Conclusion: Despite the increased serum follistatin levels in patients with ovarian endometrioma, CA-125 was determined to be a more sensitive and specific marker than follistatin for the
Trang 1Original Article
ovarian endometrioma and benign ovarian cysts
€Omer Ant, Gülnur €Ozaks¸it, Ali _Irfan Güzel, Sabri Cavkaytar, Metin Kaba,
Dr Zekai Tahir Burak Women's Health Education and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey
a r t i c l e i n f o
Article history:
Accepted 17 March 2014
Keywords:
CA-125
CA 19-9
diagnostic marker
endometriosis
follistatin
a b s t r a c t
Objective: To determine the clinical significance of serum follistatin levels in women with an ovarian endometrioma
Materials and methods: This is a prospective study of 89 women, 56 with an ovarian endometrioma (endometrioma group) and 33 with a benign ovarian cyst (control group) who underwent laparoscopic excision Age, parity, body mass index, serum CA-125, serum CA 19-9, and serum follistatin levels were determined for all participants and evaluated as potential prognostic factors prior to laparoscopic cystectomy
Results: There were no significant differences in demographic factors between the endometrioma group and the control group However, serum follistatin levels were significantly higher in the endometrioma group (9350± 895 pg/mL vs control group 725 ± 72 pg/mL, p < 0.05) The optimal diagnostic cut-off values (sensitivity and specificity) of CA-125, CA 19-9, and follistatin for ovarian endometrioma were 23.2 IU/mL (82.14% and 72.73%), 30.14 IU/mL (45.28% and 87.50%), and 2350 pg/mL (53.7% and 60.61%), respectively Conclusion: Despite the increased serum follistatin levels in patients with ovarian endometrioma,
CA-125 was determined to be a more sensitive and specific marker than follistatin for the diagnosis of ovarian endometrioma and endometriosis
Copyright© 2015, Taiwan Association of Obstetrics & Gynecology Published by Elsevier Taiwan LLC All
rights reserved
Introduction
Endometriosis is a chronic condition characterized by the
growth of hormone-responsive endometrial tissue outside the
uterine cavity[1] An ovarian endometrioma is a cyst composed of
endometrial tissue detected in 20e40% of women with
endome-triosis[1,2] The gold standard for diagnosis of endometriosis is
histological examination, which requires an invasive procedure,
such as laparoscopy or laparotomy, to obtain tissue samples[3,4]
Many serum biochemical markers, such as cytokines, hormones,
and growth factors, which may be released into the bloodstream by
ectopic endometrial tissue, have been suggested for noninvasive
diagnosis of endometriosis Although these markers have some
clinical value, diagnostic serum markers for endometriosis have not
been identified CA-125, a transmembrane glycoprotein, is elevated
in women with endometriosis[5], and previous studies have re-ported that ectopic endometrial tissue may release follistatin into the bloodstream[5e8]
Follistatin is an extracellular glycoprotein originally identified as
an inhibitor of pituitary follicle-stimulating hormone secretion The majority of follistatin's physiological effects are due to its ability to neutralize activin[9,10] Florio et al[11]reported that follistatin is expressed in human endometrium and ectopic endometrial tissue, and is a promising diagnostic marker due to its sensitivity and specificity for ovarian endometriomas
This study compares the serum levels of follistatin in women with ovarian endometriomas with those with benign ovarian cysts
to determine the role of follistatin in the diagnosis of ovarian endometrioma and endometriosis
Materials and methods This prospective case control study was conducted between February 2012 and May 2013 at Zekai Tahir Burak Women's Health
* Corresponding author Dr Zekai Tahir Burak Women's Health Education and
Research Hospital, Division of Gynecology, Çigdem Mahallesi 1549, Cadde, Hardem
Apartmanı, B Blok, D:12, Çankaya, Ankara, Turkey.
E-mail address: dronurtopcu@gmail.com (H.O Topçu).
Contents lists available atScienceDirect Taiwanese Journal of Obstetrics & Gynecology
j o u r n a l h o m e p a g e : w w w t j o g - o n l i n e c o m
http://dx.doi.org/10.1016/j.tjog.2014.03.010
1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology Published by Elsevier Taiwan LLC All rights reserved.
Trang 2Education and Research Hospital in Ankara, Turkey The study was
performed according to the standards of the Helsinki declaration,
and written informed consent was obtained from all participants
The study was approved by our Institutional Ethics Committee
(ethical approval no: 22-02-12/20)
Patient characteristics
Eighty-nine women with ovarian masses were enrolled in the
study: 56 women with an ovarian endometrioma (endometrioma
group) and 33 women with a benign ovarian cyst (control group)
Age, parity, body mass index, tobacco use, alcohol use, diameter of
the ovarian mass, bilaterality of the mass, platelet count, neutrophil
leukocyte ratio, serum follistatin, serum CA-125, and serum CA
19-9 levels were determined for each participant
All patients in the endometrioma group had Stage 3 or 4
endometriosis according to the revised American Society for
Reproductive Medicine classification [12] Patients in the control
group did not have endometriosis but had benign ovarian tumors
with histological confirmed final diagnoses, including serous
(n¼ 18) and mucinous (n ¼ 15) cystadenomas
Blood samples
Peripheral venous blood samples were collected from all
pa-tients prior to laparoscopic cystectomy to measure serum
folli-statin, CA-125, and CA 19-9 levels All blood samples were allowed
to clot at room temperature Samples were centrifuged at 300g for
20 minutes at room temperature, and the serum was separated
using a disposable pipette, transferred to a cryoresistant tube, and
stored at80C for 3e15 months (average 9 months)
Laboratory assays
The serum follistatin concentration was measured using a
commercially available enzyme-linked immunosorbent assay
(ELISA; Eastbiopharm Co., Ltd., Hangzhou, China) For the follistatin
ELISA, the intra- and inter-assay coefficients of variation were 3%
and 9%, respectively
The serum concentration of CA-125 was measured using an
electrochemiluminescence immunoassay kit (Roche Elecsys Kits,
Roche Diagnostics, Mannheim, Germany) The intra- and
inter-assay coefficients of variation were 3.8% and 1.5%, respectively
The reference range for serum CA-125 was 0e35 IU/mL
Serum CA 19-9 was measured using an
electro-chemiluminescence immunoassay (Roche Diagnostics E 170
analyzer) A normal CA 19-9 value was defined as < 27 IU/mL
Statistical analysis
The means and standard deviations were calculated for
continuous variables, and normal distribution was analyzed using
the KolmogoroveSmirnov test The Chi-square (c2) test and
Stu-dent t test were used to evaluate associations between the
cat-egorical and continuous variables For non-normally distributed
categorical variables, the ManneWhitney U test was used
Receiver operator characteristic (ROC) curve analysis was used to
establish the cut-off values for follistatin, CA-125, and CA 19-9
The Youden index (sensitivityþ specificity 1) was also
calcu-lated, and the cut-off value with the maximum Youden index was
deemed the optimal cut-off value A p value< 0.05 was
consid-ered statistically significant Statistical analyses were conducted
using SPSS 17.0 software for Windows (SPSS Inc., Chicago, IL,
USA)
Results Patient demographic and clinical features are presented in
Table 1 The mean age, parity, body mass index, tobacco use, and alcohol use were similar between the endometrioma and the control groups There were no statistically significant differences between the groups in terms of the mean platelet count or NLR (p> 0.05) The mean diameter of the cystic mass was 6.79 ± 1.56 cm
in the control group (benign ovarian cyst) and 5.64± 2.01 cm in the endometrioma group (p< 0.05) Serum CA-125, CA 19-9, and fol-listatin levels in the endometrioma group versus the control group were 93.45 ± 89.55 IU/mL versus 47.25 ± 72.05 IU/mL, 84.79± 93.37 IU/mL versus 34.89 ± 76.9 IU/mL, and 9350 ± 895 pg/
mL versus 725± 72 pg/mL, respectively
According to ROC curve analysis, the cut-off values (sensitivity and specificity) for serum CA-125, CA 19-9, and follistatin were 23.2 IU/mL (81.14% and 72.73%), 30.14 IU/mL (45.28% and 87.5%), and 23.5 ng/mL (53.57% and 60.61%), respectively (Fig 1) The area under the curve values for CA-125, CA 19-9, and follistatin were 0.814, 0.613, and 0.54, respectively (Table 2) Combining CA-125, CA 19-9, and follistatin levels using the cut-off values in Table 2
significantly improved the diagnostic accuracy with a specificity
of 93.75% and a sensitivity of 26.8%
Table 1 The demographic and clinical characteristics of the patients.
Endometrioma group (n ¼ 56)
Benign cyst group (n ¼ 33)
p
BMI (kg/cm 2 ) a 2.77 ± 3.71 2.3 ± 3.53 0.532
Diameter of the mass (cm) a 5.64 ± 2.01 6.79 ± 1.56 0.007
CA-125 (IU/mL) a 93.45 ± 89.55 47.25 ± 72.05 0.014 CA19-9 (IU/mL) a 84.79 ± 93.37 34.89 ± 76.9 0.010 Follistatin (pg/mL) a 9350 ± 895 725 ± 72 0.011 BMI ¼ body mass index; NLR ¼ neutrophil lymphocyte ratio.
A p value <0.05 was considered statistically significant.
a Data are presented as mean ± SD.
b Data are presented as median (minemax).
c Data are presented as n (%).
Fig 1 ROC curve of CA-125, CA 19-9, and follistatin for the discrimination of endo-metrioma cases from benign cysts AUC ¼ area under the curve; ROC ¼ receiver
Trang 3In the present study, serum follistatin levels were measured in
women with ovarian endometriomas or benign ovarian cysts
Serum CA-125, CA 19-9, and follistatin levels were significantly
different between the two groups Although the cystic mass
diameter was significantly greater in the benign cyst control group,
serum CA-125, CA 19-9, and follistatin levels were higher in the
endometrioma group ROC curve analysis indicated that CA-125, CA
19-9, and follistatin might be discriminative markers for ovarian
endometrioma The sensitivity and specificity of serum follistatin
for the diagnosis of endometrioma were 53.57% and 60.61%,
respectively
The diagnosis of endometriosis is currently dependent upon
postoperative histopathological examination, since a noninvasive
method for the diagnosis of endometriosis has yet to be validated
Biomarkers such as CA-125, annexin V, vascular endothelial growth
factor, soluble intercellular adhesion molecule-1, and glycodelin
have been investigated as potential diagnostic markers for
endo-metriosis [13] However, despite advanced technological
de-velopments, an ideal diagnostic biomarker has not been identified
In a meta-analysis, CA-125 was a better diagnostic marker for
Grades 3 and 4 endometriosis than Grades 1 and 2 endometriosis
[14] In another study, serum CA-125 levels were similar between
women with Grades 1 or 2 endometriosis and those without
endometriosis However, serum CA-125 levels were found to be
significantly higher in women with Grades 3 or 4 endometriosis
than Grade 1 endometriosis[15] In the present study, all patients
in the endometrioma group had Grades 3 or 4 (severe)
endome-triosis, and when CA-125 levels were compared between the
endometrioma group and the control group, the predictive value of
CA-125 was significantly higher in the endometrioma group with
severe endometriosis
The diagnostic significance of CA 19-9 levels in endometriosis
remains unclear due to conflicting data[16e18] While one study
reported significantly higher CA 19-9 levels in all stages of
endo-metriosis[16], others reported no association between serum CA
19-9 levels and endometriosis[17,18] In the present study serum
Ca-19-9 levels were not significantly different between the
endo-metrioma and control groups
Follistatin was first isolated from follicular fluid [10], and 15
years after its initial isolation, it was detected in human
endome-trium[19] Follistatin wasfirst investigated as a potential biomarker
for endometriosis in 2009 by Florio et al[11]
During the late secretory phase of the menstrual cycle, Rocha
et al [20] found an increase in follistatin mRNA in the eutopic
endometrium and in endometriomas of women with
endometri-osis compared with healthy controls Therefore, it has been
sug-gested that activin and follistatin mRNA expression are altered in
endometriosis and can be used for diagnostic purposes [20] In
another study, follistatin, follistatin-related gene, and activin A
binding proteins showed an impaired expression pattern in women
with endometriosis, which may cause insufficient angiogenesis and
endometrial differentiation due to altered activin A expression[7]
Altered follistatin expression and the subsequent physiologic
changes detailed above may account for the association between
high follistatin levels and infertility in women with endometriosis Additional research is needed to investigate this hypothesis
In a study by Floria et al[11], serum follistatin levels were higher
in women with ovarian endometrioma than those with benign ovarian cysts In addition, the level of follistatin was significantly higher in cysticfluid than in peritoneal fluid Therefore, the authors claim follistatin had high sensitivity and specificity for ovarian endometrioma and was a useful diagnostic marker However, this finding is not consistent with data from the present study Our data indicate that while serum follistatin was significantly different between the endometrioma and control groups, CA-125 is a su-perior diagnostic marker for the discrimination between ovarian endometriomas and benign ovarian cysts In a recent study of 28 biomarkers, the combined evaluation of serum annexin V, vascular endothelial growth factor, CA-125, and soluble intercellular adhe-sion molecule-1 or glycodelin had a sensitivity of 81e90% and a specificity of 63e81% for the diagnosis of endometriosis[13] In the present study, the combination of CA-125, CA 19-9, and follistatin levels produced a high specificity of 93.75% and a low sensitivity of 26.8% for the diagnosis of endometriosis
In summary, follistatin may be a promising marker for the diagnosis of endometriosis, although CA-125 was determined to be a superior diagnostic marker for severe (Stages 3 and 4) endometriosis and ovarian endometrioma There are limited studies on the asso-ciation between follistatin levels and endometriosis in literature, and this study provides important information about serum folli-statin levels and endometriosis However, additional investigations using large study populations should be carried out to identify other promising biomarkers for the diagnosis of endometriosis
Conflicts of interest The authors have no conflicts of interest relevant to this article Acknowledgments
We would like to thank www.textcheck.com (certificate/ aHQWcC) for the English revision of our manuscript
References [1] Giudice LC, Kao LC Endometriosis Lancet 2004;364:1789e99 [2] Sengoku K, Miyamoto T, Horikawa M, Katayama H, Nishiwaki K, Kato Y, et al Clinicopathologic risk factors for recurrence of ovarian endometrioma following laparoscopic cystectomy Acta Obstet Gynecol Scand 2013;92: 278e84
[3] Crosignani P, Olive D, Bergqvist A, Luciano A Advances in the management of endometriosis: an update for clinicians Hum Reprod Update 2006;12: 179e89
[4] de Ziegler D, Borghese B, Chapron C Endometriosis and infertility: patho-physiology and management Lancet 2010;376:730e8
[5] Barbieri RL, Niloff JM, Bast Jr RC, Scaetzl E, Kistner RW, Knapp RC Elevated serum concentrations of CA-125 in patients with advanced endometriosis Fertil Steril 1986;45:630e4
[6] Reis FM, Luisi S, Abrao MS, Rocha AL, Vigano P, Rezende CP, et al Diagnostic value of serum activin A and follistatin levels in women with peritoneal, ovarian and deep infiltrating endometriosis Hum Reprod 2012;27:1445e50 [7] Torres PB, Florio P, Ferreira MC, Torricelli M, Reis FM, Petraglia F Deranged expression of follistatin and follistatin-like protein in women with ovarian endometriosis Fertil Steril 2007;88:200e5
Table 2
The cut-off values of tumor markers and follistatin levels in the detection of ovarian endometrioma.
CI ¼ confidence interval; LR ¼ likelihood ratio.
Trang 4[8] May KE, Villar J, Kirtley S, Kennedy SH, Becker CM Endometrial alterations in
endometriosis: a systematic review of putative biomarkers Hum Reprod
Update 2011;17:637e53
[9] Kumar TR Too many follistatins: racing inside and getting out of the cell.
Endocrinol 2005;146:5048e51
[10] Ueno N, Ling N, Ying SY, Esch F, Shimasaki S, Guillemin R Isolation and partial
characterization of follistatin: a single-chain Mr 35,000 monomeric protein
that inhibits the release of follicle-stimulating hormone Proc Natl Acad Sci
USA 1987;84:8282e6
[11] Florio P, Reis FM, Torres PB, Calonaci F, Abrao MS, Nascimento LL, et al High
serum follistatin levels in women with ovarian endometriosis Hum Reprod
2009;24:2600e6
[12] Revised American Society for Reproductive Medicine classification of
endo-metriosis: 1996 Fertil Steril 1997;67:817e21
[13] Vodolazkaia A, El-Aalamat Y, Popovic D, Mihalyi A, Bossuyt X, Kyama CM, et al.
Evaluation of a panel of 28 biomarkers for the non-invasive diagnosis of
endometriosis Hum Reprod 2012;27:2698e711
[14] Mol BW, Bayram N, Lijmer JG, Wiegerinck MA, Bongers MY, van der Veen F,
et al The performance of CA-125 measurement in the detection of
endome-triosis: a meta-analysis Fertil Steril 1998;70:1101e8
[15] Kurdoglu Z, Gursoy R, Kurdoglu M, Erdem M, Erdem O, Erdem A Comparison
of the clinical value of CA 19-9 versus CA 125 for the diagnosis of endome-triosis Fertil Steril 2009;92:1761e3
[16] Harada T, Kubota T, Aso T Usefulness of CA19-9 versus CA125 for the diag-nosis of endometriosis Fertil Steril 2002;78:733e9
[17] Somigliana E, Vigano P, Tirelli AS, Felicetta I, Torresani E, Vignali M, et al Use
of the concomitant serum dosage of CA 125, CA 19-9 and interleukin-6 to detect the presence of endometriosis Results from a series of reproductive age women undergoing laparoscopic surgery for benign gynaecological con-ditions Hum Reprod 2004;19:1871e6
[18] Xavier P, Beires J, Belo L, Rebelo I, Martinez-de-Oliveira J, Lunet N, et al Are we employing the most effective CA 125 and CA 19-9 cut-off values to detect endometriosis? Eur J Obstet Gynecol Reprod Biol 2005;123:254e5 [19] Jones RL, Salamonsen LA, Zhao YC, Ethier JF, Drummond AE, Findlay JK Expression of activin receptors, follistatin and betaglycan by human endo-metrial stromal cells; consistent with a role for activins during decidualiza-tion Mol Hum Reprod 2002;8:363e74
[20] Rocha AL, Carrarelli P, Novembri R, Sabbioni L, Luisi S, Reis FM, et al Altered expression of activin, cripto, and follistatin in the endometrium of women with endometrioma Fertil Steril 2011;95:2241e6