Antti Kauppila, M.D. *t Sakari Telimaa, M.D.* Lars Ronnberg, M.D.* Juhani Vuori, B.A.:\:

Transcription

1 FERTILITY AND STERILITY Copyright 1988 The American Fertility Society Printed in U.S.A. Placebo-controlled study on serum concentrations of CA-125 before and after treatment of endometriosis with danazol or high-dose medroxyprogesterone acetate alone or after surgery Antti Kauppila, M.D. *t Sakari Telimaa, M.D.* Lars Ronnberg, M.D.* Juhani Vuori, B.A.:\: University of Oulu and Laboratory of the Deaconess Institute of Oulu, Finland Serum concentrations of CA-125 were determined in association with 6-month medical (n = 48) or surgical and medical therapy (n = 4) of endometriosis. The concentration of CA-125 was significantly higher in stages III + IV (66.6 ± 22. [standard deviation] Vlml) than in stage 1(2.9 ± 2.3 Vlml) or II (28.4 ± 2.8 Vlml); in stage II, the concentration was higher than in stage I. Surgical elemination of endometriosis significantly decreased the level of CA-125, as did danazol, but not medroxyprogesterone acetate (MPA), although these drugs were equal in clinical efficacy. The CA-125 changes during hormonal treatment did not correlate with the clinical response. Postoperatively, CA-125 responses to danazol, MP A, or placebo did not differ significantly from each other. During the 6-month follow-up after medication, the CA-125 concentrations tended to increase, especially in danazol-treated women. The determination of CA -125 is useful in estimating the extent of the disease, but it is less valuable in monitoring the treatment effect. The ability of danazol to suppress CA-125 expression emphasizes the specific properties of this drug. Fertil Steril49:37, 1988 Measurement of the serum concentration of the ovarian epithelial cell membrane antigen CA-125, present in 69% to 9% of patients with ovarian cancer, is used routinely in monitoring the efficacy of therapy in this illness.1-5 Increased concentrations of CA-125 also have been found in endometriosis 6-9 and some other benign gynecologic conditions. 4,6,9 In endometriosis, the clinical value of Received April 9, 1987; revised and accepted August 26, * Department of Obstetrics and Gynecology, University of Oulu. t Reprint requests: Antti Kauppila, M.D., Department of Ob stetrics and Gynecology, University of Oulu, SF-922 Oulu, Finland. :\: Laboratory of the Deaconess Institute of Oulu. CA-125 assay has not yet been established, although preliminary reports emphasize the potential applicability ofthis serum marker for diagnosis and for monitoring the treatment response in this disease. 6,9 To obtain more information on the clinical usefulness of CA-125, we determined serially the serum concentrations of this antigen in a double-blind, placebo-controlled study comparing danazol and high-dose medroxyprogesterone acetate (MPA) in endometriosis.lo,n At present, danazol is a standard drug in medical treatment of this disease.12 High-dose MPA was chosen as a second study drug because such therapy has been well tolerated in endometrial cancer, and danazol and high-dose MPA produce similar endometrial effects Kauppila et al. CA -125 in endometriosis 37

2 Patients MATERIALS AND METHODS Eighty-seven patients with laparoscopically confirmed endometriosis and with serial serum CA-125 determinations before, during, and after treatment were enrolled in this study. The indications for the initial laparoscopy were infertility, suspicion of endometriosis because of secondary dysmenorrhea, or pelvic tumor. The study protocol, approved by the appropriate Medical Review Boards, included two treatment schemes: the medical therapy and the combined surgical and medical treatment modalities. Forty-seven women were assigned to medical treatment alone and 4 women were assigned to surgical plus medical treatment. In the medical treatment group, endometriosis was of stage I (n = 37) or II (n = 1) according to the criteria of The American Fertility Society (AFS).16 In the surgical plus medical treatment group, 1 patients had stage I disease, 15 had stage II disease, and 15 had stage III or stage IV endometriosis. In stages I and II, ovarian endometrioma andlor tubal occlusion or adhesions in association with infertility indicated laparotomy, whereas the milder forms with patent tubes and without adhesions were treated with medical therapy alone. In the whole population, endometriosis was classified to be in AFS stage I in 37 cases, stage II in 25 cases, and stage III or IV in 15 cases. After laparoscopy or laparotomy, the patients were allocated to receive danazol (2 mg three times daily), MPA (1 mg once daily plus two times placebo daily), or placebo (three times daily) for 6 months. All drug packages and capsules looked identical. The randomization code was separate for both treatment groups. In the medical treatment group, the study groups were similar regarding the age of the patients: 31.1 ± 5.6 standard deviation (SD) years in the danazol group, 32.5 ± 5.9 years in the MPA group, and 31.9 ± 6. years in the placebo group. The number of patients with AFS stages 1111 were as follows: 11/6 in the danazol group, 12/4 in the MPA group, and 14/ in the placebo group. Therefore, by chance, the composition of the study patients differed significantly among the groups (P=.18; Fisher's exact probability test). At the diagnostic laparoscopy, electrocautery of some peritoneal implants was performed in three patients receiving danazol, in two patients receiving MPA, and in four patients receiving placebo. In the combined surgical and medical treatment groups, the age of the patients treated with danazol, MPA, or placebo did not differ from one another: 32.1 ± 6.7 years, 29.5 ± 5.8 years, and 28.2 ± 5.6 years, respectively. There were no significant differences between the treatment groups according to the severity of endometriosis as evaluated by the ratio of AFS stages I + II to AFS stages III + IV (1:5 in the danazol group, 9:4 in the MPA group, 6:6 in the placebo group). At operation, ovarian resection was performed in 1 of 15 patients receiving danazol, in 9 of 13 patients receiving MP A, and in 11 of 12 patients receiving placebo. Repeat laparoscopy was done 6 months after the end of medication (i.e., 1 year after the start of the trial in each case). For evaluation of the therapy effect, the endometriosis scores,16 but not the scores related to adhesions, were registered in the pretreatment and repeat visual examination of the pelvic cavity. The code identifying the medicament was not broken before all clinical and biochemical data were registered on the study formulas at the end of the study. There were no discontinuations among the women followed by serial CA-125 determinations. Venous blood samples for CA-125 determinations were drawn before laparoscopyllaparotomy, and 1, 3, 6, and 12 months after the beginning of the therapy. The number of specimens varied from 4 to 5 per patient. The total number of specimens was 411. Serum was separated by centrifugation and stored at -2 C until assayed. CA-125 was measured by a simultaneous sandwich solid phase radioimmunoassay (RIA) using a commercial kit (Abbott CA 125 RIA, Abbott Diagnostic Division, North Chicago, IL). The sensitivity was 5 IU/ml and the coefficient of variation 1% at the level 13 IU Iml, and 9% at the level 83 IU Iml. All specimens were assayed in duplicate. Statistics The Biomedical Computer Program's statistical software (University of California, 1983) was used in the statistical evaluation of the results. Analysis of variance for time-dependent (BMDP2V) and time-independent (BMDP7D) variables was used in the comparisons within the groups and between the groups, respectively, followed, when needed, by the modified Bonferroni test, or nonparametric t test, when appropriate, in the pair-wise comparison of the groups. The chi-square test was used in the 38 Kauppila et a1. CA-125 in endometriosis Fertility and Sterility

3 E It) ('II,.. I 4 c( 2 r-- * * * -----, r-**---,,-- * ---, 361 o o --- a, ci t d3 e~- 8 --_Q._ II 8 III-IV Figure 1 Serum concentrations of CA-125 in women with endometriosis classified into AFS clinical stages I, II and III + IV. The horizontal line indicates the mean of the values in each group. Significance of the difference between the groups (P <.1) was calculated by analysis of variance. *P <.5, **P <.1, ***P <.1 in Mann-Whitney test. comparison of the frequency figures between the groups and the paired t-test in the evaluation ofthe effect of surgery on CA-125 levels within each group. The paired t-test also was employed to study the recovery of CA-125 levels within each group during the follow-up period of 6 months after medication. danazol group (3.3 ± 2.2 versus 1.6 ± 1.5; P =.18), but not in the placebo group (1.8 ±.9 versus 2. ± 1.8). The concentration of CA-125 decreased significantly only during danazol treatment (P <.1), whereas MP A and placebo had no significant effect (Fig. 2A). During the follow-up period of 6 months after medication, the concentrations of CA-125 increased in the danazol (P =.1), MPA (P =.4), and placebo (P =.2) groups. With the individual CA-125 changes between the time periods ( to 1, to 3, and to 6 months) as variable, the decrease in the CA-125 concentration during danazol therapy was significant at 1, 3, and 6 months compared with placebo, and at 3 months compared with MPA (Fig. 3A). During the 6-month follow-up period without medicament, there were no significant difference between the groups. Vsing the decrease in the endometriosis score as a marker of response, there were 18 responders among women treated with danazol or MPA (mean AFS endometriosis scores were 3.2 and 1. in primary and repeat laparoscopy, respectively) and 15 nonresponders (endometriosis scores 3.1 and 3.2, respectively). The decrease in the serum concentration of CA-125 during treatment did not differ between responders and nonresponders (data not shown). This also was true for danazol-treated patients alone, and it did not depend on the initial serum CA-125 level. RESULTS CA-125 Concentrations Before Therapy The serum concentrations ofca-125 varied from <6 IV Iml to 361 IV Iml in patients with endometriosis (Fig. 1). In AFS stages III + IV, the mean (±SD) concentration ofca-125 (66.6 ± 22. IVlml) was significantly higher than in AFS stages I (2.9 ± 2.3 IVlml) or II (28.4 ± 2.8 IV/ml), and was higher in AFS stage II than in stage I (Fig. 1). High (>3 IV Iml) values appeared significantly more often (P =.3) in AFS stages III + IV (73%) than in stages I (19%) or II (28%). CA-125 Concentrations During Hormone Therapy The decrease in endometriosis scores, estimated by laparoscopy before therapy and 6 months after therapy, was significant in the MPA group (2.9 ± 3.1 [SD] versus 2.2 ± 3.7; P =.27) and the... I III N C U A...--.OZl C>-<> PL..._.MPA ---.>--_---<>--<:.~L..aP=O.9 \ P<O.1 OIO~----~--~/~~~II~'~~'~ MONTHS Figure 2 Mean serum concentrations of CA-125 in patients treated with danazol (DZL), medroxyprogesterone acetate (MPA), or placebo (PL) in women with endometriosis treated by medical therapy alone (A) or by postoperative medical therapy (B). Note the difference in the scale of CA-125 concentrations in the upper and lower panels. Significance of withingroup variability is indicated in each treatment group during the 6-month therapy and the 6-month follow-up separately. Kauppila et al. CA-125 in endometriosis 39

4 +15 A (42) (1) ( 21) ~ -+1 ~*--, r**-, ~ r**, r-* ~ _~: --LrJl: 13 --af1!--rj!! y-'- y"" I/) N ~:] :1m--[r--lJ--~ -2 ~ L**---l -3 (.5) _ ~ ~ ~ months of trial Figure 3 Means (± standard error of mean) of the individual changes in the serum concentration of CA-125 from the initial level () to the level at the given month (1, 3, or 6) during the therapy, and from 6 to 12 months of the trial in women treated for endometriosis with danazol (open bars), MP A (hatched bars), or placebo (cross-hatched bars) alone (A) or after surgical treatment of endometriosis (B). Significances of the differences between the groups were evaluated by analysis of variance (P value in parentheses), followed by the modified Bonferroni test (indicated by asterisks between the groups of comparison; P <.5, p <.1). Below the columns, the numbers indicate the patients evaluated each time. Note the difference in the scale of CA-125 concentration in the upper and lower panels. CA-125 Concentrations During Surgical and Hormone Therapy The decrease in endometriosis score evaluated in initial laparotomy and laparoscopically 6 months after therapy was significant (P <.1) in the danazol group (6.2 ± 3.7 versus.8 ±.4), in the MPA group (6.2 ± 4.1 versus.4 ±.2), and in the placebo group (8.8 ± 3.9 versus 4.3 ± 3.1). One month after operation (4 patients), the concentration of CA-125 (2.6 ± 12. [SD] IV/ml) was significantly lower than that (44.6 ± 56.7 IV/ml) before operation (P =.1). A similar decrease in CA-125 levels also was evident when patients receiving placebo only were analyzed (39. ± 16.6 IV/ml and 25.5 ± 11.6 IV/ml, respectively; P =.19). During the whole treatment period, there were significant changes in the mean concentration of CA-125 among women receiving danazol (P <.1), MPA (P <.1), or placebo (P <.1; Fig. 2B). During the follow-up time after the end of medication, from 6 to 12 months of the trial, the concentrations of CA -125 increased significantly in the MPA (P =.1) and danazol (P =.9) groups. The CA-125 changes between the time periods, depicted in Figure 3B, did not differ significantly between the groups, whereas during the follow-up time of 6 months after treatment, the increase in the concentration of CA-125 in the danazol group was significantly greater than in the placebo group. DISCUSSION Our study confirmed that the serum concentration of CA-125 is increased in endometriosis. 6,s,9 It further showed that the increase in CA-125 concentration is directly correlated with the extent of disease in AFS classification. The dependence of the CA-125 level on the amount of endometriosis tissue was further emphasized by the decreased serum CA-125 level after surgical reduction of endometriosis. Another possible way to decrease serum CA-125 level is to suppress synthesis and/or release of CA -125 by endometriotic cells by hormonal treatment. The serum concentration of CA-125, indeed, decreased significantly during danazol therapyan effect that was not seen during high-dose MPA administration. The reason for this difference does not seem to be related to the clinical treatment response, which is similar for MPA and danazol. 1,11 This assumption was reinforced by the observation that the changes in the serum concentrations of CA-125 were similar in responders and nonresponders, a finding that is in contrast to the previous results of Pittaway and Fayez. 9 Danazol exerts typical progestin-like endometrial effects, identical to those caused by MP A, as evaluated by histopathologic l3,14 and biochemicaf4,15 methods. Therefore, the danazol-induced decrease in the cell surface antigen CA-125 level seems to be specific for this drug and to be related to factors other than the progestagenic one, such as the ability of danazol to alter the production of a variety of human proteins,17 or a direct cell membrane effect seen in immune thrombocytopenic purpura, where it decreases the cellular binding sites for specific immunoglobulins. IS The relatively stable CA-125 levels during the postoperative treatment did not differ significantly among the groups. The suppressed CA-125 production in the danazol group was, however, very likely due in part to the specific effects of this drug, since after the medication the rise in the concentration of CA-125, in relation to placebo, was significant in the danazol group but not in the MP A group. 4 Kauppila et al. CA-125 in endometriosis Fertility and Sterility

5 Serum concentrations of CA-125 have been shown to be increased during menstruation, indicating that desquamative endometrium participates in the expression ofthis cell surface antigen,9 detected in the stromal and glandular elements of the endometrium. 6 About two thirds of the women receiving danazol or high-dose MPA in the present study had break-through bleedings. lo,l1 The possible production of CA-125 by the bleeding intrauterine endometrium during the trial cannot be excluded, which creates difficulties in interpreting the value of CA-125 determination as an indicator of hormone treatment effectiveness in endometriosis. The general tendency of serum CA-125 antigen to increase after the therapy possibly reflects the natural course of the disease, characterized by a high rate of recurrence,19 and it may be a sign of reactivation of medically suppressed endometriosis, or advancement of microscopic and minimal lesions at operation to a clinically manifest disease. 2 REFERENCES 1. Bast RC Jr, Klug TL, St John E, Jenison E, Niloff JM, Lazarus H, Berkowitz RS, Leavitt T, Griffiths CT, Parker L, Zurawski VR, Knapp RC: A radioimmunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer. N Engl J Med 39:883, Niloff JM, Knapp RC, Schaetzl E, Reynolds C, Bast RC Jr: Ca -125 antigen levels in obstetrics and gynecologic patients. Obstet Gynecol 64:73, Bast RC Jr, Knapp RC: Monitoring epithelial ovarian cancer. Lab Med 16:315, Halila H, Stenman U-H, Seppala M: Ovarian cancer antigen CA-125 levels in pelvic inflammatory disease and pregnancy. Cancer 57:1327, Kivinen S, Kuoppala T, Leppilampi M, Vuori J, Kauppila A: Tumor-associated antigen CA-125 before and during the treatment of ovarian cancer. Obstet Gynecol 67:468, Barbieri RL, Niloff JM, Bast RC Jr, Schaetzl E, Kistner RW, Knapp RC: Elevated serum concentrations of CA-125 in patients with advanced endometriosis. Fertil Steril 45:63, Giudice LC, Jacobs A, Pineda J, Bell CE, Lippman L: Serum levels of CA-125 in patients with endometriosis: a preliminary report. Fertil Steril 45:876, Patton EP, Field CS, Harms RW, Coulam CB: CA-125 levels in endometriosis. Fertil Steril 45:77, Pittaway DE, Fayez JA: The use of CA-125 in the diagnosis and management of endometriosis. Fertil Steril46:79, Telimaa S, Puolakka J, Ronnberg L, Kauppila A: Placebocontrolled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis. Gynecol Endocrinol 1:13, Telimaa S, Ronnberg L, Kauppila A: Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis after conservative surgery. Gynecol Endocrinol, in press 12. Kauppila A, Ronnberg L, Vihko R: Danazol. In Gynecological Endocrinology, Edited by AR Genazzani, A Volpe, F Facchinetti. Cranforth, UK, The Parthenon Publishing Group, 1985, p Wentz AC, Jones GS, Sapp KC, King TM: Progestational activity of danazol in the human female subject. Am J Obstet Gynecol 126:378, Kauppila A, Isotalo H, Kivinen S, Stenback F, Vihko R: Short-term effects of danazol and medroxyprogesterone acetate on cytosol and nuclear estrogen and progestin receptors, 17{:l-hydroxysteroid dehydrogenase activity, histopathology, and ultrastructure of human endometrial adenocarcinoma. Int J Cancer 35:157, Kokko E, Janne, Kauppila A, Ronnberg L, Vihko R: Danazol has progestin-like actions on the human endometrium. Acta Endocrinol (Copenh) 99:588, The American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, Agnello V, Parisert K, Gell J, Gelfand J, Turksoy RN: Preliminary observations on danazol therapy of systemic lupus erythematosus: effects on DNA antibodies, thrombocytopenia and complement. J Rheumatol 1:682, Schreiber AD, Chien P, Tomaski A, Cines DB: Effect of danazol in immune thrombocytopenic purpura. N Engl J Med 316:53, Schmidt CL: Endometriosis: a reappraisal of pathogenesis and treatment. Fertil Steril 44:157, Thomas EJ, Cooke ID: Impact of gestrinone on the course of asymptomatic endometriosis. Br Med J 294:272, 1987 Kauppila et al. CA-125 in endometriosis 41