A 35-year-old woman presents with infertility and palpable pelvic mass. Her CA-125 level is 90 mIU/mL diagnosis is:
Ans. is b, i.e. EndometriomaRef Novak Gynecology 14th/ed, p1466, 1146, 1147; William's Gynae 1st/ed, p232,210 Textbook of Gynae, sheila Balakrishnan p185In this question we have insufficient information to make any definite diagnosis. At the best we can try to make the most probable diagnosis.CA-125* This is a non-specific tumor marker* CA-125 is a glycoprotein which is normally not produced by ovarian epithelium but may be produced by both malignant and benign epithelial ovarian tumors.* Cut off level of CA-125 is <35U/mL.* Levels of CA-125 can be raised in| CA-125Neoplastic conditionsNon-neoplastic/Benign conditionsGynecological* Ovarian cancer (non mucinous)* Endometrial cancer* Tubal cancerNon-gynecological* Lung cancer* Breast cancer* Ca Pancreas* Colon cancer* Endometriosis* Peritoneal inflammation, including PID* Tuberculosis* Hemorrhagic ovarian cysts* Liver disease* Leiomyoma* Pregnancy* Menstruation* Thus, CA-125 levels, can be raised in all the four options, given in the question* Palpable mass may also be present in all the four conditions.* Infertility is a feature of endometriosis and tuberculosis. But for ovarian cancers, infertility (due to use of ovulation inducing drugs) is a risk factor, not a presenting symptom.* Coming to Age: Patient is 35 years old.* Age of 35 years favors endometrioma (endometriosis) the most.* Peak incidence of invasive epithelial ovarian cancer (most common ovarian cancer) is at 56-60 years of age and for border line tumor average age is 46 years approximately - (Novak 14th/ed, p1466)* Patient with tuberculosis are in their twenties commonly, the maximum age incidence at diagnosis being 28 years.* Also in tuberculosis, CA-125 has least significance as it is neither used for diagnosis nor for follow up* Thus, based on age and infertility - the most probable diagnosis is endometrioma/endometriosis.* Our answer is further supported by following lines from - Textbook ofgynae, Sheila Balakrishnan 1st/ed, p185* Serum CA 125 "This is useful in post menopausal women when a high level may indicate malignancy. In the reproductive age group, the predictive value is not good as the marker may be raised in endometriosis".In young females if the value of CA-125 is >200IU/mL, it is considered to indicate malignancy.
Ovarian Ca
Endometrioma
Tuberculosis
Borderline ovarian tumor
Endometriosis