Silvia Giudici

The utility of serum human epididymis protein 4 (HE4) in patients with a pelvic mass

Aim: Although CA125 is the most widely used cancer marker in the diagnostic approach of pelvic masses in women, its clinical usefulness is limited because it lacks expression of the antigen in the early stages of disease. The human epididymis protein 4 (HE4) is frequently over‐expressed in ovarian cancer, whereas its expression in normal tissues, including the ovary, is low. The aim of this study was to assess the concentration of both HE4 and CA125 in patients with different forms of benign and malign pelvic masses.

HE4 in ovarian cancer: from discovery to clinical application.

Despite the relatively low prevalence, ovarian cancer is the fifth leading cause of death from cancer among women. As such, an early diagnosis for establishing a timely surgical and/or chemotherapeutic treatment is essential for improving the outcome. The most reliable, but not always straightforward, approach to diagnose ovarian cancer relies on multiple, time-consuming and expensive investigative tools. These typically include clinical presentation (i.e., pelvic or abdominal pain, urinary frequency or urgency, increased abdominal size or bloating) with pelvic examination, transvaginal ultrasonography (US), and measurement of carbohydrate antigen 125 (CA125). Although the conventional pathway to develop and market a clinically useful biomarker is challenging, recent advances in genomic and proteomic technologies have led to the identification of previously unknown candidate markers of ovarian cancer. Some of these are currently under clinical validation. The human epididymis protein 4 (HE4) has recently been approved by the Food and Drug Administration for monitoring recurrence or progression of epithelial ovarian cancer. Nevertheless, reliable clinical evidence demonstrates that HE4, used alone or in combination with CA125, substantially improves the accuracy of screening and/or disease monitoring. This chapter will review the current knowledge on biologic and clinical applications of ovarian cancer biomarkers, with particular emphasis on the newly proposed marker, HE4.

Prognostic significance of preoperative plasma fibrinogen in endometrial cancer

OBJECTIVE To investigate the prognostic significance of preoperative plasma fibrinogen concentration, with particular focus on tumor dissemination and nodal involvement, in a substantial cohort of patients with endometrial cancer. METHODS The study population comprised 336 women with endometrial cancer who underwent surgical staging at two tertiary institutions, from 2000 to 2009. Pretreatment plasma samples from the study cohort were assayed for fibrinogen by the Clauss assay. Information on demographics, laboratory testing, histopathology and follow-up was gathered from databases of prospectively collected data. Factors associated with survival were identified in a Cox proportional hazards model. Univariate and multivariate analyses were used to evaluate predictors of extrauterine disease and nodal metastasis. RESULTS One-hundred-thirty-seven (40.8%) patients exhibited preoperative hyperfibrinogenemia. Univariate analysis demonstrated that histological type, tumor grade, depth of myometrial invasion, surgical stage, patient age, and hyperfibrinogenemia affect disease-free (DFS) and overall survival rates significantly. When these variables were entered simultaneously into a Cox regression model, raised preoperative levels of plasma fibrinogen retained significance as poor prognosticator of DFS (HR 2.0, 95%CI 1.1-3.6) and overall survival (HR 2.7, 95%CI 1.3-5.5). Preoperative hyperfibrinogenemia was an independent determinant of extrauterine disease (OR 2.7, 95%CI 1.3-5.6). In the subcohort of women with endometrioid histology, increased fibrinogen concentration at presentation was predictive of pelvic nodal involvement (OR 3.6, 95%CI 1.1-11.7). CONCLUSION Plasma fibrinogen level may be of value in the prediction of outcome, improve the stratification of endometrial cancer patient, at diagnosis, based on their risk of recurrence, and possibly alter their treatment accordingly.

Aberrant MicroRNA Expression in Patients With Endometrial Cancer

Objective Current evidence suggests that no single serum biomarker displays satisfactory diagnostic performance in patients with endometrial carcinoma (EC), the most frequent gynecological cancer in developed countries. However, aberrant tissue microRNA (miRNA) expression has been recently described in EC. Therefore, this study aimed to investigate the differential expression of 4 serum miRNAs and their association with CA125 (cancer antigen 125) and HE4 (human epididymis protein 4) in EC patients and in a control population. Methods Forty-six consecutive women with EC and 28 matched control subjects without a history of cancer or other diseases were enrolled. Total serum RNA was extracted using mirVana PARIS Kit. TaqMan MicroRNA Assay was used for quantitative real-time reverse transcriptase–polymerase chain reaction on ABI 7500 Sequence Detection System to assess differential miRNAs expression. The relative expression levels of 4 miRNAs (miR-222, miR-223, miR-186, and miR-204) were normalized to miR-16 and calculated using the 2-△Ct approach. Results Serum levels of miR-186, miR-222, and miR-223 appeared to be significantly higher in patients compared with control subjects (P = 0.004, P = 0.002, and P < 0.0001). Contrarily, serum miR-204 was found to be significantly lower in EC patients (P < 0.0001). The diagnostic performance of miRNAs was found to be significantly better than that of CA125. Among the various biomarker tested, serum miR-204 and HE4 exhibited the best diagnostic performance for discriminating EC patients from control subjects. Conclusions These results underpin that the 4 miRNAs that we have investigated are implicated in development and progression of EC, thus opening new avenues in EC diagnostics.

Highly-sensitive troponin I is increased in patients with gynecological cancers

OBJECTIVES To investigate troponin I (TnI) in patients with gynecological cancers. METHODS Highly-sensitive (HS) and conventional TnI were measured in 25 patients with untreated ovarian cancer, 25 with endometriosis and 25 with benign masses. RESULTS Both HS and conventional TnI were increase in cancer patients. Values above the cut-off were found in 44% and 16% cancer patients using HS and conventional TnI methods, respectively. CONCLUSIONS Cardiac involvement is frequent in patients with gynecological cancers and should be preferably assessed using HS troponin immunoassays.

Evaluation of mir-203 Expression Levels and DNA Promoter Methylation Status in Serum of Patients with Endometrial Cancer

BACKGROUND Endometrial cancer (EC) is currently considered the fourth most frequent female cancer in Europe. In an attempt to achieve an early diagnosis, many studies have identified some putative biomarkers for gynecologic cancers, including circulating microRNAs (miRs) and aberrant promoter methylation status. Previous studies which have investigated miR-203 expression profiles in EC tissues and normal endometrial tissues concluded that miR-203 is regulated by methylation promoter. The aim of this study was to investigate the expression of miR-203 and promoter methylation levels in serum of EC patients and healthy controls (HC). METHODS Forty-five EC patients (64 ± 12 years) and 30 HC (63 ± 13 years) were enrolled before undergoing therapeutic procedures. RNA extraction from serum was performed with mirVana PARIS Isolation Kit (Thermo Scientific). miR expression was assessed by quantitative RT-PCR (Applied Biosystems). The expression levels of miR were normalized to miR-16 and calculated using the 2-ΔCt method. A quantitative methylation-specific PCR (MSP) technique was used to analyze miR-203 promoter methylation status. Differences between groups were assessed by Mann-Whitney test (for continuous variables) and chi-squared test (for categorical variables), whereas the correlation was calculated using Spearmans test. The diagnostic performance of miR-203 was defined using receiver operator characteristic (ROC) curves. RESULTS Serum expression levels of miR-203 were higher in EC patients compared to HC (p = 0.002). Aberrant miR-203 methylation was detected in 11/45 (24.4%) EC patients and in 2/30 (6.6%) HC (p = 0.046). The expression levels of miR-203 were not significantly correlated with promoter methylation status. The area under the curve of miR-203 expression was 0.71 (p = 0.002). CONCLUSIONS The high circulating miR-203 expression levels in EC patients compared to HC confirm the role of this miR as a potential biomarker for diagnosis of EC. Aberrant miR-203 methylation assessed in the peripheral blood does not apparently reflect cancer biology.

The clinical significance of DJ-1 and HE4 in patients with endometrial cancer

The non‐invasive diagnostic approach for early detection of endometrial cancer (EC) remains limited. To date, human epididymis protein 4 (HE4) has been intensively studied but its diagnostic is controversial in EC. DJ‐1 is an oncoprotein secreted by cancer cells, recently identified as a potential diagnostic biomarker for breast cancer, melanoma, and pancreatic cancer. The aim of this study was to compare the diagnostic performances of DJ‐1 and HE4 measured in EC patients and healthy controls (HC).