Research

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ONCOLOGY

Comparison of a novel multiple marker assay vs the Risk

of Malignancy Index for the prediction of epithelial
ovarian cancer in patients with a pelvic mass
Richard G. Moore, MD; Moune Jabre-Raughley, MD; Amy K. Brown, MD; Katina M. Robison, MD; M. Craig Miller, BS;
W. Jeffery Allard, PhD; Robert J. Kurman, MD; Robert C. Bast, MD; Steven J. Skates, PhD
OBJECTIVE: We sought to compare the Risk of Malignancy Index (RMI)

RESULTS: At a set specificity of 75%, ROMA had a sensitivity of

to the Risk of Ovarian Malignancy Algorithm (ROMA) to predict epithelial

ovarian cancer (EOC) in women with a pelvic mass.
STUDY DESIGN: In all, 457 women with imaging results from ultrasound, computed tomography, magnetic resonance imaging, and serum HE4 and CA125 determined prior to surgery for pelvic mass were
evaluable. RMI values were determined using CA125, imaging score,
and menopausal status. ROMA values were determined using HE4,
CA125, and menopausal status.

94.3% and RMI had a sensitivity of 84.6% for distinguishing benign

status from EOC (P .0029). In patients with stage I and II disease,
ROMA achieved a sensitivity of 85.3% compared with 64.7% for
RMI (P .0001).
CONCLUSION: The dual marker algorithm utilizing HE4 and CA125 to
calculate a ROMA value achieves a significantly higher sensitivity for
identifying women with EOC than does RMI.

Cite this article as: Moore RG, Jabre-Raughley M, Brown AK, et al. Comparison of a novel multiple marker assay vs the Risk of Malignancy Index for the prediction
of epithelial ovarian cancer in patients with a pelvic mass. Am J Obstet Gynecol 2010;203:228.e1-6.

B ACKGROUND AND O BJECTIVE

Differentiating malignant from benign
pelvic masses is important for optimal
patient care. Recent studies indicate that
women operated on by surgeons special-

izing in the management of epithelial

ovarian cancer (EOC) and at centers experienced in the surgical and medical
management of patients with this disease
have decreased morbidity and mortality

From the Center for Biomarkers and Emerging Technologies, Program in Womens
Oncology, Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode
Island, Warren Alpert Medical School, Brown University, Providence, RI (Drs Moore, JabreRaughley, and Robison); the Department of Obstetrics and Gynecology, Hartford Hospital,
Hartford, CT (Dr Brown); Medivice consulting, New Durham, NH (Mr Miller and Dr
Allard); the Department of Pathology, Johns Hopkins Medical School, Baltimore, MD (Dr
Kurman); the Department of Experimental Therapeutics, University of Texas M.D. Anderson
Cancer Center, Houston, TX (Dr Bast); and the Department of Obstetrics and Gynecology,
Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr Skates).
Presented at the 40th Annual Meeting on Womens Cancer, Society of Gynecologic Oncologists,
San Antonio, TX, Feb. 5-8, 2009.
Financial support was provided by National Cancer Institute Grants CA086381 and CA105009,
the M.D. Anderson Cancer Center Ovarian Specialized Programs of Research Excellence 1 P50
Grant, and Fujirebio Diagnostics Inc.
Participating institutions: Richard Moore, MD, Women and Infants Hospital of Rhode Island,
Providence, RI; Dan Schlitzer, MD, Healthcare for Women Inc, New Bedford, MA; Steven
DePasquale, MD, Chattanooga Gyn-Oncology, Chattanooga, TN; Walter Gajewski, MD, New
Hanover Regional Medical Center, Wilmington, NC; Laura Havrilesky, MD, Duke University
Medical Center, Durham, NC; Donald Chamberlain, MD, Chattanooga Gyn-Oncology,
Chattanooga, TN; Amy Kirkpatrick Brown, MD, MPH, Hartford Hospital, Hartford, and New Britain
General Hospital of Central Connecticut, New Britain, CT; Alan Gordon, MD, Arizona GynOncology, Phoenix, AZ; Scott McMeekin, MD, Oklahoma University Health Science Center,
Oklahoma City, OK; Howard Homesley, MD, Brody School of Medicine, Leo Jenkins Cancer
Center, Greenville, NC; Elizabeth Swisher, MD, University of Washington Medical Center, Seattle,
WA; Audrey Garrett, MD, Northwest Gynecologic Oncology, Eugene, OR; Alexander Burnett, MD,
University of Arkansas for Medical Sciences, Little Rock, AR.
0002-9378/free 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.03.043

228

American Journal of Obstetrics & Gynecology SEPTEMBER 2010

and an increase in overall survival.

Therefore, it is critical that women with a
pelvic mass or ovarian cyst considered at
high risk for a malignancy be referred to
appropriate centers prior to their surgery
to improve the quality of care and enhance survival for ovarian cancer
patients.
We conducted a prospective multicenter clinical trial to validate a predictive model, called the Risk of Ovarian
Malignancy Algorithm (ROMA), to estimate the risk of EOC in women presenting with a pelvic mass. The results of the
dual marker combination of HE4 and
CA125 used in the ROMA were compared with the Risk of Malignancy Index
(RMI) for the detection of EOC in
women presenting with an ovarian cyst
or pelvic mass.

M ATERIALS AND M ETHODS

This was a prospective multicenter trial.
To be eligible for enrollment, patients
had received a diagnosis of an ovarian
cyst or a pelvic mass with a planned surgical intervention. All patients had radiologic imaging by pelvic ultrasound or
computed tomography scanning and/or
magnetic resonance imaging. Immediately prior to surgery, blood and urine

Oncology

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Research

TABLE

Comparison of the receiver operating characteristicarea under curve

for Risk of Ovarian Malignancy Algorithm and Risk of Malignancy Index
n (%)

ROCAUC (95% CI)

Group

Benign

Cancer

ROMA

RMI

P value

Benign vs EOC and LMP

312 (68)

145 (32)

91.3% (88.294.4)

84.4% (79.888.9)

.0015

Benign vs stage I-IV EOC

312 (72)

123 (28)

95.3% (93.097.5)

87.0% (82.591.6)

.0001

Benign vs stage I-II EOC

312 (90)

34 (10)

90.9% (85.796.0)

76.2% (67.085.5)

.0007

Benign vs stage III-IV EOC

312 (78)

86 (22)

97.6% (95.999.4)

91.9% (87.096.8)

.0198

Benign vs stages I-IIIB

and IIIC (omentum and
lymph node)

312 (88)

44 (12)

92.1% (87.996.2)

75.8% (66.984.6)

.0002

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

AUC, area under curve; CI, confidence interval; EOC, epithelial ovarian cancer; LMP, low malignant potential; RMI, Risk of Malignancy Index; ROC, receiver operating characteristic; ROMA, Risk of
Ovarian Malignancy Algorithm.
Moore. Comparison of a novel multiple marker assay vs the RMI. Am J Obstet Gynecol 2010.

samples were obtained. Serum CA125

concentrations were measured by trained
operators using the Architect CA125II
(Abbott Diagnostics, Chicago, IL) assay
and serum HE4 levels were determined using the HE4 EIA assay (Fujirebio Diagnostics Inc., Malvern, PA).
All patients underwent surgical removal of the ovarian masses or cysts. If a
patient was diagnosed with EOC, surgical staging was required by protocol.
Separate 2 2 tables for the premenopausal and postmenopausal groups for
ROMA and RMI were constructed to determine the number of true-positive,
true-negative, false-positive, and falsenegative results. These results were combined to determine the sensitivity and
specificity and the positive and negative
predictive values. The sensitivities for
ROMA and RMI were compared using a
test of equality of proportions using large
sample statistics.

R ESULTS
Twelve geographically dispersed sites enrolled 566 patients into the trial from December 2005 through February 2007. Of
the 531 patients evaluable for primary
endpoint of the protocol, 457 patients
had sufficient imaging results for the secondary analysis. Among these 457 patients, there were 123 EOCs, 22 low malignant potential (LMP) tumors, and 312
patients with benign disease. There were
212 premenopausal and 245 postmenopausal patients.

Examination of benign cases (n

312) and all stages of EOC at a set specificity of 75% revealed that the ROMA
obtained a sensitivity of 94.3% and the
RMI had a sensitivity of 84.6% for distinguishing benign disease from EOC (P
.0029). In patients with stage I and II disease, the ROMA achieved a sensitivity of
85.3%, compared with 64.7% (P
.0001).
Examination of benign cases vs all
stages of LMP tumors plus all stages of
EOC patients (n 145) at a set specificity of 75% revealed that the ROMA had a
sensitivity of 89.0% and the RMI had a
sensitivity of 80.7% (P .0133). Significant increases in area under the curve
(AUC) for ROMA compared to RMI occurred in distinguishing benign disease
from all EOC; from EOC stages I and II;
from EOC stages I, II, IIIA, IIIB, and
node-positive-only IIIC disease; from
EOC stages III and IV; and from LMP
tumors and all EOC tumors (ROMAAUC vs RMI-AUC, P .0015) (Table).

C OMMENT
Accurate triage and referral of women
with a pelvic mass to appropriate surgeons and institutions will result in improved care for all women ultimately
diagnosed with an EOC. HE4 is complementary to CA125 as it is not falsely elevated in many of the benign gynecologic
conditions that can cause an elevated
CA125. Also, for the 20% of ovarian cancer patients whose tumors do not express

CA125 as a marker for their disease, serum HE4 is elevated in 50% of these
patients. Additionally, in patients with
early-stage disease, HE4 has been shown
to have greater sensitivity than CA125
alone. Each of these factors contributes
to the complementary nature of HE4 to
CA125, which increases the sensitivity
and specificity of the dual marker algorithm over that of either biomarker
alone.
Currently, a well-established algorithm
for predicting the risk of malignancy in
women with a pelvic mass, the RMI, uses a
combination of CA125 serum levels, pelvic
sonography, and menopausal status. In the
current study, the RMI score was calculated using pelvic sonography, computed
tomography scans, magnetic resonance
imaging, or any combination of the 3 imaging modalities. The sensitivities reported
in the current study for the RMI were similar to those reported by Bailey et al for
RMI. Examining benign and invasive
EOC, the RMI algorithm achieved a sensitivity of 84.6%, whereas the ROMA
achieved a sensitivity of 94.3%, which was
significantly higher. The predictive probability algorithm, or ROMA, without the
use of imaging, achieved a higher sensitivity at a set specificity when considering
EOC and LMP tumors as well. In addition,
when averaged over all specificities, the average sensitivity (or AUC) was higher in
ROMA than RMI for comparisons of
many tumor subgroups with benign
disease.

SEPTEMBER 2010 American Journal of Obstetrics & Gynecology

229

Research

Oncology

ROMA, utilizing the dual marker

combination of HE4 and CA125, can be
used to classify both postmenopausal
and premenopausal women into highand low-risk groups, allowing for the effective triage of women to appropriate
centers for their care.

www.AJOG.org

CLINICAL IMPLICATIONS

The novel serum biomarker HE4

complements CA125 for the differentiation of malignant and benign ovarian neoplasms.
The Risk of Ovarian Malignancy Al-

gorithm accurately classifies women

at high and low risk for epithelial
ovarian cancer.
The Risk of Ovarian Malignancy Algorithm can be used as an effective triage tool for women presenting with a
pelvic mass.
f

Expression of soluble interleukin-6 receptor

in malignant ovarian tissue
Kellie S. Rath, MD; Holly M. Funk, BSc; Marcia C. Bowling, MD; William E. Richards, MD; Angela F. Drew, PhD
OBJECTIVE: The objective of the study was to investigate interleukin-6

RESULTS: IL6R expression was increased in malignant ovarian tumors and

receptor (IL6R) isoforms and sheddases in the ovarian tumor

microenvironment.
STUDY DESIGN: Expression of IL6R and sheddases was measured in
tissue samples of papillary serous ovarian carcinomas and benign ovaries by real-time polymerase chain reaction and immunohistochemistry. Murine xenograft samples were tested by enzyme-linked immunosorbent assay to discriminate and evaluate tumor and host
contributions of IL6R.

localized to epithelial cells. Expression of a soluble splice variant of IL6R was

increased in malignant tumors, as were the sheddases for the full-length
isoform. An in vivo xenograft model showed that host IL6R expression is
also increased and regulated by tumor-associated inflammation.
CONCLUSION: IL6R is overexpressed in epithelial ovarian malignancies
because of increases in a soluble IL6R variant, in the sheddases for fulllength IL6R and host IL6R expression. Soluble IL6R may be an efficacious target for reducing IL6-mediated ovarian tumor progression.

Cite this article as: Rath KS, Funk HM, Bowling MC, et al. Expression of soluble interleukin-6 receptor in malignant ovarian tissue. Am J Obstet Gynecol
2010;203:230.e1-8.

B ACKGROUND AND O BJECTIVE

Interleukin-6 (IL-6) is an important
proinflammatory cytokine that is frequently up-regulated in acute and
chronic inflammatory conditions, including many cancers. IL-6 signaling
occurs through a hexameric complex
From the Department of Cancer and Cell
Biology (Drs Rath and Drew and Ms Funk)
and the Division of Gynecologic Oncology,
Department of Obstetrics and Gynecology
(Drs Rath and Richards), University of
Cincinnati School of Medicine, and the
Department of Obstetrics and Gynecology
(Dr Bowling), Christ Hospital, Cincinnati,
OH.
This study was supported in part by the
American Cancer Society Grant RSG-06-14101-CSM (to A.F.D.) and the Department of the
Army, Department of Defense Ovarian Cancer
Research Program Grant (OC080273) (to
A.F.D.).
0002-9378/free
2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.03.034

230

of IL-6, a specific receptor (IL6R;

gp80), and a shared -signaling receptor (gp130). Dimerization of gp130
leads to activation of Janus tyrosine kinases and subsequent translocation of
signal transducer and activator of transcription (Stat) transcription factors.
Stat3 is the major Stat induced by IL-6
signaling, and its nuclear translocation
induces a transcriptional program resulting in inflammation, cell survival,
or differentiation, depending on the
cellular context. Several soluble isoforms exist in addition to membranebound IL6R.
Expression of both membranebound and soluble forms of IL6R is
largely restricted to hepatocytes and
immune cells; therefore, signaling
through membrane-bound IL6R is restricted to these cells. However, the
soluble isoforms of IL6R are excreted
from these cells types and unexpectedly function as agonists for IL6R signaling and hence allow IL6R-mediated

American Journal of Obstetrics & Gynecology SEPTEMBER 2010

signaling in cells that do not express

IL6R.
Soluble IL6R can be generated by 2
distinct processes: differential splicing
and proteolytic cleavage. The differentially spliced isoform lacks a transmembrane domain and is secreted as a soluble, functional receptor. The proteolytic
enzymes responsible for cleavage of fulllength IL6R are a disintegrin and metalloprotease domain (ADAM)-17, also
known as tumor necrosis factor alpha
converting enzyme, and to a lesser extent, ADAM10. These sheddases cleave
full-length IL6R in a membrane proximal site to release a soluble, functional
receptor.
It is well established that IL-6 is upregulated in both the serum and ascites
of ovarian cancer patients and is associated with disease progression. IL-6
has also been implicated in chemotherapeutic resistance in ovarian cancer
cell lines and in patients with ovarian
cancer. However, the status of IL6R ex-