Ca 125 test endometrial cancer

CA-125, the abbreviated name for cancer antigen 125, is a protein that’s often elevated in ovarian cancer as well as other types of cancers, such as those of the lung and breast. It was discovered at Dana-Farber in 1981 by Robert Bast, MD, and Robert Knapp, MD, who quickly realized this protein could be used to follow treatment once the presence of ovarian cancer was found. The test cannot be used as a general screening exam for ovarian cancer because CA-125 levels are not elevated in all women diagnosed with this malignancy. The test is performed by drawing blood from a patient and testing it for the CA-125 protein. All content in these blogs is provided by independent writers and does not represent the opinions or advice of Dana-Farber Cancer Institute or its partners. A 30 yr old unmarried female presented to casualty with complaints of abdominal pain for past 3 days.
She had irregular cycles at intervals of 15-25 days which lasted for 3-4 days and were associated with dysmenorrhoea. Routine investigations including complete haemogram, blood sugar, renal function test, liver function test and electrolytes were within normal limits. With clinical diagnosis of acute abdomen, an ultrasound examination was sought which revealed bulky uterus with small anterior wall fibroid (Fig.
Patient was taken up for diagnostic laparoscopy, that revealed bilateral tubo-ovarian abscesses and sigmoid adhesions on left side. The histopathological examination revealed strips of ovarian tissue covered on external aspect by fibrinous necrotic material containing neutrophils.
Although in the past, tubo-ovarian abscess occurred primarily in an older age group; over the past several decades, a progressively younger patient group has been encountered. Objectives: To assess the feasibility of laparoscopic surgery in cases of moderate-severe endometriosis.
It’s also elevated when disease or inflammation arises in the pleura – the tissue that enfolds the lungs – or the inner lining of the abdomen. They developed the CA-125 test, which measures the level of CA-125 in the blood to determine how well treatment for ovarian cancer is working or to see if ovarian cancer has recurred following treatment. In postmenopausal women, about 20 percent will not present with an elevated CA-125, according to Suzanne Berlin, DO, a specialist in gynecologic cancers at Dana-Farber’s Susan F. Smith Center have opened a clinical trial of an ovarian cancer drug that reflects scientists’ understanding of CA-125.
But rarity does appear when atypical manifestation of endometriosis presents in clinical practice.
Current literature describes three different mechanisms by which endometriotic cysts originate.
On abdominal examination – slight guarding of lower abdomen with vague tenderness in bilateral iliac fossae.
The ovarian parenchyma showed a cyst cavity lined by columnar endometrial type lining cells with underlying endometrial stroma and partly by clusters of siderophages. The young patient with a tubo-ovarian abscess who desires to maintain reproductive function presents a significant dilemma to the gynaecologist today.
Reoperation after laparoscopic treatment of ovarian endometriomas by excision and fenestration.
Materials and Methods: A prospective study was carried out in a tertiary centre over a period of 2 years.
This condition is characterized by variable clinical manifestations and surgical appearance and often there is poor correlation between the two. Correlation between endometriosis-associated dysmenorrhea and the presence of typical or atypical lesions. Ovarian endometriomas: Effect of laparoscopic cystectomy on ovarian response in IVF-ET cycles. Reproductive outcome after laparoscopic treatment of endometriosis in an infertile population. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. The test is also used for women who have had or are being treated for peritoneal, or fallopian tube cancer as well as certain types of endometrial carcinoma.
The drug is a combination of an antibody and chemotherapy which homes in on a protein called MUC16 that is often overabundant in ovarian tumors.
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Cortical invagination cyst arises when surface ovarian endometriotic deposits adhere to another structure (such as broad ligament, uterus, etc.) blocking the egress of menstrual fluid produced cyclically which then collects and causes the ovarian cortex to be invaginated. Both ovaries were well visualized and enlarged in size with complex cystic areas in both ovaries forming ovarian masses, with significant free fluid in the abdomen. Moderate to severe endometriosis was defined by revised American fertility society (rAFS) classification (41 patients). Although there are many diagnostic tests available like imaging studies and blood tests like CA-125, none of them are confirmatory. Surface inclusion cysts in relation to endometriotic cysts develop when endometriotic tissue colonizes pre-existing inclusion cysts.

The gold standard diagnostic test is direct visualization of lesions by either laparotomy or laparoscopy. Such “false positive” results can create needless anxiety and cause women to undergo further, costly tests.
A positive reading can also arise from normal conditions such as menstruation and pregnancy, as well as from non-cancerous conditions such as diverticulitis (inflammation of the intestines or bladder), liver cirrhosis, uterine fibroids (benign growths of the uterus), endometriosis (growth of uterine-lining tissue outside the uterus), leiomyoma (a benign growth of smooth muscle), and pelvic inflammatory disease. It is open to patients with ovarian cancer whose disease has progressed or relapsed after treatment with platinum-based chemotherapy. In patients with severe endometriosis, lesions usually involve the posterior cul-sac, anterior rectum, one or both pelvic side walls involving ureters, rectosigmoid and less commonly anterior bladder, appendix, and small bowel. Deep, fibrotic endometriotic deposits can usually be palpated clinically in such cases of extensive endometriosis. Laparoscopically, there may be presence of extensive adhesions with distortion of pelvic anatomy in such cases. Of the total 9 patients with primary infertility and moderate-severe endometriosis, 5 patients (55.5%) conceived after surgery. The cul-de sac may be completely obliterated, rectum stuck to the posterior surface of cervix and vagina and the ureters may be involved causing hydronephrosis. Conclusion: There is good evidence that in experienced hands laparoscopic surgery helps in long-term symptomatic relief, improves pregnancy rates and reduces recurrence of disease with largely avoiding complications. As there is such extensive involvement, thorough and lengthy surgical procedures may be required in these cases of endometriosis.Laparoscopy as a method of treatment offers certain advantages and we aim to evaluate in this study the efficacy of laparoscopy as the surgical procedure of choice for such conditions. A total of 100 women with provisional diagnosis of endometriosis were taken up for laparoscopy. Women with extensive endometriosis involving the ureters, bowel, or bladder but with no peritoneal endometriosis were also included in the series even though they had low rAFS scores (4 patients). In these women operative laparoscopy along with definitive treatment of the endometriotic lesions was planned at the same setting. The secondary outcome measures included operating time, blood loss, conversion to laparotomy, bladder, bowel, ureteric injury, analgesic requirement of the patient postoperatively, recovery period, and patient satisfaction with the procedure.Also various patient parameters like symptomatology, clinical findings, and their correlation with laparoscopic findings were analysed. Of the four women who were primiparas, two had a previous history of primary infertility but conceived spontaneously. Majority of women who presented with dysmenorrhoea and dyspareunia were mostly found to have endometriosis involving the pouch of Douglas, the rectovaginal septum and the uterosacral ligaments.
Majority of patients with infertility presented with endometriomas in the ovary along with superficial peritoneal involvement.
Endometriosis is also commonly associated with adenomyosis of the uteri, clinically seen as bulky uterus (19.5% patients). Two patients also had a visible bluish nodule in the posterior fornix indicating endometriotic involvement of the vagina [Figure 5]. This makes per-speculum examination a very important component of examination for endometriosis. The findings that suggest endometriosis on ultrasound include ground glass appearance of ovaries (endometrioma) but USG has a limited role in the diagnosis of adhesions or superficial peritoneal implants.
This is because majority of patients belonged to younger age group with either infertility or desired preservation of the uterus and the adnexa. Many such patients had endometriomas of ovaries as well as adhesions in POD and required both procedures. Total laparoscopic hysterectomy with or without ooperectomy was done in older patients with endometriosis (31.7%).
Certain procedures like ureterolysis, adhesiolysis and resection of rectal nodules take up more time because of extensive dissection and vital organs involved.Also, blood loss in all procedures was minimal varying between 100 ml 200ml.
This is because precise haemostasis is possible in laparoscopic surgery with use of energy sources like bipolar, vessel sealing devices, and harmonic. Complications There were no major intraoperative or postoperative complications in all 41 patients. Open surgery with excision of the rectal wall along with the nodule was done as expertise to treat this laparoscopically was not available. One patient with an endometriotic nodule infiltrating upto the bladder mucosa refused a cystostomy and was put on suppressive therapy. There were no complications in form of injury to the ureters, bladder, rectosigmoid, or small bowel.
Thus in expert hands even for difficult cases of severe endometriosis, laparoscopy is a very safe procedure.Of the 41 patients, 63% were operated on day care basis and were discharged the same day.
These mainly included patients undergoing total laparoscopic hysterectomy and those undergoing extensive resection for endometriosis.
These were generally patients in younger age group who did not want treatment for fertility at present and were put on post operative suppression therapy. The author does not favour medical therapy with GnRH agonist because of the associated side effects and incomplete suppression in extra-gonadal areas. Patients who had associated adenomyosis of the uterus but were of younger age group or nulligravidas and wanted preservation of uterus were put on additional medical therapy. Those patients with severe dyspareunia and dysmenorrhoea had deep infiltrating lesions in POD and adhesions and fibrosis of uterosacral ligaments.

Patients presenting with utereric, bladder or bowel endometriosis had low scores but extensive disease on laparoscopy. The low scores were due to paucity of peritoneal disease.Diagnosis and treatment of endometriosis by laparoscopy requires a surgeon with expertise in laparoscopic surgery as endometriosis can present with classic lesions as well as have non-classical appearance.
In many patients only fibrosis or adhesions may be seen on initial evaluation and diagnosis of endometriosis can be totally missed. For example, there may be an endometriotic collection in the rectovaginal septum and it may present as adhesions of rectum to POD and fibrosis of uterosacral ligaments. Unless extensive adhesiolysis is done and fibrotic lesions excised, one may miss the lesion and cannot offer complete symptom relief to the patient. In such situations laparoscopy provides an ideal setup with its benefits of good visualization of pelvic anatomy and magnification.
This helps to identify non-classic lesions and visualize clearly the lesions on bladder, bowel, ureters, and POD. Also, there is minimum tissue handling and desiccation and precise haemostasis during laparoscopy.
Minimal suturing and small incisions on the abdomen leads to minimal postoperative pain and faster patient recovery.
In comparison, visualization at laparotomy is inadequate due to restricted space and presence of the recto-sigmoid. Medical therapy can also be offered to patients of endometriosis but the disadvantages are many.
These include hypoestrogenic effects and recurrence of endometriosis as soon as the therapy is stopped.
Also the drugs need to be taken daily and for longer duration and hence is inconvenient to the patient.
Surgery on the other hand offers complete resection of endometriotic lesions and hence total symptom relief. The surgical treatment in severe endometriosis varies according to patient's age, fertility status, symptomatology and desires. Infertility requires special care even in cases of severe endometriosis and the surgeon is not to be very aggressive so as to spare the ovarian reserve in such patients. Pregnancy rates have been shown to be highest in first 6 months after surgery in the present study and many others.
Help of expert colorectal surgeon and urologist should be sought for a better patient management, if required.Endometriosis involving the urologic system also deserves a special mention here as it is a rare and silent disorder that can lead to renal failure. Involvement of the bladder, ureter, kidney, and urethra is 85, 10, 4, and 2%, respectively.
Ureteric endometriosis is usually extrinsic because of proximity of ureters to the uterosacral ligaments and hence can be involved in fibrosis of uterosacral ligaments. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis.
One case was of a 19-year-old unmarried girl with a history of previous left nephrectomy for severe hydronephrosis presenting with dysmenorrhoea, right flank pain and mass in right iliac fossa.
IVP showed right hydronephrosis and on laparoscopy right ureteric nodule constricting the ureter with right endometrioma was seen. Both were excised and patient is pain-free now with normal renal functions.Second case was of a 30-year-old woman with recurrent endometriosis who was found to have extensive peritoneal endometriosis with a large endometrioma. On cystoscopy a 2-cm endometriotic nodule was found protruding in bladder mucosa [Figure 6]. One patient was converted to laparotomy as she had extensive endometriosis involving the rectum and open surgery with excision of lesion was considered a better option. This was a case of 35-year patient with primary infertility who presented with dysmenorrhoea, dyspareunia, and dyschezia. The case was then converted to laparotomy where full-thickness resection of rectum with repair was done. Although the case was done by laparotomy, we have the availability of circular staplers laparoscopically and an expert colorectal surgeon can perform such procedures laparoscopically.Thus it can be concluded that surgical treatment of severe endometriosis by laparoscopy is the treatment of choice now with the availability of expertise and precise surgical equipments.
With various clinical presentations, a risk of recurrence and involvement of vital organs in an increasing younger population, subjecting them to laparotomy is unnecessary and uncalled for. Laparoscopy in expert hands offers optimal results even in extensive tissue involvement and should be the first option. Severe endometriosis poses a challenge for a surgeon and is technically demanding but the rewards for patients are high.
There is good evidence that in experienced hands laparoscopic surgery helps in long term symptomatic relief, improves pregnancy rates and reduces recurrence of disease with largely avoiding major complications.

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