105Journal of The Association of Physicians of India ■ Vol. 64 ■ August 2016

C o r r e s p o n d e n C e

CA-125 Testing in Females with Ascites: A Red HerringRathindranath Sarkar1, Rudrajit Paul2, Rajesh Pandey3, Indranil Thakur2, Jayati Mondal4, TJ Sau5

1Professor and HOD, 2Assistant Professor, 3Postgraduate Trainee, Dept. of Medicine, Medical College, Kolkata, West Bengal; 4RMO-cum-Clinical Tutor, Chittaranjan Seva Sadan, Kolkata, West Bengal; 5Professor, Dept. of Medicine, Medical College, Kolkata, West Bengal

Sir,

CA-125 is a commonly used tumour marker in clinical medicine. It is

most commonly used as a marker of epithelial ovarian cancer.1 However, this biomarker may be elevated in some benign conditions too. Hence, as the case below demonstrates, judicious use of this test is recommended.

We present the case of a 54 year old woman who presented to her GP with ascites. As a part of the initial investigations, a CA-125 assay was done which was found to be very high (1400 IU/L) (N :< 35 IU/L). The woman was told about the possibility of cancer and she came to our hospital, extremely depressed and distraught.

However, at our institution, a CT scan of the abdomen showed only ascites with no evidence of any tumour or peritoneal mass. A transvaginal sonography was also negative for any ovarian mass. The ascitic fluid study revealed high-SAAG fluid with cell count of 50/cmm. The fluid was

negative for malignant cells. Blood test revealed hemoglobin of 7.4 gm/dl. Liver function test revealed bilirubin 2 mg/dl, SGOT 60 IU/L, SGPT 82 IU/L, albumin 2.7 gm/dl and globulin 5 gm/dl. Prothrombin time was 19 seconds with INR of 1.6. Upper GI endoscopy showed early esophageal varices. Thus, the patient was diagnosed as a case of chronic liver disease. She responded to oral diuretics and after one year of follow up till now, has not developed any feature of malignancy. Her CA-125 level remains elevated at 470 IU/L.

We report this case to highlight the devastating effect of a spuriously high CA 125 level on the patient. She had searched the internet and had also been told about the possibility of ovarian cancer as a result of this report. This affected her psyche a lot.

Chronic liver disease with ascites is an established cause of high CA-125 levels.2 In fact, elevated CA-125 is a sensitive marker of ascites in cases of cirrhosis.2 This test can predict the onset of ascites even before ultrasonographic detection in some cases.3 Awareness about this fact by clinicians can avoid unnecessary tests and anxiety for the patient. As a raised CA-125 level may lead to a decision for exploratory laparotomy or even hysterectomy, extra care is needed in interpreting the test result.

S o m e s t u d i e s h a v e f o u n d a correlation between the volume of ascitic fluid and serum CA-125 levels.3 Also, there is no upper limit of the elevation of CA-125 levels in ascites due

to any cause, benign or malignant. As published case reports show, CA-125 may be e levated even up to 4000 IU/L due to benign ascites.4 In severe myxedema too, ascites with raised CA-125 may be found.5

However, sometimes, CA-125 may be elevated long before the appearance of the macroscopic features of ovarian cancer. Hence, although an alarmist approach is to be avoided once elevated CA-125 is found, regular follow up is needed to look for appearance of new features that may suggest malignancy.

The main point of this letter is to highlight the fact that in middle aged or post-menopausal women, CA-125 should not be the first line test for ascites, unless other benign causes have been ruled out. A spuriously elevated level in benign conditions like chronic liver disease may lead to unnecessary anxiety (as in our patient) and surgical interventions.

References 1. Karam AK, Karlan BY. Ovarian cancer: the duplicity of CA125

measurement. Nature Reviews Clinical Oncology 2010; 7:335-9.

2. Jabłkowski M, Białkowska J, Koktysz R, Bartkowiak J, Stankiewicz W, Dworniak D. Cancer antigen 125 as a marker of ascites in patients with liver cirrhosis. Pol Merkur Lekarski 2004; 17Suppl1:149-52.

3. Zuckerman E, Lanir A, Sabo E, Rosenvald-Zuckerman T, Matter I, Yeshurun D, et al. Cancer antigen 125: a sensitive marker of ascites in patients with liver cirrhosis. Am J Gastroenterol 1999; 94:1613-8.

4. Silberstein LB, Rosenthal AN, Coppack SW, Noonan K, Jacobs IJ. Ascites and a raised serum Ca 125--confusing combination. JR Soc Med 2001; 94:581-2.

5. Bou Khalil R, El Rassi P, Chammas N, Obeid J, Ghabach M, Sakr C, et al. Myxedema ascites with high CA-125: Case and a review of literature. World J Hepatol 2013; 5:86-9.