IJC International Journal of Cancer
The utility of serum CA-125 in predicting extra-uterine disease in apparent early-stage endometrial cancer James Nicklin1, Monika Janda2, Val Gebski3, Thomas Jobling4, Russell Land1, Tom Manolitsas4, Anthony McCartney5, Marcelo Nascimento1, Lewis Perrin1, Jannah F. Baker2 and Andreas Obermair1 for the LACE Trial Investigators 1
Queensland Centre for Gynaecological Cancer, Brisbane, Australia Queensland University of Technology, School of Public Health, Institute of Health and Biomedical Innovation, Queensland, Australia 3 University of Sydney NHMRC Clinical Trials Centre, Sydney, Australia 4 Department of Gynaecologic Oncology, Monash Medical Centre, Melbourne, Australia 5 St John of God Hospital, Perth, Australia 2
The routine use of pelvic and para-aortic lymphadenectomy in the surgical management of endometrial cancer is controversial.1,2 Staging lymphadenectomy has the potential to identify occult advanced, metastatic disease. This has prognostic implications, more accurately defines the extent of disease,
may confer some therapeutic benefit, and allows rational deployment of adjuvant therapies. A majority of patients with endometrial cancer present with early-stage, low-grade disease, however. Prospective randomized studies of predominantly low-risk patients with
Key words: uterine cancer, staging, CA-125, lymphadenectomy Abbreviations: DOI: depth of invasion; ECOG: Eastern cooperative oncology group; QOL: quality of life; ROC: receiver operating characteristic All authors reviewed the article before submission. Peta Forder provided statistical advice. Dan Jackson, Jessica Mayerseidl, and Trudi Cattley assisted with data management. Simon Forsyth assisted in programming of the electronic case report forms. Anthony McCartney has shares and stock ownership of Gynetech. He has received occasional consultancy honoraria from Gate Healthcare. Andreas Obermair on behalf of the University of Queensland is the recipient of an unrestricted travel grant provided by Gate Healthcare. All other authors have no declared conflicts of interest. Grant sponsors: Cancer Council Queensland, Cancer Council New South Wales, Cancer Council Victoria, Cancer Council Western Australia; The Women and Infants Research Foundation, Western Australia; Royal Brisbane and Women’s Hospital Foundation; Wesley Research Institute; Gallipoli Research Foundation; Gynetech; TYCO Healthcare, Australia; Johnson and Johnson Medical, Australia; Hunter New England Centre for Gynaecological Cancer; Genesis Oncology Trust; Smart Health Research Grant/QLD Health; Grant numbers: NHMRC project grant 456110; Cancer Australia project grant 631523 DOI: 10.1002/ijc.26433 History: Received 6 Jun 2011; Accepted 24 Aug 2011; Online 14 Sep 2011 Correspondence to: ndreas Obermair, MD, Gynaecological Oncologist, Director of Research, Queensland Centre for Gynaecological Cancer, Professor, School of Medicine, University of Queensland, Royal Brisbane & Women’s Hospital, 6th Floor Ned Hanlon Building, HERSTON QLD 4029, Brisbane, Australia, TelAndreas: þ61-7-3636-8501, Fax: þ61-7-3636-5289, E-mail:
[email protected]
C 2011 UICC Int. J. Cancer: 131, 885–890 (2012) V
Early Detection and Diagnosis
Surgical staging in early-stage uterine cancer is controversial. Preoperative serum CA-125 may be of clinical value in predicting the presence of extra-uterine disease in patients with apparent early-stage endometrial cancer. Between October 6, 2005, and June 17, 2010, 760 patients were enrolled in an international, multicentre, prospective randomized trial (LACE) comparing laparotomy with laparoscopy in the management of endometrial cancer apparently confined to the uterus. Of these, 657 patients with endometrial adenocarcinoma had a preoperative serum CA-125 value recorded. Multiple cross-validation analysis was undertaken to correlate preoperative serum CA-125 with stage of disease (Stage I vs. Stage II1) after surgery. Patients’ median preoperative serum CA-125 was 14 U/ml. A cutoff point of 30 U/ml was associated with the smallest misclassification error, and using this cutoff, 98 patients (14.9%) had elevated CA-125 levels. Of those, 36 (36.7%) had evidence of extra-uterine disease. Of the 116 patients (17.7%) with evidence of extra-uterine disease, 31.0% had an elevated CA-125 level. On univariate and multivariable logistic regression analysis, only preoperative CA-125 level, but no other preoperative clinical characteristics were found to be associated with extra-uterine spread of disease. Utilizing a cutoff point of 30 U/ml achieved a sensitivity, specificity, positive predictive value and negative predictive value of 31.0, 88.5, 36.7 and 85.7%, respectively. Elevated CA-125 above 30 U/ml in patients with apparent early-stage disease is a risk factor for the presence of extra-uterine disease and may assist clinicians in the management of patients with clinical Stage I endometrial cancer.
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Early Detection and Diagnosis
endometrial cancer have failed to demonstrate a benefit with staging lymphadenectomy.3,4 This was true despite quite different inclusion criteria and trial methodology. Panici et al. excluded patients from lymphadenectomy if they had a welldifferentiated tumour and/or a depth of invasion (DOI) of the myometrium of
