et al., 2009 (32) | HE4 might be a favorable and excellent biomarker for diagnosis of pelvic masses. | Italy | 99 |
| Abdel-Azeez et al., 2010 (33) | HE4 has the highest sensitivity to detect ovarian cancer in patients with pelvic masses particularly early stage disease. | Egypt | 65 |
| Richards et al., 2015 (17) | Human epididymis protein 4 (HE4) is a modern biomarker for epithelial ovarian cancer diagnosis. | Australia | 50 |
| Chen et al., 2015 (6) | HE4 was associated with growth and cancer cell adhesion. | China | 232 |
| Cho et al., 2014 (29) | HE4 is a good diagnostic marker for epithelial ovarian cancer in Korean women with pelvic mass. | Korea | 27 |
3.1.1. Comparison Between HE4 with CA125 in Patients with Pelvic Mass
• HE4 is a strong instrument in comparison to CA125 to diagnosis of epithelial ovarian cancer (31).
• HE4 is better than CA125 in terms of specificity in the identification of malignant pelvic mass (6).
• HE4 has higher sensitivity than CA125 (90% vs. 83.3%), higher specificity compared to CA125 (95% vs. 85%), higher positive and negative predictive value (93.1% vs. 80.7%), and (92.7% vs. 87.2%) than CA125 (34).
• HE4 has better performance than CA125 with respect to specificity (P = 0.022) for diagnosis of ovarian cancer, especially in pre-menopausal women in Australian population (17).
• Mean value of CA125 and HE4 was more in patients with EOC compared to benign tumors (P < 0.0001) (35).
Opinion about the combination of CA125 and HE4 in patients with pelvic mass is shown in Table 3.
Opinion About Combination of CA125 and HE4 in Patients with Pelvic Mass
| Study | Results | Country | Number |
|---|---|---|---|
| Chen et al., 2015 (6) | HE4 in combination with CA125 improves specificity for ovarian cancer. | China | 100 malignant ,132 benign |
| Asher et al., 2010 (36) | Combination of HE4 and CA125 supply the highest discrimination between benign and malignant cancer. | UK | 1 case |
| Zhang et al., 2015 (31) | Combination of HE4 with CA125 and ROMA can be effective for malignancy evaluation. | China | 2481 |
| Moore et al., 2008 (28) | A combination of CA125 and HE4 caused significant elevation in sensitivity and specificity. | USA | 249 |
3.2. ROMA
Studies about the role of ROMA in pelvic mass were shown in Table 4.
Studies About the Role of ROMA in Patients with Pelvic Masses
| Study | Result | Country | Number |
|---|---|---|---|
| Moore et al., 2009 (35) | ROMA had 92.3% sensitivity in post-menopausal women and 76.5% in pre-menopausal women with pelvic mass. | USA | 531 |
| Sandri et al., 2013 (37) | ROMA index can help triage of pelvic mass in post-menopausal women. | Italy | 349 |
| Lokich et al., 2015 (5) | ROMA with clinical assessment can identify women with a pelvic mass. | USA | 498 |
| Zhang et al, 2015 (31) | ROMA can be used for discriminating benign pelvic mass (BPM) and epithelial ovarian cancer. | China | 2481 |
| Lokich et al., 2015 (5) | ROMA has a high sensitivity, specificity, and negative predictive value for predicting the presence of ovarian cancer in women with a pelvic mass. | USA | 498 |
| Romagno et al., 2016 (38) | ROMA algorithm shows the better diagnostic impression to differentiate epithelial ovarian cancer. | Italy | 405 |
| Yanaranop et al., 2017 (39) | ROMA can be used in women with pelvic masses to arrange risk groups for ovarian cancer. | Thailand | 260 |
3.2.1. Comparison of ROMA with CA125 and HE4
• Accuracy value of CA125 (pre-menopausal status) and ROMA (post-menopausal patients) was 89.8% and 93.3%, respectively. Area under the curve (AUC) for ROMA in post-menopausal patients was higher than CA125 (P = 0.001) (39).
• The sensitivity and specificity of ROMA was detected 0.873, 0.855, sensitivity and specificity of CA125 was 0.796, 0.825 and sensitivity and specificity of HE4 was 0.817, 0.851 in patients with ovarian cancer (40).
• HE4 and ROMA have better performance considering specificity and worse efficacy in terms of sensitivity compared to CA125 and RMI in pre-menopausal women (41).
• Higher sensitivity of ROMA was observed than RMI to distinguish benign status from epithelial ovarian cancer (42).
• HE4 or ROMA can help differentiating ovarian cancer from other pelvic masses even in early stage of cancer (19).
• Sensitivity of ROMA was 94.3% and RMI 84.6% at a set specificity of 75% for the prediction of epithelial ovarian cancer in patients with a pelvic mass (34).
3.3. RMI
Studies about the role of RMI in pelvic mass were shown in Table 5.
Studies About the Role of RMI in Pelvic Mass
| Study | Result | Country | Number of Patients |
|---|---|---|---|
| Van den Akker et al., 2010 (43) | RMI improves differentiation between malignant and non-malignant pelvic masses. | Netherlands | 548 |
| Akturk et al., 2011 (25) | RMI can correctly differentiate benign from malignant pelvic masses. | Turkey | 100 |
| Bouzari et al., 2011 (3) | RMI is the best technique to differentiate benign and malignant pelvic masses. | Iran | 182 |
| Hakansson et al., 2012 (44) | RMI with sensitivity of 92% can distinguish benign pelvic masses and ovarian cancer. | Denmark | 78 with pelvic mass and 251 with ovarian cancer |
| Park et al., 2012 (8) | Four RMIs as diagnostic criteria can discriminate benign and malignant pelvic masses. | Korea | 547 |
| Karimi-Zarchi et al., 2014 (30) | RMI2 had sensitivity (79.36%), specificity (78.95%), accuracy (78.93%) and negative predictive value (90.08%). | Iran | 200 |
3.3.1. Comparison Between RMI with CA125, HE4, and ROMA
• Both CA125 and RMI can be applied in ovarian cancer diagnosis. Sensitivity of CA 125 is higher, but specificity of RMI is higher than CA125 (41).
• RMI has lower sensitivity than ROMA (94%) at specificity of 75% (4).
• RMI and ROMA acted equally to differentiate benign pelvic masses and ovarian cancer (45).
• Sensitivity of ROMA was reported 94.3% in comparison with sensitivity of RMI 84.6 % for distinguishing of benign mass from epithelial ovarian cancer in patients with a pelvic mass (5).
• Sensitivity and specificity of CA125 was 92.3% and 59.4%, HE4 84.6% and 94.2%, and ROMA 84.6% and 81.2% for epithelial ovarian cancer in pre-menopausal women (46).
• Sensitivity and specificity of CA125 was 94.3% and 82.3%, HE4 78.2% and 99.0% and ROMA 93.1% and 84.4% in epithelial ovarian cancer in post-menopausal women (46).
• Specificity of CA125 was 62.2, HE4 63.2, ROMA 76.5 and RMI (81.5) to different ovarian cancer from benign disease at a set sensitivity of 94.4 (45).
• Sensitivity and specificity of CA125 was 91% and 24.6%; HE4 83.6% and 65%, RMI 80.6% and 65.6% and ROMA 91.0% and 42.6% (47).
• The sensitivity and specificity to discriminate ovarian cancer from benign tumor for HE4 was 86.2 %, 87.4, CA125 86.2 % and 78.9 and ROMA 93.1 % and 90.7% (48).
4. Conclusions
According to the results of this study, the combination of these biomarkers or at least 2 or 3 biomarkers are suggested for early stage diagnosis of pelvic mass with high sensitivity and specificity.
Acknowledgements
References
-
1.
Karimi-Zarchi M, Mojaver SP, Rouhi M, Hekmatimoghaddam SH, Moghaddam RN, Yazdian-Anari P, et al. Diagnostic value of the risk of malignancy index (RMI) for detection of pelvic malignancies compared with pathology. Electron Physician. 2015;7(7):1505-10. [PubMed ID: 26767105]. [PubMed Central ID: PMC4700897]. https://doi.org/10.19082/1505.
-
2.
Alanbay I, Akturk E, Coksuer H, Ercan M, Karasahin E, Dede M, et al. Comparison of risk of malignancy index (RMI), CA125, CA 19-9, ultrasound score, and menopausal status in borderline ovarian tumor. Gynecol Endocrinol. 2012;28(6):478-82. [PubMed ID: 22122561]. https://doi.org/10.3109/09513590.2011.633663.
-
3.
Bouzari Z, Yazdani S, Shirkhani Kelagar Z, Abbaszadeh N. Risk of malignancy index as an evaluation of preoperative pelvic mass. Caspian J Intern Med. 2011;2(4):331-5. [PubMed ID: 24551441]. [PubMed Central ID: PMC3895832].
-
4.
Bast RC Jr, Skates S, Lokshin A, Moore RG. Differential diagnosis of a pelvic mass: Improved algorithms and novel biomarkers. Int J Gynecol Cancer. 2012;22 Suppl 1:S5-8. [PubMed ID: 22543921]. [PubMed Central ID: PMC3389992]. https://doi.org/10.1097/IGC.0b013e318251c97d.
-
5.
Lokich E, Palisoul M, Romano N, Craig Miller M, Robison K, Stuckey A, et al. Assessing the risk of ovarian malignancy algorithm for the conservative management of women with a pelvic mass. Gynecol Oncol. 2015;139(2):248-52. [PubMed ID: 26364809]. [PubMed Central ID: PMC4868067]. https://doi.org/10.1016/j.ygyno.2015.09.010.
-
6.
Chen X, Zhou H, Chen R, He J, Wang Y, Huang L, et al. Development of a multimarker assay for differential diagnosis of benign and malignant pelvic masses. Clin Chim Acta. 2015;440:57-63. [PubMed ID: 25447698]. https://doi.org/10.1016/j.cca.2014.11.013.
-
7.
Goff BA, Mandel L, Muntz HG, Melancon CH. Ovarian carcinoma diagnosis. Cancer. 2000;89(10):2068-75. [PubMed ID: 11066047].
-
8.
Park JW, Park JH, Song ES, Lee BI, Lee JH, Kim KW, et al. Four risk of malignancy indices in evaluation of pelvic masses. Korean J Obstet Gynecol. 2012;55(9):636-43. https://doi.org/10.5468/KJOG.2012.55.9.636.
-
9.
Schutter EM, Sohn C, Kristen P, Mobus V, Crombach G, Kaufmann M, et al. Estimation of probability of malignancy using a logistic model combining physical examination, ultrasound, serum CA 125, and serum CA 72-4 in postmenopausal women with a pelvic mass: An international multicenter study. Gynecol Oncol. 1998;69(1):56-63. [PubMed ID: 9570999]. https://doi.org/10.1006/gyno.1998.4942.
-
10.
Duffy MJ, Bonfrer JM, Kulpa J, Rustin GJ, Soletormos G, Torre GC, et al. CA125 in ovarian cancer: European Group on Tumor Markers guidelines for clinical use. Int J Gynecol Cancer. 2005;15(5):679-91. [PubMed ID: 16174214]. https://doi.org/10.1111/j.1525-1438.2005.00130.x.
-
11.
Davis HM, Zurawski VR Jr, Bast RC Jr, Klug TL. Characterization of the CA 125 antigen associated with human epithelial ovarian carcinomas. Cancer Res. 1986;46(12 Pt 1):6143-8. [PubMed ID: 2430690].
-
12.
Yin BW, Lloyd KO. Molecular cloning of the CA125 ovarian cancer antigen: Identification as a new mucin, MUC16. J Biol Chem. 2001;276(29):27371-5. [PubMed ID: 11369781]. https://doi.org/10.1074/jbc.M103554200.
-
13.
Karimi-Zarchi M, Dehshiri-Zadeh N, Sekhavat L, Nosouhi F. Correlation of CA-125 serum level and clinico-pathological characteristic of patients with endometriosis. Int J Reprod Biomed (Yazd). 2016;14(11):713-8. [PubMed ID: 28008424]. [PubMed Central ID: PMC5153578].
-
14.
Gilani MM, Zarchi MK, Ghaemmaghami F, Behtash N, Mousavi AS, Ansaripoor S. RETRACTED: A study to evaluate the utility of presurgical CA125 to predict optimal tumor cytoreduction of epithelial ovarian cancer. Gyncol Oncol. 2007;105(3):780-3.
-
15.
Simmons AR, Baggerly K, Bast Jr RC. The emerging role of HE4 in the evaluation of advanced epithelial ovarian and endometrial carcinomas. Oncol (Williston Park, NY). 2013;27(6):548–556. [PubMed ID: 23909069].
-
16.
Hellstrom I, Raycraft J, Hayden-Ledbetter M, Ledbetter JA, Schummer M, McIntosh M, et al. The HE4 (WFDC2) protein is a biomarker for ovarian carcinoma. Cancer Res. 2003;63(13):3695-700. [PubMed ID: 12839961].
-
17.
Richards A, Herbst U, Manalang J, Pather S, Saidi S, Tejada-Berges T, et al. HE4, CA125, the risk of malignancy algorithm and the risk of malignancy index and complex pelvic masses-a prospective comparison in the pre-operative evaluation of pelvic masses in an Australian population. Aust N Z J Obstet Gynaecol. 2015;55(5):493-7. [PubMed ID: 26172511]. https://doi.org/10.1111/ajo.12363.
-
18.
Pitynski K, Sporek A, Lipinska I, Banas T, Ludwin A, Balajewicz-Nowak M. Significance of adding progesterone to the risk of ovarian malignancy algorithm for early stage ovarian cancer detection in patients with a pelvic mass: A single-center case-control study. Taiwan J Obstet Gynecol. 2015;54(6):766-72. [PubMed ID: 26701000]. https://doi.org/10.1016/j.tjog.2015.10.006.
-
19.
LeBleu VS, Teng Y, O'Connell JT, Charytan D, Muller GA, Muller CA, et al. Identification of human epididymis protein-4 as a fibroblast-derived mediator of fibrosis. Nat Med. 2013;19(2):227-31. [PubMed ID: 23353556]. [PubMed Central ID: PMC4457508]. https://doi.org/10.1038/nm.2989.
-
20.
Galgano MT, Hampton GM, Frierson HF Jr. Comprehensive analysis of HE4 expression in normal and malignant human tissues. Mod Pathol. 2006;19(6):847-53. [PubMed ID: 16607372]. https://doi.org/10.1038/modpathol.3800612.
-
21.
O'Neal RL, Nam KT, LaFleur BJ, Barlow B, Nozaki K, Lee HJ, et al. Human epididymis protein 4 is up-regulated in gastric and pancreatic adenocarcinomas. Hum Pathol. 2013;44(5):734-42. [PubMed ID: 23084584]. [PubMed Central ID: PMC3556378]. https://doi.org/10.1016/j.humpath.2012.07.017.
-
22.
Kamei M, Yamashita S, Tokuishi K, Hashioto T, Moroga T, Suehiro S, et al. HE4 expression can be associated with lymph node metastases and disease-free survival in breast cancer. Anticancer Res. 2010;30(11):4779-83. [PubMed ID: 21115941].
-
23.
Granato T, Porpora MG, Longo F, Angeloni A, Manganaro L, Anastasi E. HE4 in the differential diagnosis of ovarian masses. Clin Chim Acta. 2015;446:147-55. [PubMed ID: 25892674]. https://doi.org/10.1016/j.cca.2015.03.047.
-
24.
Yamamoto Y, Yamada R, Oguri H, Maeda N, Fukaya T. Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses. Eur J Obstet Gynecol Reprod Biol. 2009;144(2):163-7. [PubMed ID: 19327881]. https://doi.org/10.1016/j.ejogrb.2009.02.048.
-
25.
Akturk E, Karaca RE, Alanbay I, Dede M, Karasahin E, Yenen MC, et al. Comparison of four malignancy risk indices in the detection of malignant ovarian masses. J Gynecol Oncol. 2011;22(3):177-82. [PubMed ID: 21998760]. [PubMed Central ID: PMC3188716]. https://doi.org/10.3802/jgo.2011.22.3.177.
-
26.
Manjunath AP, Pratapkumar, Sujatha K, Vani R. Comparison of three risk of malignancy indices in evaluation of pelvic masses. Gynecol Oncol. 2001;81(2):225-9. [PubMed ID: 11330953]. https://doi.org/10.1006/gyno.2001.6122.
-
27.
Morgante G, la Marca A, Ditto A, De Leo V. Comparison of two malignancy risk indices based on serum CA125, ultrasound score and menopausal status in the diagnosis of ovarian masses. Br J Obstet Gynaecol. 1999;106(6):524-7. [PubMed ID: 10426607].
-
28.
Moore RG, Brown AK, Miller MC, Skates S, Allard WJ, Verch T, et al. The use of multiple novel tumor biomarkers for the detection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol. 2008;108(2):402-8. [PubMed ID: 18061248]. https://doi.org/10.1016/j.ygyno.2007.10.017.
-
29.
Cho HY, Kyung MS. Serum CA19-9 as a predictor of malignancy in primary ovarian mucinous tumors: A matched case-control study. Med Sci Monit. 2014;20:1334-9. [PubMed ID: 25073801]. [PubMed Central ID: PMC4117678]. https://doi.org/10.12659/MSM.890954.
-
30.
Karimi-Zarchi M, Baghdadabad A, Baghdadabad MR, Zahir Sh T, Abadi RD, Teimoori S, et al. Evaluation of serum CA 125 level and its relation to surgical, histopathologic and ultrasonographic findings in patients with pelvic mass. Eur J Gynaecol Oncol. 2014;35(1):67-71. [PubMed ID: 24654466].
-
31.
Zhang P, Wang C, Cheng L, Zhang P, Guo L, Liu W, et al. Comparison of HE4, CA125, and ROMA diagnostic accuracy: A prospective and multicenter study for chinese women with epithelial ovarian cancer. Medicine (Baltimore). 2015;94(52). e2402. [PubMed ID: 26717395]. [PubMed Central ID: PMC5291636]. https://doi.org/10.1097/MD.0000000000002402.
-
32.
Montagnana M, Lippi G, Ruzzenente O, Bresciani V, Danese E, Scevarolli S, et al. The utility of serum human epididymis protein 4 (HE4) in patients with a pelvic mass. J Clin Lab Anal. 2009;23(5):331-5. [PubMed ID: 19774626]. https://doi.org/10.1002/jcla.20340.
-
33.
Abdel-Azeez HA, Labib HA, Sharaf SM, Refai AN. HE4 and mesothelin: Novel biomarkers of ovarian carcinoma in patients with pelvic masses. Asian Pac J Cancer Prev. 2010;11(1):111-6. [PubMed ID: 20593939].
-
34.
Hamed EO, Ahmed H, Sedeek OB, Mohammed AM, Abd-Alla AA, Abdel Ghaffar HM. Significance of HE4 estimation in comparison with CA125 in diagnosis of ovarian cancer and assessment of treatment response. Diagn Pathol. 2013;8:11-4. [PubMed ID: 23343214]. [PubMed Central ID: PMC3621278]. https://doi.org/10.1186/1746-1596-8-11.
-
35.
Moore RG, McMeekin DS, Brown AK, DiSilvestro P, Miller MC, Allard WJ, et al. A novel multiple marker bioassay utilizing HE4 and CA125 for the prediction of ovarian cancer in patients with a pelvic mass. Gynecol Oncol. 2009;112(1):40-6. [PubMed ID: 18851871]. [PubMed Central ID: PMC3594094]. https://doi.org/10.1016/j.ygyno.2008.08.031.
-
36.
Asher V, Hammond R, Duncan TJ. Pelvic mass associated with raised CA 125 for benign condition: A case report. World J Surg Oncol. 2010;8(28):1-10. [PubMed ID: 20398372]. [PubMed Central ID: PMC2861664]. https://doi.org/10.1186/1477-7819-8-28.
-
37.
Sandri MT, Bottari F, Franchi D, Boveri S, Candiani M, Ronzoni S, et al. Comparison of HE4, CA125 and ROMA algorithm in women with a pelvic mass: Correlation with pathological outcome. Gynecol Oncol. 2013;128(2):233-8. [PubMed ID: 23200911]. https://doi.org/10.1016/j.ygyno.2012.11.026.
-
38.
Romagnolo C, Leon AE, Fabricio ASC, Taborelli M, Polesel J, Del Pup L, et al. HE4, CA125 and risk of ovarian malignancy algorithm (ROMA) as diagnostic tools for ovarian cancer in patients with a pelvic mass: An Italian multicenter study. Gynecol Oncol. 2016;141(2):303-11. https://doi.org/10.1016/j.ygyno.2016.01.016.
-
39.
Yanaranop M, Anakrat V, Siricharoenthai S, Nakrangsee S, Thinkhamrop B. Is the risk of ovarian malignancy algorithm better than other tests for predicting ovarian malignancy in women with pelvic masses? Gynecol Obstet Invest. 2017;82(1):47-53. [PubMed ID: 27197526]. https://doi.org/10.1159/000446238.
-
40.
Dayyani F, Uhlig S, Colson B, Simon K, Rolny V, Morgenstern D, et al. Diagnostic performance of risk of ovarian malignancy algorithm against CA125 and HE4 in connection with ovarian cancer: A meta-analysis. Int J Gynecol Cancer. 2016;26(9):1586-93. [PubMed ID: 27540691]. https://doi.org/10.1097/IGC.0000000000000804.
-
41.
Al Musalhi K, Al Kindi M, Al Aisary F, Ramadhan F, Al Rawahi T, Al Hatali K, et al. Evaluation of HE4, CA-125, risk of ovarian malignancy algorithm (ROMA) and risk of malignancy index (RMI) in the preoperative assessment of patients with adnexal mass. Oman Med J. 2016;31(5):336-44. [PubMed ID: 27602187]. [PubMed Central ID: PMC4996955]. https://doi.org/10.5001/omj.2016.68.
-
42.
Moore RG, Jabre-Raughley M, Brown AK, Robison KM, Miller MC, Allard WJ, et al. Comparison of a novel multiple marker assay vs the risk of malignancy index for the prediction of epithelial ovarian cancer in patients with a pelvic mass. Am J Obstet Gynecol. 2010;203(3):228 e1-6. [PubMed ID: 20471625]. [PubMed Central ID: PMC3594101]. https://doi.org/10.1016/j.ajog.2010.03.043.
-
43.
van den Akker PA, Aalders AL, Snijders MP, Kluivers KB, Samlal RA, Vollebergh JH, et al. Evaluation of the risk of malignancy index in daily clinical management of adnexal masses. Gynecol Oncol. 2010;116(3):384-8. [PubMed ID: 19959215]. https://doi.org/10.1016/j.ygyno.2009.11.014.
-
44.
Hakansson F, Hogdall EV, Nedergaard L, Lundvall L, Engelholm SA, Pedersen AT, et al. Risk of malignancy index used as a diagnostic tool in a tertiary centre for patients with a pelvic mass. Acta Obstet Gynecol Scand. 2012;91(4):496-502. [PubMed ID: 22229703]. https://doi.org/10.1111/j.1600-0412.2012.01359.x.
-
45.
Karlsen MA, Sandhu N, Hogdall C, Christensen IJ, Nedergaard L, Lundvall L, et al. Evaluation of HE4, CA125, risk of ovarian malignancy algorithm (ROMA) and risk of malignancy index (RMI) as diagnostic tools of epithelial ovarian cancer in patients with a pelvic mass. Gynecol Oncol. 2012;127(2):379-83. [PubMed ID: 22835718]. https://doi.org/10.1016/j.ygyno.2012.07.106.
-
46.
Bandiera E, Romani C, Specchia C, Zanotti L, Galli C, Ruggeri G, et al. Serum human epididymis protein 4 and risk for ovarian malignancy algorithm as new diagnostic and prognostic tools for epithelial ovarian cancer management. Cancer Epidemiol Biomarkers Prev. 2011;20(12):2496-506. [PubMed ID: 22028406]. [PubMed Central ID: PMC3237732]. https://doi.org/10.1158/1055-9965.EPI-11-0635.
-
47.
Winarto H, Laihad BJ, Nuranna L. Modification of cutoff values for HE4, CA125, the risk of malignancy index, and the risk of malignancy algorithm for ovarian cancer detection in Jakarta, Indonesia. Asian Pac J Cancer Prev. 2014;15(5):1949-53. [PubMed ID: 24716917].
-
48.
Ortiz-Munoz B, Aznar-Oroval E, Garcia Garcia A, Covisa Peris A, Perez Ballestero P, Sanchez Yepes M, et al. HE4, Ca125 and ROMA algorithm for differential diagnosis between benign gynaecological diseases and ovarian cancer. Tumour Biol. 2014;35(7):7249-58. [PubMed ID: 24771264]. https://doi.org/10.1007/s13277-014-1945-6.