| Abstract|| |
Background: Gall bladder carcinoma is endemic in North India along the Ganges belt. Most of the cases usually present in late stage when prognosis is poor. That mandates a necessity for proper screening in these areas for gall bladder lesions. Tumor markers CA 19-9 and CA 125 have been studied in various GI cancers and may also help in the screening, diagnosis and evaluation of gall bladder carcinoma. Aims: To assess serum CA19-9 and serum CA125 in patients with gall bladder lesions and find out a cut off value for diagnosis of carcinoma gallbladder. Methods and Material: Study included 118 cases, with female: male ratio of 4:1.Out of it, 91 (77 %) cases were benign and 27 (23 %) were malignant. Patients' sera was collected and analyzed for CA19-9 and CA 125 by CMIA method. Results: The Mean (SD) value of CA19-9 for benign and malignant cases was found to be 12.86 (17.54) and 625.35(186.52) U/ml. For CA 125 it was found to be 17.98(13.69) and 239.63(73.72) U/ml respectively. The difference was statistically significant (P< 0.001). When Mean - 2SD value of malignant lesions were taken as cut off a value of CA 19-9 and CA 125 were found be 252.31 U/ml & 92.19U/ml respectively, found to be significant to suggest /diagnose a case of carcinoma gall bladder along with clinicoradiological findings. Taking these value as cut off Sensitivity & Specificity for CA 19-9 and CA 125 in detecting malignant cases were found to be 100% & 98.90% and 100% & 94.50% respectively. Conclusions: It is concluded that both serum CA 19-9 and serum CA 125 may act as a good adjunct for diagnosis of cases of carcinoma gallbladder along with imaging studies. However, changes in CA19-9 are more significant than CA 125.
Keywords: Cholecystitis, gallbladder, neoplastic, tumor markers
|How to cite this article:|
Bind MK, Mishra RR, Kumar V, Misra V, Singh PA. Serum CA 19-9 and CA 125 as a diagnostic marker in carcinoma of gallbladder. Indian J Pathol Microbiol 2021;64:65-8
|How to cite this URL:|
Bind MK, Mishra RR, Kumar V, Misra V, Singh PA. Serum CA 19-9 and CA 125 as a diagnostic marker in carcinoma of gallbladder. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Jan 16];64:65-8. Available from: https://www.ijpmonline.org/text.asp?2021/64/1/65/306520
| Introduction|| |
Gallbladder is one of the organs having a wide spectrum of diseases ranging from congenital anomalies, calculi, and its complications, non-inflammatory, inflammatory, and neoplastic lesions. Gallstones are one of the major causes of morbidity and mortality all over the world. It affects around 10% of adult population. Its incidence increases progressively with age. Diseases of gallbladder are manifested as biliary pain in epigastrium and right upper quadrant of abdomen, radiating to interscapular area, right scapula and shoulder, associated with nausea, vomiting, jaundice, anorexia, fever, and chills.
Benign lesions of the gallbladder are relatively common, but only adenomatous polyps are considered to have malignant potential. Although ultrasonography can be useful in evaluating these lesions, considerable difficulty may be encountered in establishing the diagnosis preoperatively. These lesions include Cholesterol polyps, inflammatory polyp, adenomyomatosis, and adenomatous polyp.
Gallbladder cancer is a disease of the elderly; it affects patients in their sixth or seventh decades of life, with a female to male ratio of 5:1. Gallbladder carcinoma is known as an aggressive malignancy, with most large series reporting 5-year survival rates of 5-15%. In 25% of the patients the cancer is localized to gallbladder wall, in 35% it may spread beyond the wall to adjuvant soft tissue, and in 45% distant metastases may occur.
Early-stage gallbladder carcinoma lacks typical clinical manifestations, leading to a poor 5-year survival. At the time of diagnosis, most patients are at advanced stage, and thus lose the chances of radical cure. It is therefore important to diagnose gallbladder carcinoma earlier. Currently, the diagnosis of gallbladder carcinoma mainly depends on non-invasive auxiliary imaging and invasive examination such as laparoscopy, cytology, and biopsy. There is no ideal single tumor marker for the diagnosis and prognosis of gallbladder carcinoma.
In earlier reports, CA19-9 and CA 125 have been studied and found to be raised in Carcinoma Gall bladder. But, no definite cutoff values have been calculated.,,,,,,,,, Therefore the present study was done to assess and find out any cutoff values for CA 19-9 and CA 125 which can help in suspecting/diagnosing cases of malignant gall bladder lesions along with clinical and imaging findings only, before subjecting patients to cyto-histopathological examination.
| Subjects and Methods|| |
This prospective study was done in the Department of Pathology in collaboration with Departments of Gastroenterology and Surgery. It included 118 cases, who reported with suspected gallbladder lesions to Department of Surgery and Gastroenterology. After taking proper consent, clinicoradiological examination was done. USG guided FNA was performed in suspected lesions. Patients with evidence of any lesion in Stomach, duodenum, and pancreas were excluded. On cytological examination smears showing loose poorly formed acinar clusters of large pleomorphic cells, having high N:C ratio, prominent nucleoli and scant amount of cytoplasm were classified as positive for malignancy. Smears showing cuboidal to columnar cells present in tight cluster without any dysplastic features were labeled as negative for malignancy. Smears showing overlapping features, where it was not possible to classify in the benign or malignant group were kept in grey zone lesions. Patient's sera was collected and processed for CA19-9 and CA 125 by chemiluminescent microparticle immunoassay (CMIA) method using Abbott Architect machine in department.(Abbot Laboratories Diagnostic Division Abbot park, IL 60064 USA) Final diagnosis was confirmed by histopathology wherever possible. Normal reference values for CA19-9 and CA 125 were 0-37 U/mL and 0-35 U/mL, respectively, as per the kit literature.
Ethical clearance from the institutional ethical committee was taken before starting the project (IEC/MLNMC/2016/No-12).
Unpaired Student's t test was used for calculating the significance of difference in the mean (SD) values of two markers in benign and malignant lesions. P ≤ 0.05 was taken as critical level of significance. Cut off values of CA 19-9 and CA 125 for differentiating benign and malignant lesions were calculated as per following formula . Here f was taken as 2 due to small sample size. As the main aim of this study was to find a cut off to differentiate malignant from benign lesions, mean (SD) value of benign lesions were taken as negative controls for calculation of cut off rather than normal range given by manufacturer as suggested by Classen et al.
| Results|| |
This study included 118 cases with female:male ratio of 4:1. Out of these, 85 (72%) cases were benign and 27 (23%) cases were malignant. In remaining 6 (5%) cases it was not possible to definitely classify in benign or malignant group based on clinicoradiological and cytological findings and were considered as gray zone or indeterminate group for correlating with serological findings. Mean (SD) age for the benign group was 43.08 (14.43) years and for malignant was 53.80 (10.30) years. Most of the patients in gray zone group were of older age 50.66 (6.86) years [Table 1], had diffuse thickening of the gall bladder wall on ultrasonographical examination. Cytological findings were reported as suspicious of malignancy due to presence of small clusters of cells displaying atypia in a background of degenerative changes.
The Mean (SD) value of CA19-9 for benign and malignant groups was 12.86 (17.54) U/mL (range 2–136) and 625.35 (186.52) U/mL (range 306.9–910.2), respectively; for CA 125 was 17.98 (13.69) U/mL (range 4.6–65.3) and 239.63 (73.72) U/mL (range 108.2–360.8) respectively [Figure 1]. The difference was statistically highly significant (P < 0.001) for both CA19-9 and CA 125. When compared according to age and sex of cases in the malignant group, the difference was statistically not significant [Table 2].
|Figure 1: Bar diagram showing values of CA19-9 and CA 125 in benign and malignant lesions of gall bladder|
Click here to view
|Table 2: Serum levels of CA 19-9 and CA 125 according to age and sex of gall bladder carcinomas|
Click here to view
Evaluation of cut off levels of CA 19-9 and CA 125
When Mean+2SD value (47.94 U/mL) of benign lesions was taken as cut off, 90 (98.91%) benign cases had value less than this. Only 01 case (1.09%) had value more than this. When Mean-2SD value (252.31 U/mL) of malignant lesions was taken as cut off, all 27 cases (100%) had values more than this.
Thus we can infer that serum value of CA19-9 less than 47.94 U/mL can be taken as true negative and value more than 252.31 U/mL can be taken as true positive for malignant lesion. When 252.31 U/mL of CA 19-9 is taken as cut off limit for malignancy all the 27 cases had a value more than this (True Positive) and when 47.94 U/mL taken as cut off for benign, 90 cases have values less than this (True Negative). Only one cases had value above the cut off that was taken as false positive. Thus Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for CA 19-9 in detecting malignant cases was found to be 100%, 98.90%, 96.42%, and 100% respectively.
When Mean+2SD value (45.36U/mL) of benign lesion was taken as cut off, 86 cases (94.50%) had value less than this. 5 cases (5.50%) had value more than this. When Mean-2SD value (92.19U/mL) of malignant lesion was taken as cut off, all 27 cases (100%) had a higher value.
Thus we can infer that serum value less than 45.36U/mL can be taken as true negative and value more than 92.19U/mL can be taken as true positive for malignant lesion.
When 92.19 U/mL of CA 125 is taken as cut off limit for malignancy, all the 27 cases had a value more than this (True Positive) and when 45.36 U/mL taken as cut off for benign, 86 cases had values less than this (True Negative). Five cases had value above the cut off that is false positive. Thus Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for CA 125 for malignant cases was found to be 100%, 94.50%, 84.37%, and 100% respectively.
Complete gall bladder specimen were received in all benign cases and 10 cases with malignant lesions. In rest of the malignant lesion only biopsy was received. Therefore pathological TNM staging and its correlation with serum CA 19-9 and CA 125 could not be done in all malignant cases.
Of the 6 cases defined as gray zone, one case had high value of CA 19-9 whereas 5 out of six had increased CA 125. However, none of them could cross the lower cut off for malignant lesions [Table 1]. On histopathological examination, none of these cases turned out to be malignant emphasizing that isolated inflammatory lesions may sometimes have raised serological markers but fail to cross cutoff for malignant lesions and in such cases further cyto-histological examination is mandatory.
| Discussion|| |
This study included 118 cases whose age ranged from 18 to 78 years with mean (SD) age 45.53 (14.29) years. The mean value of serum CA 19-9 in benign group were comparable to the study done by Wang et al. (12.86 U/Ll vs 15.17 U/mL). In malignant group the value of serum CA 19-9 in the present study were much higher (626.35 U/mL vs 238.17 U/mL). The difference was most probably due to difference in the population studied and stage of the disease at the time of inclusion in the study. Significantly high values in benign group (401.92 U/mL) as compared to this study was reported by Lin et al. that may be attributed to the inclusion of cases of pancreatico-biliary diseases also. In the malignant group the mean values were comparable (826.83 U/mL) to this study. Kankonkar et al. also found the similar value (847.6 U/mL) in their study. Shukla et al. also found the raised value of serum CA19-9 in malignant lesions as compared to the benign lesions of gallbladder (211.27 U/mL vs 86.06 U/mL). Other studies also identified serum CA 19-9 as a sensitive marker for carcinoma gallbladder.,,, The mean value of serum CA 125 in benign group was comparable to the study done by Wang et al. (17.98 U/mL vs 12.99 U/mL). In malignant group, the value of serum CA 125 in the present study was much higher (239.63 U/mL vs 55.34 U/mL). The difference in the malignant group was most probably due to difference in the population studied and stage of the disease at which the patients were included in the study. Shukla et al. also found the raised levels in malignant group as compared to benign group (253.61 U/mL vs 65.5 U/mL, P < 0.05) the difference was statistically significant. Other studies also found significantly raised value of serum CA 125 in malignant group as compared to benign group (77.44 U/mL vs 7.85 U/mL)., Variation in the serological values of markers may also be due to use of different assay methods and other technical parameters and factors and therefore these factors should be considered and taken care of before making any definite opinion.
When Mean+2SD value (47.94 U/mL) of benign lesions was taken as cut off, 90 (98.91%) benign cases had value less than this. Only 01 case (1.09%) had value more than this. When Mean-2SD value (252.31 U/mL) of malignant lesions was taken as cut off all 27 cases (100%) had values more than this.
Thus we can infer that serum value of CA19-9 less than 47.94 U/mL can be taken as true negative and value more than 252.31 U/mL can be taken as true positive for malignant lesion. Patients having value in between should be further subjected to proper clinical, imaging, and morphological evaluation to differentiate between benign and malignant lesion.
Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of CA19-9 was found to be 100%, 98.90%, 96.42%, and 100% respectively which were higher as compared to other studies done by Wang et al. and Lin et al., It was probably due to the inclusion of cases of chronic cholecystitis and cholelithiasis, which may show mildly increased values and thereby affect the sensitivity and positive predictive value.
In this study, we have taken the mean+2SD value (45.36 U/mL) of benign lesion and Mean-2SD value (92.19 U/mL) of malignant lesion as cut off. Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for CA 125 in malignant cases was found to be 100%, 94.50%, 84.37%, and 100% respectively which were higher as compared to other studies done by Wang et al. and Chaube et al.,
In the present study, levels of CA19-9 and CA 125 were assessed as serological markers in cases of benign and malignant gall bladder lesions which were classified based on the clinico-radiological and cytological studies, followed by histological confirmation, to calculate the cut-off values of the index serological markers for diagnosis of benign and malignant gall bladder lesions. Values of >252.31 U/mL for CA 19-9 and >92.19 U/mL for CA 125 were found to label a lesion as malignant. However, like many other described biomarkers in gall bladder lesions, a zone of overlap exists. Especially applying these cutoffs alone may not be sufficient to decide on the cytological grey zone cases, as noted in this study.
Serum CA19-9 and CA 125 may also increase in diseases of other organ of pancreaticobiliary region. In this study, we could get the clear cutoff points values of serum CA 19-9 and CA 125 as patients with diseases of other organ of pancreaticobiliary region were excluded from the study. This point should be considered while interpreting the value in routine clinical practice.
The main shortcoming of the present study was small sample size and lack of correlation with TNM staging of tumors as many patients either referred to higher center or left after initial diagnosis. Even pathological staging was could not be done as only laproscopic biopsy was received in most of the malignant cases.
Thus it can be concluded that these cut off values of serum CA 19-9 and serum CA 125 may act as a good adjunct for initial screening of suspected cases of Carcinoma GB which can be further investigated with help of cyto-histology for confirmation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chauhan HM, Damor NT, Jadavc HR. Histological study of human gallbladder. Int J Biomed Adv Res 2013;4:2229-3809.
Hu L, Wang B, Liu X, Lv Y. Unsuspected gallbladder cancer. A clinical retrospective study. Arch Iran Med 2013;16:631-35.
Wang Y-F, Feng F-L, Zhao H-H, Ye Z-X, Zeng H-P, Li Z, et al
. Combined detection tumor markers for diagnosis and prognosis of gallbladder cancer. World J Gastroenterol 2014;20:4085-92.
Lin MS, Huang JX, Yu H. Elevated serum level of carbohydrate antigen 19-9 in benign biliary stricture diseases can reduce its value as a tumor marker. Int J Clin Exp Med 2014;7:744-50.
Kankonkar SR, Joshi SV, Deshpande RR. Significance of tumour markers in cancer of gall bladder. Open J Immunol 2013;3:33-6.
Shukla VK, Gurubachan, Sharma D, Dixit VK, Usha. Diagnostic value of serum CA242, CA 19-9, CA 15-3 and CA 125 in patients with carcinoma of the gallbladder. Trop Gastroenterol 2006;27:160-5.
Pavai S, Yap SF. The clinical significance of elevated levels of serum CA 19-9. Med J Malaysia 2003;58:667-72.
McLaughlin R, O'Hanlon D, Kerin M, Kenny P, Grimes H, Given HF. Are elevated levels of the tumour marker CA19-9 of any clinical significance?--an evaluation. Ir J Med Sci 1999;168:124-6.
Albert MB, Steinberg WM, Henry JP. Elevated serum levels of tumor marker CA19-9 in acute cholangitis. Dig Dis Sci 1988;33:1223-5.
Craxi A, Patti C, Aragona E. Serum CA 19-9 levels in patients with hepatocellular carcinoma or cirrhosis. Ital J Gastroenterol 1985;17:288-89.
Chaube A, Tewari M, Singh U, Shukla HS. CA 125 A potential tumor marker for gallbladder cancer. J SurgOncol 2006;93:665-9.
Daoud E, Bodor G. CA-125 concentrations in malignant and nonmalignant disease. Clin Chem 1991;37:1968-74.
Classen DC, Morningstar JM, Shanley JD. Detection of antibody to murine cytomegalovirus by enzyme-linked immunosorbent and indirect immunofluorescence assays. J Clin Microbiol 1987;25:600-4.
Deparment of Pathology, M.L.N.Medical College, Allahabad - 211 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]