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LETTER TO THE EDITOR
Year : 2017  |  Volume : 32  |  Issue : 1  |  Page : 79-80  

Metastatic adenocarcinoma and raised serum ca-125 levels: Looking beyond the ovaries with 18f-fluorodeoxyglucose positron emission tomography/computed tomography


Department of Nuclear Medicine and PET/CT, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India

Date of Web Publication17-Jan-2017

Correspondence Address:
Punit Sharma
Department of Nuclear Medicine and PET/CT, 13 Canal Circular Road, Kolkata - 700 054, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.198503

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How to cite this article:
Sharma P. Metastatic adenocarcinoma and raised serum ca-125 levels: Looking beyond the ovaries with 18f-fluorodeoxyglucose positron emission tomography/computed tomography. Indian J Nucl Med 2017;32:79-80

How to cite this URL:
Sharma P. Metastatic adenocarcinoma and raised serum ca-125 levels: Looking beyond the ovaries with 18f-fluorodeoxyglucose positron emission tomography/computed tomography. Indian J Nucl Med [serial online] 2017 [cited 2019 Dec 6];32:79-80. Available from: http://www.ijnm.in/text.asp?2017/32/1/79/198503

Sir,

CA-125 is widely employed as a tumor marker for gynecological cancers, including ovary and endometrium. However, certain nongynecological malignancies can have elevated CA-125 too. We present such a case here. A 48-year-old postmenopausal woman presented with progressively increasing abdominal and bone pain of 4 months duration. Ultrasound of the abdomen revealed hepatic space occupying lesions suspicious for metastases. Bilateral ovaries and uterus were normal. No ascites was seen. Fine-needle aspiration cytology from the hepatic lesion showed metastatic adenocarcinoma. Serum tumor marker evaluation was done which showed normal levels of serum CA-19.9, CEA, CA-15.3 and acute flaccid paralysis, but serum CA-125 levels were elevated (338 IU/dL, normal <35 IU/dL). Suspecting a small ovarian/endometrial malignancy, the patient underwent contrast-enhanced computed tomography (CT) of abdomen which showed no definite ovarian or endometrial lesion. It showed additional bone metastases, apart from already known liver metastases. Endometrial curettage and cytology were also done and were negative for malignancy. The patient was then advised for 18 F-fluorodeoxyglucose (18 F-FDG) positron emission tomography/CT (PET/CT) for localization of primary tumor. Maximum intensity projection PET [Figure 1]a showed multiple hypermetabolic foci in thorax, abdomen, and bones. Transaxial PET/CT image of the thorax showed a spiculated 18 F-FDG avid mass [Figure 1]b, arrow] in left lung upper lobe (SUVmax - 14.1) with pleural tagging, suspicious for primary tumor. Furthermore, hypermetabolic metastatic mediastinal and hilar lymphadenopathy [Figure 1]c, arrow], liver metastases [Figure 1]d, arrow], and bone metastases [Figure 1]e, arrows] were noted. No space-occupying lesion or focal 18 F-FDG uptake is seen in bilateral ovaries [Figure 1]f and [Figure 1]g, arrows]. Based on PET/CT findings, a diagnosis of primary adenocarcinoma of left lung with metastases was made. Biopsy from the left lung lesion confirmed adenocarcinoma and was positive for thyroid transcription factor-1 and epidermal growth factor receptor. The patient was started on palliative chemotherapy.
Figure 1: Maximum intensity projection positron emission tomography image (a) multiple hypermetabolic foci in thorax, abdomen, and bones. Transaxial positron emission tomography/computed tomography image of the thorax showed a spiculated 18F-fluorodeoxyglucose avid mass (b, arrow) in left lung upper lobe (SUVmax - 14.1) with pleural tagging, suspicious for primary tumor. Other lesions seen are hypermetabolic metastatic mediastinal and hilar lymphadenopathy (c, arrow), liver metastases (d, arrow) and bone metastases (e, arrows). No space occupying lesion or focal 18F-fluorodeoxyglucose uptake is seen in bilateral ovaries (f and g, arrows)

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CA-125 is a repeating peptide epitope of the mucin MUC16, which promotes cancer cell proliferation and inhibits anticancer immune responses.[1],[2] It is predominantly employed as a tumor marker in patients with ovarian cancer.[3]

However, elevated levels of CA-125 can be seen in cancers of other sites such as endometrium,  Fallopian tube More Details, lung, breast, pancreas, and gastrointestinal tracts,[4] and in some benign diseases such as endometriosis, cirrhosis, and even in pregnancy.[5] In menopausal women without ovarian cancer, carcinoma lung was found to the second most common associated primary (after endometrium) and most common cause of cancer-related death.[6] Hence, lung cancer should always be considered as a possible diagnosis in patients with elevated CA-125 and no definite ovarian/endometrial malignancy. Therefore, looking beyond ovary is mandatory in such patients.18 F-FDG PET/CT being a highly sensitive whole-body imaging technique is very helpful in this regard and can prevent many unnecessary downstream investigations. Elevated levels of CA-125 are usually associated with aggressive and advanced disease in lung cancer as was the case in the present report and heralds a poor prognosis.[7]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Hattrup CL, Gendler SJ. Structure and function of the cell surface (tethered) mucins. Annu Rev Physiol 2008;70:431-57.  Back to cited text no. 1
    
2.
Bast RC Jr., Spriggs DR. More than a biomarker: CA125 may contribute to ovarian cancer pathogenesis. Gynecol Oncol 2011;121:429-30.  Back to cited text no. 2
    
3.
Bottoni P, Scatena R. The role of CA 125 as tumor marker: Biochemical and clinical aspects. Adv Exp Med Biol 2015;867:229-44.  Back to cited text no. 3
    
4.
Patsner B, Yim GW. Predictive value of preoperative serum CA-125 levels in patients with uterine cancer: The Asian experience 2000 to 2012. Obstet Gynecol Sci 2013;56:281-8.  Back to cited text no. 4
    
5.
Fritsche HA, Bast RC. CA 125 in ovarian cancer: Advances and controversy. Clin Chem 1998;44:1379-80.  Back to cited text no. 5
    
6.
Terada KY, Elia J, Kim R, Carney M, Ahn HJ. Abnormal CA-125 levels in menopausal women without ovarian cancer. Gynecol Oncol 2014;135:34-7.  Back to cited text no. 6
    
7.
Ying L, Wu J, Zhang D, Li Z, Li D, Pan X, et al. Preoperative serum CA125 is an independent predictor for prognosis in operable patients with non-small cell lung cancer. Neoplasma 2015;62:602-9.  Back to cited text no. 7
    


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