Are preoperative serum cancer antigen 125 levels a prognostic factor for outcome in epithelial ovarian cancer? A systematic review
Main Article Content
Keywords
Ovarian Cancer, Cancer Antigen 125, Outcome, Survival
Abstract
Background: Most patients with epithelial ovarian cancers (EOC) present with advanced-stage disease because of non-specific symptoms and lack of reliable strategies for early diagnosis. Cancer antigen 125 (CA-125) is suggested as a useful prognostic biomarker, its serum level is raised in over 80.0% of patients with EOC. Primary debulking surgery (PDS) followed by chemotherapy is the conventional treatment, but neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) is offered to patients with unresectable disease. There are inconsistencies regarding the role of preoperative CA-125 serum levels to adopt in stratifying patients for treatment choice that offers the most benefit. This review aimed to determine the role of preoperative CA-125 levels in predicting optimal cytoreduction and the association between optimal cytoreduction and survival outcome in patients with EOC.
Methodology: Three electronic databases CINAHL, Cochrane library and PubMed were searched for potentially relevant articles from 2016 to 2021 on the role of preoperative CA-125 levels in predicting optimal cytoreduction and survival in patients with epithelial ovarian carcinomas.
Conclusion: In patients who underwent NACT-IDS, a lower preoperative CA-125 value is a predictor of optimal cytoreduction and an increase in preoperative CA-125 value is consistently associated with a decrease in optimal cytoreduction. There was insufficient data to assess overall survival. However, a raised preoperative CA-125 level is poor predictor of chance of achieving optimal cytoreduction and the rate of optimal cytoreduction was a weak predictor of overall survival in women who had primary debulking surgery.
References
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14. Cho JH, Kim S, Song YS. Neoadjuvant chemotherapy in advanced ovarian cancer: optimal patient selection and response evaluation. Chinese clinical oncology. 2018;7(6):58-.
15. Rodriguez N, Miller A, Richard SD, Rungruang B, Hamilton CA, Bookman MA, et al. Upper abdominal procedures in advanced stage ovarian or primary peritoneal carcinoma patients with minimal or no gross residual disease: an analysis of Gynecologic Oncology Group (GOG) 182. Gynecologic oncology. 2013;130(3):487-492.
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18. Thibault B, Clement E, Zorza G, Meignan S, Delord JP, Couderc B, et al. F14512, a polyamine-vectorized inhibitor of topoisomerase II, exhibits a marked anti-tumor activity in ovarian cancer. Cancer Lett. 2016;370(1):10-18.
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20. Carlsten M, Norell H, Bryceson YT, Poschke I, Schedvins K, Ljunggren HG, et al. Primary human tumor cells expressing CD155 impair tumor targeting by down-regulating DNAM-1 on NK cells. J Immunol. 2009;183(8):4921-4930.
21. Giannakouros P, Matte I, Rancourt C, Piché A. Transformation of NIH3T3 mouse fibroblast cells by MUC16 mucin (CA125) is driven by its cytoplasmic tail. Int J Oncol. 2015;46(1):91-98.
22. Thériault C, Pinard M, Comamala M, Migneault M, Beaudin J, Matte I, et al. MUC16 (CA125) regulates epithelial ovarian cancer cell growth, tumorigenesis and metastasis. Gynecol Oncol. 2011;121(3):434-443.
23. Zhang H, Yang Y, Wang Y, Gao X, Wang W, Liu H, et al. Relationship of tumor marker CA125 and ovarian tumor stem cells: preliminary identification. J Ovarian Res. 2015;8:19.
24. Suidan RS, Ramirez PT, Sarasohn DM, Teitcher JB, Mironov S, Iyer RB, et al. A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer. Gynecol Oncol. 2014;134(3):455-461.
25. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
26. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Bmj. 2016;355:i4919.
27. Thomson H, Craig P, Hilton-Boon M, Campbell M, Katikireddi SV. Applying the ROBINS-I tool to natural experiments: an example from public health. Syst Rev. 2018;7(1):15.
28. Pradjatmo H, Pradjatmo H. Impact of Preoperative Serum Levels of CA 125 on Epithelial Ovarian Cancer Survival. Asian Pac J Cancer Prev. 2016;17(4):1881-1886.
29. Bachmann R, Brucker S, Stäbler A, Krämer B, Ladurner R, Königsrainer A, et al. Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer. Mol Clin Oncol. 2021;14(1):8.
30. Morimoto A, Nagao S, Kogiku A, Yamamoto K, Miwa M, Wakahashi S, et al. A preoperative low cancer antigen 125 level (≤25.8 mg/dl) is a useful criterion to determine the optimal timing of interval debulking surgery following neoadjuvant chemotherapy in epithelial ovarian cancer. Jpn J Clin Oncol. 2016;46(6):517-521.
31. Matsuhashi T, Takeshita T, Yamamoto A, Kawase R, Yamada T, Kurose K, et al. Serum CA 125 Level after Neoadjuvant Chemotherapy is Predictive of Prognosis and Debulking Surgery Outcomes in Advanced Epithelial Ovarian Cancer. J Nippon Med Sch. 2017;84(4):170-176.
32. Merlo S, Besic N, Drmota E, Kovacevic N. Preoperative serum CA-125 level as a predictor for the extent of cytoreduction in patients with advanced stage epithelial ovarian cancer. Radiol Oncol. 2021;55(3):341-346.
33. Bai H, Sha G, Xiao M, Gao H, Cao D, Yang J, et al. The prognostic value of pretreatment CA-125 levels and CA-125 normalization in ovarian clear cell carcinoma: a two-academic-institute study. Oncotarget. 2016;7(13):15566-15576.
34. May T, Stewart JM, Bernardini MQ, Ferguson SE, Laframboise S, Jiang H, et al. The prognostic value of perioperative, pre-systemic therapy CA125 levels in patients with high-grade serous ovarian cancer. Int J Gynaecol Obstet. 2018;140(2):247-252.
35. Muallem MZ, Parashkevova A, Almuheimid J, Richter R, Diab Y, Braicu EI, et al. Preoperative CA-125 Values as a Predictive Factor for the Postoperative Outcome in Primary Serous Ovarian Cancer. Anticancer Res. 2017;37(6):3157-3161.
36. Parashkevova A, Sehouli J, Richter R, Dimitrova D, Braicu EI, Muallem MZ. Preoperative CA-125 Value as a Predictive Factor for Postoperative Outcome in First Relapse of Platinum-sensitive Serous Ovarian Cancer. Anticancer Res. 2018;38(8):4865-4870.
37. Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess. 2003;7(27):iii-x, 1-173.
38. Gupta M, Patel SM, Arora R, Tiwari R, Dave P, Desai A, et al. Does preoperative CA-125 cutoff value and percent reduction in CA-125 levels correlate with surgical and survival outcome after neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer? - Our experience from a tertiary cancer institute. South Asian J Cancer. 2020;9(1):30-33.
39. Hartling L, Hamm MP, Milne A, Vandermeer B, Santaguida PL, Ansari M, et al. Testing the risk of bias tool showed low reliability between individual reviewers and across consensus assessments of reviewer pairs. J Clin Epidemiol. 2013;66(9):973-981.
40. Morgan RL, Thayer KA, Santesso N, Holloway AC, Blain R, Eftim SE, et al. Evaluation of the risk of bias in non-randomized studies of interventions (ROBINS-I) and the ‘target experiment’concept in studies of exposures: rationale and preliminary instrument development. Environment international. 2018;120:382-387.
41. Jeyaraman MM, Rabbani R, Al-Yousif N, Robson RC, Copstein L, Xia J, et al. Inter-rater reliability and concurrent validity of ROBINS-I: protocol for a cross-sectional study. Systematic reviews. 2020;9(1):1-12.
42. Minozzi S, Cinquini M, Gianola S, Castellini G, Gerardi C, Banzi R. Risk of bias in nonrandomized studies of interventions showed low inter-rater reliability and challenges in its application. Journal of clinical epidemiology. 2019;112:28-35.
43. Pelissier A, Bonneau C, Chéreau E, Rouge TdLM, Fourchotte V, Daraï E, et al. CA125 kinetic parameters predict optimal cytoreduction in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy. Gynecologic oncology. 2014;135(3):542-546.
44. Mury D, Woelber L, Jung S, Eulenburg C, Choschzick M, Witzel I, et al. Prognostic and predictive relevance of CA-125 at primary surgery of ovarian cancer. J Cancer Res Clin Oncol. 2011;137(7):1131-1137.
45. Memarzadeh S, Lee SB, Berek JS, Farias-Eisner R. CA125 levels are a weak predictor of optimal cytoreductive surgery in patients with advanced epithelial ovarian cancer. Int J Gynecol Cancer. 2003;13(2):120-124.
46. Chi DS, Venkatraman ES, Masson V, Hoskins WJ. The ability of preoperative serum CA-125 to predict optimal primary tumor cytoreduction in stage III epithelial ovarian carcinoma. Gynecol Oncol. 2000;77(2):227-231.
47. Chi DS, Zivanovic O, Palayekar MJ, Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al. A contemporary analysis of the ability of preoperative serum CA-125 to predict primary cytoreductive outcome in patients with advanced ovarian, tubal and peritoneal carcinoma. Gynecol Oncol. 2009;112(1):6-10.
48. Cooper BC, Sood AK, Davis CS, Ritchie JM, Sorosky JI, Anderson B, et al. Preoperative CA 125 levels: an independent prognostic factor for epithelial ovarian cancer. Obstet Gynecol. 2002;100(1):59-64.
49. Mahner S, Woelber L, Jung S, Eulenburg CZ, Ihnen M, Schwarz J, et al. Prognostic significance of CA-125 in the management of patients with recurrent epithelial ovarian carcinoma selected for secondary cytoreduction. Anticancer Res. 2009;29(7):2817-2821.
50. Harter P, Hilpert F, Mahner S, Kommoss S, Heitz F, Pfisterer J, et al. Prognostic factors for complete debulking in first- and second-line ovarian cancer. Int J Gynecol Cancer. 2009;19 Suppl 2:S14-17.
51. Makar AP, Kristensen GB, Kaern J, Børmer OP, Abeler VM, Tropé CG. Prognostic value of pre- and postoperative serum CA 125 levels in ovarian cancer: new aspects and multivariate analysis. Obstet Gynecol. 1992;79(6):1002-10.
52. Høgdall EV, Christensen L, Kjaer SK, Blaakaer J, Kjærbye-Thygesen A, Gayther S, et al. CA125 expression pattern, prognosis and correlation with serum CA125 in ovarian tumor patients: From The Danish “MALOVA” ovarian cancer study. Gynecologic oncology. 2007;104(3):508-515.
2. Akaev I, Rahimi S, Onifade O, Gardner FJE, Castells-Rufas D, Jones E, et al. Tumour Versus Germline BRCA Testing in Ovarian Cancer: A Single-Site Institution Experience in the United Kingdom. Diagnostics. 2021;11(3):547.
3. Wright AA, Bohlke K, Armstrong DK, Bookman MA, Cliby WA, Coleman RL, et al. Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology clinical practice guideline. Gynecologic oncology. 2016;143(1):3-15.
4. Sudolmuş S, Köroğlu N, Yıldırım G, Ülker V, Gülkılık A, Dansuk R. Can CA-125 predict lymph node metastasis in epithelial ovarian cancers in Turkish population? Disease markers. 2014;2014.
5. Zhou D, Li J, Learoyd M, Bui K, Berges A, Milenkova T, et al. Efficacy and safety exposure‐response analyses of olaparib capsule and tablet formulations in oncology patients. Clinical Pharmacology & Therapeutics. 2019;105(6):1492-1500.
6. Bast RC, Jr. Status of tumor markers in ovarian cancer screening. J Clin Oncol. 2003;21(10 Suppl):200s-5s.
7. Yawn BP, Barrette BA, Wollan PC. Ovarian cancer: the neglected diagnosis. Mayo Clin Proc. 2004;79(10):1277-1282.
8. Scholler N, Urban N. CA125 in ovarian cancer. Biomark Med. 2007;1(4):513-523.
9. Gómez-Hidalgo NR, Martinez-Cannon BA, Nick AM, Lu KH, Sood AK, Coleman RL, et al. Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: Time to incorporate laparoscopic assessment into the standard of care. Gynecol Oncol. 2015;137(3):553-558.
10. Charkhchi P, Cybulski C, Gronwald J, Wong FO, Narod SA, Akbari MR. CA125 and Ovarian Cancer: A Comprehensive Review. Cancers (Basel). 2020;12(12).
11. Morales-Vásquez F, Pedernera E, Reynaga-Obregón J, López-Basave HN, Gómora MJ, Carlón E, et al. High levels of pretreatment CA125 are associated to improved survival in high grade serous ovarian carcinoma. J Ovarian Res. 2016;9(1):41.
12. Tian C, Markman M, Zaino R, Ozols RF, McGuire WP, Muggia FM, et al. CA-125 change after chemotherapy in prediction of treatment outcome among advanced mucinous and clear cell epithelial ovarian cancers: a Gynecologic Oncology Group study. Cancer. 2009;115(7):1395-1403.
13. Sato S, Itamochi H. Neoadjuvant chemotherapy in advanced ovarian cancer: latest results and place in therapy. Ther Adv Med Oncol. 2014;6(6):293-304.
14. Cho JH, Kim S, Song YS. Neoadjuvant chemotherapy in advanced ovarian cancer: optimal patient selection and response evaluation. Chinese clinical oncology. 2018;7(6):58-.
15. Rodriguez N, Miller A, Richard SD, Rungruang B, Hamilton CA, Bookman MA, et al. Upper abdominal procedures in advanced stage ovarian or primary peritoneal carcinoma patients with minimal or no gross residual disease: an analysis of Gynecologic Oncology Group (GOG) 182. Gynecologic oncology. 2013;130(3):487-492.
16. Zeppernick F, Meinhold-Heerlein I. The new FIGO staging system for ovarian, fallopian tube, and primary peritoneal cancer. Arch Gynecol Obstet. 2014;290(5):839-842.
17. Momenimovahed Z, Tiznobaik A, Taheri S, Salehiniya H. Ovarian cancer in the world: epidemiology and risk factors. Int J Womens Health. 2019;11:287-299.
18. Thibault B, Clement E, Zorza G, Meignan S, Delord JP, Couderc B, et al. F14512, a polyamine-vectorized inhibitor of topoisomerase II, exhibits a marked anti-tumor activity in ovarian cancer. Cancer Lett. 2016;370(1):10-18.
19. Gubbels JA, Belisle J, Onda M, Rancourt C, Migneault M, Ho M, et al. Mesothelin-MUC16 binding is a high affinity, N-glycan dependent interaction that facilitates peritoneal metastasis of ovarian tumors. Molecular cancer. 2006;5(1):1-15.
20. Carlsten M, Norell H, Bryceson YT, Poschke I, Schedvins K, Ljunggren HG, et al. Primary human tumor cells expressing CD155 impair tumor targeting by down-regulating DNAM-1 on NK cells. J Immunol. 2009;183(8):4921-4930.
21. Giannakouros P, Matte I, Rancourt C, Piché A. Transformation of NIH3T3 mouse fibroblast cells by MUC16 mucin (CA125) is driven by its cytoplasmic tail. Int J Oncol. 2015;46(1):91-98.
22. Thériault C, Pinard M, Comamala M, Migneault M, Beaudin J, Matte I, et al. MUC16 (CA125) regulates epithelial ovarian cancer cell growth, tumorigenesis and metastasis. Gynecol Oncol. 2011;121(3):434-443.
23. Zhang H, Yang Y, Wang Y, Gao X, Wang W, Liu H, et al. Relationship of tumor marker CA125 and ovarian tumor stem cells: preliminary identification. J Ovarian Res. 2015;8:19.
24. Suidan RS, Ramirez PT, Sarasohn DM, Teitcher JB, Mironov S, Iyer RB, et al. A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer. Gynecol Oncol. 2014;134(3):455-461.
25. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
26. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Bmj. 2016;355:i4919.
27. Thomson H, Craig P, Hilton-Boon M, Campbell M, Katikireddi SV. Applying the ROBINS-I tool to natural experiments: an example from public health. Syst Rev. 2018;7(1):15.
28. Pradjatmo H, Pradjatmo H. Impact of Preoperative Serum Levels of CA 125 on Epithelial Ovarian Cancer Survival. Asian Pac J Cancer Prev. 2016;17(4):1881-1886.
29. Bachmann R, Brucker S, Stäbler A, Krämer B, Ladurner R, Königsrainer A, et al. Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer. Mol Clin Oncol. 2021;14(1):8.
30. Morimoto A, Nagao S, Kogiku A, Yamamoto K, Miwa M, Wakahashi S, et al. A preoperative low cancer antigen 125 level (≤25.8 mg/dl) is a useful criterion to determine the optimal timing of interval debulking surgery following neoadjuvant chemotherapy in epithelial ovarian cancer. Jpn J Clin Oncol. 2016;46(6):517-521.
31. Matsuhashi T, Takeshita T, Yamamoto A, Kawase R, Yamada T, Kurose K, et al. Serum CA 125 Level after Neoadjuvant Chemotherapy is Predictive of Prognosis and Debulking Surgery Outcomes in Advanced Epithelial Ovarian Cancer. J Nippon Med Sch. 2017;84(4):170-176.
32. Merlo S, Besic N, Drmota E, Kovacevic N. Preoperative serum CA-125 level as a predictor for the extent of cytoreduction in patients with advanced stage epithelial ovarian cancer. Radiol Oncol. 2021;55(3):341-346.
33. Bai H, Sha G, Xiao M, Gao H, Cao D, Yang J, et al. The prognostic value of pretreatment CA-125 levels and CA-125 normalization in ovarian clear cell carcinoma: a two-academic-institute study. Oncotarget. 2016;7(13):15566-15576.
34. May T, Stewart JM, Bernardini MQ, Ferguson SE, Laframboise S, Jiang H, et al. The prognostic value of perioperative, pre-systemic therapy CA125 levels in patients with high-grade serous ovarian cancer. Int J Gynaecol Obstet. 2018;140(2):247-252.
35. Muallem MZ, Parashkevova A, Almuheimid J, Richter R, Diab Y, Braicu EI, et al. Preoperative CA-125 Values as a Predictive Factor for the Postoperative Outcome in Primary Serous Ovarian Cancer. Anticancer Res. 2017;37(6):3157-3161.
36. Parashkevova A, Sehouli J, Richter R, Dimitrova D, Braicu EI, Muallem MZ. Preoperative CA-125 Value as a Predictive Factor for Postoperative Outcome in First Relapse of Platinum-sensitive Serous Ovarian Cancer. Anticancer Res. 2018;38(8):4865-4870.
37. Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess. 2003;7(27):iii-x, 1-173.
38. Gupta M, Patel SM, Arora R, Tiwari R, Dave P, Desai A, et al. Does preoperative CA-125 cutoff value and percent reduction in CA-125 levels correlate with surgical and survival outcome after neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer? - Our experience from a tertiary cancer institute. South Asian J Cancer. 2020;9(1):30-33.
39. Hartling L, Hamm MP, Milne A, Vandermeer B, Santaguida PL, Ansari M, et al. Testing the risk of bias tool showed low reliability between individual reviewers and across consensus assessments of reviewer pairs. J Clin Epidemiol. 2013;66(9):973-981.
40. Morgan RL, Thayer KA, Santesso N, Holloway AC, Blain R, Eftim SE, et al. Evaluation of the risk of bias in non-randomized studies of interventions (ROBINS-I) and the ‘target experiment’concept in studies of exposures: rationale and preliminary instrument development. Environment international. 2018;120:382-387.
41. Jeyaraman MM, Rabbani R, Al-Yousif N, Robson RC, Copstein L, Xia J, et al. Inter-rater reliability and concurrent validity of ROBINS-I: protocol for a cross-sectional study. Systematic reviews. 2020;9(1):1-12.
42. Minozzi S, Cinquini M, Gianola S, Castellini G, Gerardi C, Banzi R. Risk of bias in nonrandomized studies of interventions showed low inter-rater reliability and challenges in its application. Journal of clinical epidemiology. 2019;112:28-35.
43. Pelissier A, Bonneau C, Chéreau E, Rouge TdLM, Fourchotte V, Daraï E, et al. CA125 kinetic parameters predict optimal cytoreduction in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy. Gynecologic oncology. 2014;135(3):542-546.
44. Mury D, Woelber L, Jung S, Eulenburg C, Choschzick M, Witzel I, et al. Prognostic and predictive relevance of CA-125 at primary surgery of ovarian cancer. J Cancer Res Clin Oncol. 2011;137(7):1131-1137.
45. Memarzadeh S, Lee SB, Berek JS, Farias-Eisner R. CA125 levels are a weak predictor of optimal cytoreductive surgery in patients with advanced epithelial ovarian cancer. Int J Gynecol Cancer. 2003;13(2):120-124.
46. Chi DS, Venkatraman ES, Masson V, Hoskins WJ. The ability of preoperative serum CA-125 to predict optimal primary tumor cytoreduction in stage III epithelial ovarian carcinoma. Gynecol Oncol. 2000;77(2):227-231.
47. Chi DS, Zivanovic O, Palayekar MJ, Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al. A contemporary analysis of the ability of preoperative serum CA-125 to predict primary cytoreductive outcome in patients with advanced ovarian, tubal and peritoneal carcinoma. Gynecol Oncol. 2009;112(1):6-10.
48. Cooper BC, Sood AK, Davis CS, Ritchie JM, Sorosky JI, Anderson B, et al. Preoperative CA 125 levels: an independent prognostic factor for epithelial ovarian cancer. Obstet Gynecol. 2002;100(1):59-64.
49. Mahner S, Woelber L, Jung S, Eulenburg CZ, Ihnen M, Schwarz J, et al. Prognostic significance of CA-125 in the management of patients with recurrent epithelial ovarian carcinoma selected for secondary cytoreduction. Anticancer Res. 2009;29(7):2817-2821.
50. Harter P, Hilpert F, Mahner S, Kommoss S, Heitz F, Pfisterer J, et al. Prognostic factors for complete debulking in first- and second-line ovarian cancer. Int J Gynecol Cancer. 2009;19 Suppl 2:S14-17.
51. Makar AP, Kristensen GB, Kaern J, Børmer OP, Abeler VM, Tropé CG. Prognostic value of pre- and postoperative serum CA 125 levels in ovarian cancer: new aspects and multivariate analysis. Obstet Gynecol. 1992;79(6):1002-10.
52. Høgdall EV, Christensen L, Kjaer SK, Blaakaer J, Kjærbye-Thygesen A, Gayther S, et al. CA125 expression pattern, prognosis and correlation with serum CA125 in ovarian tumor patients: From The Danish “MALOVA” ovarian cancer study. Gynecologic oncology. 2007;104(3):508-515.
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May 23, 2024
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Shittu, M. A., Olaoye, S. O., & Umar, F. K. (2024). Are preoperative serum cancer antigen 125 levels a prognostic factor for outcome in epithelial ovarian cancer? A systematic review. Nigerian Medical Journal, 65(2), 108–118. https://doi.org/10.60787/nmj-v65i2-418
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