Recurrent Endometriotic Cyst with High Ca-125 Level Mimicking Malignancy

Recurrent Endometriotic Cyst with High Ca-125 Level Mimicking Malignancy Life Science-Obstetrics and Gynaecology DOI: https://doi.org/10.22376/ijlpr.2023.13.6.L153-L157Keywords: CA 125, Endometriosis, Recurrent Endometriosis, Ovarian Endometrioma, peri-menopausal high CA 125Abstract Gynecologists who treat endometriosis, a chronic, disabling disease, face difficulties diagnosing and treating the condition. Endometriotic cyst, with internal septations and opacities sonologically, mimics malignancy. Increased levels of CA 125 Are used as a tumor marker in epithelial ovarian malignancies. It is also an important prognostic indicator and follow-up tool in managing ovarian malignancies. A moderate increase in CA125 levels is observed in physiological conditions like ovulation and benign conditions like endometriosis and PID. We present here a case of extremely elevated serum CA 125 level in a patient who presented with recurrent ovarian endometriosis. Mrs. X, 46 years old, presented with a complex ovarian cyst with CA 125 level- 1021 iu/ml. With a history of laparotomy for endometriotic cysts in the past. Intraoperatively bilateral complex ovarian cysts were identified, which were densely adherent to the lateral pelvic wall and rectum posteriorly. The ovarian cysts were excised with a hysterectomy. The Patient developed dribbling of urine on the third postoperative day. CT urogram revealed a right ureterovaginal fistula. Laparotomy done. Uretero ureteral anastomosis done by a urologist. The Postoperative patient remained dry. Histopathological evaluation revealed benign endometriosis. Extensive and aggressive surgeries are usually done for ovarian malignancies to provide optimal reduction. However, in our patient, risk assessment for malignancy based on radiological factors and tumor markers was highly suggestive of malignancy. Yet, the histopathology turned out to be benign endometriosis. Therefore, to avoid invasive investigations and surgeries associated with high morbidity, emphasis must be made on the possibility of raised CA 125 levels in benign conditions such as endometriosis. References Nisenblat V, Bossuyt PM, Shaikh R, Farquhar C, Jordan V, Scheffers CS et al. Blood biomarkers for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2016(5): CD012179. doi: 10.1002/14651858.CD012179, PMID 27132058. Bast RC Jr., Badgwell D, Lu Z, Marquez R, Rosen D, Liu J et al. New tumor markers: CA125 and beyond. Int J Gynecol Cancer. 2005;15; Suppl 3, no. 6:274-81. doi: 10.1111/j.1525-1438.2005.00441.x, PMID 16343244. Barbieri RL, Niloff JM, Bast RC Jr., Scaetzl E, Kistner RW, Knapp RC. We have elevated serum concentrations of CA-125 in patients with advanced endometriosis. Fertil Steril. 1986;45(5):630-4. doi: 10.1016/s0015-0282(16)49333-7, PMID 3457709. Boyer CM, Knapp RC, Bast RC Jr. Biology and immunology. In: Berek JS, Hacker NF, editors. Practical gynecologic oncology. 2nd ed. Baltimore: Williams & Wilkins; 1994. p. 89-90. Bast RC Jr., Feeney M, Lazarus H, Nadler LM, Colvin RB, Knapp RC. Reactivity of a monoclonal antibody with human ovarian carcinoma. J Clin Invest. 1981;68(5):1331-7. doi: 10.1172/jci110380, PMID 7028788. Myers ER, Bastian LA, Havrilesky LJ, Kulasingam SL, Terplan MS, Cline KE, et al. Management of adnexal mass. Evid Rep Technol Assess (Full Rep). 2006;130(130):1-145. PMID 17854238. Timmerman D, Testa AC, Bourne T, Ferrazzi E, Ameye L, Konstantinovic ML et al. Logistic regression model to distinguish between the benign and malignant adnexal mass before surgery: a multicenter study by the international ovarian tumor analysis group. J Clin Oncol. 2005;23(34):8794-801. doi: 10.1200/JCO.2005.01.7632, PMID 16314639. Rustin GJ, Bast RC, Kelloff GJ, Barrett JC, Carter SK, Nisen PD, et al. Use of CA-125 in clinical trial evaluation of new therapeutic drugs for ovarian cancer. Clin Cancer Res. 2004;10(11):3919-26. doi: 10.1158/1078-0432.CCR-03-0787, PMID 15173101. RCOG. Management of suspected ovarian masses in premenopausal women (Green-Top Guideline No. 62); 2011. Yilmazer M, Sonmezer M, Gungor M, Fenkci V, Cevrioglu S. Unusually elevated serum carbohydrate antigen 125 (CA125) and CA19-9 levels as a result of unruptured bilateral endometrioma. Aust N Z J Obstet Gynaecol. 2003;43(4):329-30. doi: 10.1046/j.0004-8666.2003.00088.x, PMID 14714723. Shiau CS, Chang MY, Chiang CH, Hsieh CC, Hsieh TT. Ovarian endometrioma is associated with very high serum CA-125 levels. Chang Gung Med J. 2003;26(9):695-9. PMID 14651169. Kahraman K, Ozguven I, Gungor M, Atabekoglu CS. The highest value reported is an extremely elevated serum CA-125 level due to unruptured unilateral endometrioma. Fertil Steril. 2007;88(4):968.e15-7. doi: 10.1016/j.fertnstert.2006.12.076, PMID 17544420. 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 endometriosis: a meta-analysis. Fertil Steril. 1998;70(6):1101-8. doi: 10.1016/s0015-0282(98)00355-0, PMID 9848302. Cheng YM, Wang ST, Chou CY. Serum CA-125 in preoperative patients at high risk for endometriosis. Obstet Gynecol. 2002;99(3):375-80. doi: 10.1016/s0029-7844(01)01731-8, PMID 11864662. Gynecologists TACoOa, "Practice bulletin no. 114: management of endometriosis," Obstetrics and Gynecology, 2010;116(1):223-36. Hornstein MD, Harlow BL, Thomas PP, Check JH. Use of a new CA 125 assay in the diagnosis of endometriosis. Hum Reprod. 1995;10(4):932-4. doi: 10.1093/oxford journals. humrep.a136064, PMID 7650145. Pittaway DE, Fayez JA. Serum CA-125 antigen levels increase during menses. Am J Obstet Gynecol. 1987;156(1):75-6. doi: 10.1016/0002-9378(87)90207-9, PMID 3467595. Jacobs I, Bast RC Jr. The CA 125 tumor-associated antigen: a review of the literature. Hum Reprod. 1989;4(1):1-12. doi: 10.1093/oxford journals. humrep.a136832, PMID 2651469, P. 4. Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am. 1997;24(2):411-40. doi: 10.1016/s0889-8545(05)70311-9, PMID 9163774. London S, Parmley T. Endometriosis and ascites. South Med J. 1993;86(10):1173-5. doi: 10.1097/00007611-199310000-00022, PMID 8211342. Published How to Cite Issue Section Copyright (c) 2023 Dr. Vidhya Selvam, Dr. C. Minu Priya This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.