Mean of CA 125 in Making Therapy Decision in Adnexal Inflammatory Tumors

Laboratory fi ndings such are white blood count and sedimentation rate are of relative value in infl ammations of the upper genital tract and adnexal infl ammatory tumors. Antibiotics are administrated in all cases according to the protocol but some of them need operative treatment also. Infl ammatory tumors can develope in endometriotic and even in cancer adnexal masses. CA  is elevated in great number of patients with advanced ovarian cancer. It can also be elevated in endometriosis, infl ammations and in nongynecological malignacies. Adnexal infl ammatory tumor was confi rmed in  patients. Laboratory fi ndings: white blood count and sedimentation rate were in normal levels in  patients. CA  was elevated in  patients.  patients were operated and CA  decreased in the fi rst  days after the operation. Only  patients without CA  elevation were sucessfully treated by mean of antibiotics. Even there is no need for routine examining of serum CA  in adnexal infl ammatory tumors it can be examined in cases with suspected Doppler ultrasonographic fi ndings or unclear clinical fi ndings. Endometriosis brings some risk of malignancy. Infl ammatory tumor can develop in endometriotic tumor as well as in necrotic malignant ovary tissue. Th ese could be reasons for making decision to do the operation in cases with infl ammatory tumor followed with increased CA , hystological assesment and serious interpretation of fi nal results.


Introduction
Endothelial cells of most pelvic organs secrete high molecular glycoprotein CA .Th is tumor marker is not specifi c for ovarian cancer but it is elevated (above  u/ml) in almost  of patients with advanced ovarian cancer stage II, III and IV.It is also elevated in more than  of patients with epithelial ovarian cancer stage I. CA  can be elevated in patients with nonginecological malignancies as well as in patients with endometriosis and infl amations of the upper genital tract (,,,).Adnexal infl ammatory tumor usualy developes in patients with sexualy transmited diseases and not treated bacterial vaginosis.Pelvic or abdominal pain, temperature over C, nausea or vomiting are predominant symptoms of adnexal infl ammatory tumor.Some cases of adnexal infl ammatory tumors are not followed with caracteristical clinical fi ndings or elevated white blood count and sedimentation rate.Unusual ultrasonographic fi ndings with low Resistance index value and hypervascularisation also needs editional examination including serum CA .CA  values could be of a great help in making a decision between conservative and operative treatment in those unclear cases even when there is a good response on antibiotic treatment.Antibiotics are administrated in all patients with adnexal inflammatory tumor according to Regimen A or alternative regimen when necessary.Some adnexal infl ammatory tumors can be clinicaly or ultrasonographicaly suspected on ovarian malignancy.The existance of malignancy in endometriosis or developing inflammatory adnexal tumor in necrotic malignant tissue needs further examinations such is measuring serum CA .Th is is also suggested in all patients with hereditary ovarian malignancy and those with adnexal tumor suspected on ovarian malignancy.Reducing risk factors results in decreasing risk of ovarian malignancy (,,,).There are no medical or economic arguments for examining serum CA  in all patients with adnexal inflammatory tumor.

Materials and Methods
Fifty-seven women were hospitalised in our Department during six months period because of suspected adnexal infl ammatory tumor.All patients were clinicaly and laboratory examined and started with antibiotic therapy according to the protocol in the fi rst day of hospitalisation.Transvaginal Doppler ultrasonography was done in all patients.We examined tumor morphology and measure Resistance Index (RI) values in suspected fi elds with hypervascularisation.In cases with suspected ultrasono-graphic fi ndings, dominant hypervascularisation and/ or RI lower than , we use to measure serum CA .Resistance Index lower than , usualy followes neovascularisation in malignancy (..).RI values above , are most common with imfl ammation and the compression of oedematous tissue on vessel wall.Initial CA  was measured in all  cases.Serial CA  levels were controled in all  with initial levels higher than u/ml.Changes in CA  values were evaluated in checking the effi cacy of chosen therapy.Decision for operative treatment was made in forty-nine patients where antibiotics were administrated at the begining of treatment.In  patients serial examination of CA  was not done because of normal initial values.Antibiotics were the only treatment choice in eight patients with initial CA  lower than u/ml with good response on chosen treatment.Average duration of hospitalisation was  days.White blood count and sedimentation rate was done - times during the hospitalisation.

Results
All patients were hospitalised because of unilateral or bilateral adnexal infl ammatory tumor.Only  patients had intrauterine device and it was extracted.Patients were aged -.Th e specifi city of this small study was that we used CA  as diagnostic test in all patients with adnexal infl ammatory tumor and evaluated it with other results to make a decision of the best method of treatment.CA  was measured in the fi rst day of hospitalisation and serial examination was done in all patients with elevated initial values until fall under u/ml.Th irty patients (,) had normal initial levels of CA  (,-,u/ml).CA  was elevated in  (,) patients and initial values were from ,u/ml-u/ml.Laboratory findings found white blood count between ,  /l-,  /l and sedimentation rate of - in all  patients with elevated initial CA  and in  patients with normal initial values.Patient with white blood count of   /l and sedimentation rate of  had normal initial CA  (,u/ml).Eight patients that were treated only by mean of antibiotics had normal initial CA , white blood count between ,  /l-and ,  /l and sedimentation rate was -.Results of treatment were controled throughout laboratory fi ndings including CA  in all  patients with elevated initial values.Chosen therapy in this group of patients was operative treatment including antibiotics according to regimen A (cephalosporine, aminoglycozide, metronidazole).Hystology assesment was done and ovarian malignancy was not confi rmed in  patients.CA  in patient with initial level of ,u/l showed decreasing rate (,u/l) on the  rd day after the operation.Hystological assesment confirmed endometriosis and inflammation in this case.Th ere was no need to repeat CA  in  patients with normal initial values.In  patients from this group inflammation was confirmed hystologicaly.CA  was not repeated in eight patients that were treated by mean of antibiotics ( regimen A) because of normal initial levels of this tumor marker.In the majority of instancies transvaginal Doppler ultrasonographical findings were caracteristic for adnexal inflammatory tumor and Resistance index values in those  patients were ,-,.Significant hypervascularisation was seen in  patients but RI lower than , was not measured.Those transvaginal Doppler ultrasonographic findings are common with inflammation.Final decision between conservative and operative treatment was given according to clinical findings of developing inflammation, paralitic ileus, peritonitis and cases with increasing CA .Hysterectomy with bilateral adnexectomy was done in  patients according to medical indications and patients age.Unilateral adnexectomy was done in  patients.Inflammation was hystologicaly confirmed in all  patients where operation was done.Seven (,) patients from this group had hystological confirmation of endometriosis common with inflamation.

Discussion
Th is presented study demonstrates that CA  could be heplful in some cases of adnexal infl ammatory tumors without clear clinical or ultrasonographic picture when we have to make a decision between conservative or operative treatment.Measuring serum CA  we can not detect risk patients in this group because this marker is elevated in genital and nongenital infl ammations and some nongynecological malignancies.Identifi cation of hereditary or other risk of malignancy (changes in tumor morphology, neoangiogenesis-RI lower than ,.hypervascularisation) in patients with adnexal infl ammarory tumor needs serum CA  examining and multidisciplinary approach in results evaluation.Th ere is no medi-cal or economic justifi cation for routine examination of CA  in patient with adnexal infl ammatory tumor.Our study did not show any significant difference in making decision for operative treatment in this group of patients with evaluated CA  between patients with adnexal infl amatory tumor treated in our Department where CA  was not routinely measured and evaluated.During this six months period patients with adnexal inflammatory tumor where antibiotics were administrated were operated because of infl ammatory process progression or developing peritonitis or paralitic ileus.No one patient was operated only because of elevated initial CA .Endometriosis is common with some risk of malignancy and needs aditional investigations.Adnexal infl ammatory tumor can develop in endometriotic tissue or in necrotic malignant tissue.Th ose are reasons to be cautious and to make a serious evaluation of all results in those patients.Th is could help in decreasing risk of overlooking ovarian malignancy.Increased CA  could be advantage in earlier treatment making decision which also could have an impact on with duration of hospitalisation and the cost benefi t.Patient with highest initial CA  level of ,u/l where antibiotics (regimen A) administrated was operated on  nd day of hospitalisation because of developed paralitic ileus.Unilateral adnexectomy was done and endometriosis common with infl amation was hystologicaly confi rmed.CA  showed decreasing rate  days after the operation.In a group of patients with elevated CA  infl ammation as the only diagnose (pyosalpinx) was confi rmed in only one patient with initial level of ,u/l.CA  decreased  days after the operation to level lower than u/l.Including CA  in diagnostic procedure in examining patients with adnexal infl ammatory tumor and comparing the results of chosen treatment with results in previous period we did not found signifi cant diff erencies in making therapy decision between conservative and operative treatment.Including serum CA  measuring we found that duration of hospitalisation was  days less than average.Th is could be explain as a period of antibiotis treatment when alternative antibiotic regimen was administrated according to cervical culture and making fi nal decision for operative treatment.

Conclusion
On the basis of the data, even if ultrasonographic picture is not clear for infl ammatory tumor, elevated CA  does not mean that there could be a developing malignancy in changed tissue.Adnexal infl ammatory tumor is usualy followed with elevated CA  but it is not a main cause for therapy making decision.It is suggested that all those patients should undergo all routine diagnostic investigation and laboratory examinations before making the fi nal decision of way of treatment.Th ere are no signifi cant changes in number of operative treatment in this group of patient where CA  was routinely examined and standard procedure in therapy making decision in patients with adnexal infl ammatory tumor.