Ovarian Cancer

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the U.S. and the fifth most common cause of cancer mortality in U.S. women. Useful biomarkers include cancer antigen 125 (CA 125) and human epididymis protein 4 (HE4).

  • Key Points
  • Diagnosis
  • Screening
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Topics
  • Videos
Primary Author: Grenache, David G., PhD.

Use of Tumor Markers in Pelvic Masses – Cancer Antigen 125 (CA 125) and Human Epididymis Protein (HE4)


  • CA 125 – glycoprotein antigen expressed in tissue derived from coelomic epithelial cells (ovary, fallopian tube, peritoneum, pericardium, colorectal, kidney, stomach)
    • Frequency of elevation correlates with clinically detected stage of cancer, tumor burden, and type of tumor
  • HE4 – secreted protein expressed in most epithelial ovarian tumors
    • Marker of relapse
    • Improves specificity of CA 125 if used in conjunction


  • Tumor markers in ovarian cancer and pelvic masses
  • In general, the combination of CA 125 and HE4 provides the highest sensitivity and specificity
Ovarian Cancer



  • Most ovarian tumors are epithelial and secrete CA 125 and HE4
    • In ~50% of patients, these markers do not increase early enough to be useful for detecting early stage ovarian cancer (National Comprehensive Cancer Network [NCCN], 2017)
    • In small number of tumors, markers are not expressed
  • Increased survival rates are associated with optimal surgical debulking in initial tumor surgery
    • Best performed at earlier stages
  • Tumor marker panels (American College of Obstetricians and Gynecologists [ACOG], 2017)
    • Insufficient data to recommend for or against use for evaluation of ovarian cancer
  • Recommendations for CA 125 assessment (ACOG, 2017)
    • Cutoffs for referral for ovarian cancer evaluation have poor sensitivity and specificity
    • Mathematical models using rates of change have better positive predictive value
    • Neither cutoffs nor serial CA 125 assessment found to reduce ovarian cancer mortality


  • Markers are useful in monitoring therapy and monitoring for recurrence if CA 125 and/or HE4 level is initially elevated
  • Increasing levels accurately predict relapse
Pelvic Mass


  • Cannot use markers to differentiate benign from malignant mass
    • False elevations of CA 125 occur in many benign gynecologic diseases (eg, endometriosis)
    • HE4 is more specific – its use alone or in combination with CA 125 is not recommended to rule out malignancy
  • Risk of Ovarian Malignancy Algorithm (ROMA) is useful for assessment of cancer risk in adnexal mass, particularly epithelial cell ovarian cancer
    • Combines CA 125 and HE4, together with menopausal status, to classify patients with adnexal mass into high- or low-risk epithelial ovarian cancer group
    • Can be used to triage patients for appropriate referral
    • Should not be used without an independent clinical radiological evaluation – not intended to be a screening test or to determine whether a patient should proceed to surgery
    • HE4 in combination with CA 125 appears more sensitive than CA 125 alone


  • CA 125 and HE4 are useful in differential diagnosis of pelvic mass
  • Decreased false-positive rate if both tests are performed
  • CA 125 >65 U/mL is highly suggestive of malignancy
  • ROMA – see Premenopausal section above

Indications for Testing

  • Increase in abdominal size or bloating
  • Pelvic or abdominal pain
  • Early satiety
  • Adnexal mass on imaging or bimanual exam

Laboratory Testing

  • Biomarkers
    • Epithelial cell tumors
      • Beta-hCG (β-hCG) – consider this test in premenopausal females to rule out pregnancy
      • Cancer antigen 125 (CA 125)
        • Not recommended as a single initial diagnostic test (although results >65 U/mL are highly suggestive of malignancy)
        • Recommended differential diagnosis of suspicious pelvic mass in postmenopausal females
      • Human epididymis protein 4 (HE4) – combining with CA 125 decreases false positives
      • Inhibin – complements CA 125
        • Best performance in mucinous subtype
      • Other markers currently available are not generally as useful
    • Granulosa-theca cell tumors
      • CA 125 – frequently normal (not useful if normal)
      • Inhibin – A and B (B usually higher than A)
        • Total inhibin – highly sensitive
      • Estradiol – often elevated
    • Germ cell tumors
      • CA 125 – not useful (usually normal)
      • β-hCG – elevated
      • Alpha fetoprotein (AFP) – elevated
      • Neuron-specific enolase (NSE) – elevated
      • Lactate dehydrogenase (LDH) – elevated


  • Surgical biopsy to determine if ovarian mass is malignant (with planned surgical debulking if malignant)
    • Avoid percutaneous biopsy – can cause tumor spillage into the pelvis
    • All tumors require histologic confirmation for diagnosis
  • Immunohistochemistry
    • Epithelial
      • Serous
        • High-grade serous carcinoma (HGSC)
          • (+) p53, Wilms tumor (WT-1), p16, estrogen receptor (ER)
        • Low-grade serous carcinoma (LGSC)
          • (+) WT-1, ER
        • (+) SALL4, PAX8
      • Mucinous
        • (+) CK 7, CK 20 (weak, focal), CDX2 (weak, focal), PAX8, SMAD4, DPC4 (testing for DPC4 not offered at ARUP Laboratories)
        • (-) ER, WT-1 (not diffusely positive), beta-catenin-1 (β-catenin-1), p16
      • Endometrioid
        • (+) ER, progesterone receptor (PR) (nuclear), β-catenin-1, vimentin, CK 7, PAX8
        • (+) p53 in some high-grade endometrioid – most lack p53, p16
        • (-) WT-1 (not diffusely positive), calretinin, inhibin, CK 20, carcinoembryonic antigen (CEA) (monoclonal or polyclonal)
      • Clear cell
        • (+) HNF1-beta (HNF1β) (testing for HNF1β not offered at ARUP Laboratories), β-catenin-1, PAX8
        • (-) ER, WT-1 – typically lack p53 unless high grade
      • Transitional cell
        • (+) WT-1, ER, p53
        • (-) p53 – typically lack p53 unless high grade
    • Granulosa/Sertoli – (+) inhibin, WT-1, calretinin
    • Germ cell – (+) CA 125, inhibin, AFP, β-hCG
  • Molecular testing based on histology
    • HGSC – BRCA1 or BRCA2 gene mutations common
    • LGSC – BRAF or KRAS gene mutations
    • Mucinous – KRAS gene mutations common
    • Endometrioid – CTNNB1 and PTEN gene mutations common
    • Clear cell – lacks BRCA1 or BRCA2 gene mutations
    • Transitional cell
      • If lacking Brenner component – BRCA1 or BRCA2 gene mutations common
    • Granulosa cell – FOXL2 gene mutations (test not offered at ARUP Laboratories)

Imaging Studies

  • Ultrasound
    • Transvaginal sonography (TVS) followed by computed tomography (CT)/magnetic resonance imaging (MRI) if suspicious TVS findings


  • p53 overexpression
    • Correlates with poor survival, propensity for recurrence, and distant recurrence
  • RAS dysregulation in serous subtype
    • Associated with poor prognosis in patients with incomplete response to platinum-based therapy
  • β-catenin-1 dysregulation in serous subtype
    • Associated with poor prognosis in patients with incomplete response to platinum-based therapy
  • EGFR overexpression
    • Associated with platinum resistance and poor prognosis
  • HER2 expression – in only 10% of patients
    • Correlates with poor survival
  • MMP-9 overexpression
    • Associated with poor prognosis
  • SALL4 overexpression
    • Associated with poor prognosis
  • PD-L1 overexpression
    • Associated with poor prognosis

 Differential Diagnosis

  • Routine screening in general population is not currently recommended by the U.S. Preventive Services Task Force (USPSTF) or American Congress of Obstetricians and Gynecologists (ACOG)
  • Trials of screening
  • Screening for specific syndromes
    • BRCA – ovarian cancer risk >50%
      • If patient chooses not to undergo total abdominal hysterectomy with bilateral salpingo-oophorectomy, begin screening at age 30
        • See National Comprehensive Cancer Network (NCCN) Genetic/Familial High-Risk Assessment (Breast and Ovarian Cancer) 2017 screening guidelines
        • Concurrent TVS and CA 125 – every 6 months
          • TVS – preferably day 1-10 of menstrual cycle in premenopausal women
          • CA 125 – preferably after day 5 of menstrual cycle in premenopausal women
    • Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]) – ovarian cancer risk 10%
      • TVS – beginning at 30-35 years (for endometrial cancer screening)
      • CA 125 – unproven efficacy due to inadequate trials
  • Hereditary breast and ovarian cancer (HBOC) genetic testing recommendations, based on personal and family history (NCCN, 2017)
    • Indications for testing in women with any of the following

      Based on family history only (in asymptomatic patient)

    • For individuals with a family history of a known pathogenic mutation previously identified in a relative – perform targeted mutation testing
  • Epithelial
    • Cancer antigen 125 (CA 125)
      • Assess patient response to chemotherapy, detect early relapse, and predict prognosis
        • Absolute serum value of CA 125 before third cycle of chemotherapy – most important factor for predicting progression at 12 months
      • Suggested monitoring – every 2-4 months for the first 2 years
        • Persistent postoperative elevation suggests poor prognosis
    • Human epididymis protein 4 (HE4)
      • Relatively new marker in ovarian cancer monitoring
      • Useful because not all patients with ovarian cancer have elevated CA 125 levels
      • May be complementary when used with CA 125 for monitoring
      • ≥25% change is considered significant
    • Inhibin – most useful in monitoring of mucinous subtype tumors
    • Other emerging markers, such as osteopontin, show promise but cannot be recommended
  • Stromal tumors (including granulosa, granulosa-theca, and Sertoli-Leydig tumors)
    • Inhibin levels – increased levels parallel tumor recurrence
  • Germ cell
    • Alpha fetoprotein (AFP), beta-hCG (β-hCG), lactate dehydrogenase (LDH)
      • Expect decrease after surgery
      • Increasing levels may signal recurrence


  • Incidence
    • Ovarian cancer – ~22,000 new cases and >14,000 deaths annually (National Comprehensive Cancer Network [NCCN], 2017)
      • Epithelial subtype – ~90% of malignant tumors (NCCN, 2017)
    • Incidence increases with age
      • 50-54 years – 20.4/100,000
      • 65-69 years – 38/100,000
      • 75-80 years – 48/100,000
  • Age – median is 63 years
    • 90% of women with ovarian cancer are >40 years
  • Sex

 Familial Genetics

  • BRCA1 and BRCA2 testing is recommended for all patients with history of ovarian cancer (NCCN, 2017)
  • TP53 gene mutations (Li-Fraumeni syndrome)
    • Present in ~50-80% of ovarian carcinomas
    • Correlate with high grade and advanced state
    • High-grade serous carcinomas are the most common tumors in this group

Hereditary gene mutations

Risk Factors

  • Increased risk associated with
    • Family history of breast or ovarian cancer (hereditary breast or ovarian cancer)
      • Associated with BRCA1, BRCA2, and Lynch Syndrome II
        • Higher probability of BRCA1 and BRCA2 gene mutations in Ashkenazi Jews
        • 10-15% of ovarian cancers are caused by BRCA1 or BRCA2 mutations
    • Nulliparity
    • Older age at first birth (≥35 years)
    • Early menarche
    • Hormone therapy
    • Pelvic inflammatory disease (PID), in vitro stimulation may increase risk
  • Decreased risk (30-60%) associated with
    • Oral contraceptive use
    • Pregnancy and first birth at young age (≤25 years)
    • Multiparity
    • Lactation (>18 months)
    • History of tubal ligation/hysterectomy
    • Early menopause/late menarche


  • Malignant transformation of Müllerian epithelium on ovarian surface or Müllerian inclusion cysts in ovarian cortex
    • Some high-grade serous carcinomas likely represent spread from a primary tumor arising in distal fallopian tube
  • Often spreads early to contiguous peritoneal mesothelium
    • Spread follows flow of peritoneal fluid
  • Types
    • Epithelial
    • Stromal
    • Germ cell
    • Metastases
    • Miscellaneous

Clinical Presentation


  • In patients with known BRCA1 or BRCA2 gene mutation who have completed childbearing, bilateral salpingo-oophorectomy dramatically reduces risk for tubo-ovarian cancer
    • Small risk will still exist for primary peritoneal serous carcinoma
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Cancer Antigen 125 0080462
Method: Quantitative Electrochemiluminescent Immunoassay


Not useful in cancer screening

Individuals with confirmed ovarian carcinoma may have pretreatment CA 125 values in the same range as healthy individuals

May be elevated in patients with nonmalignant disease

Test values for CA 125 are not interchangeable between different laboratories or test platforms – sequential monitoring should be performed at the same laboratory

Human Epididymis Protein 4 (HE4) 2003020
Method: Quantitative Enzyme Immunoassay


Not useful in cancer screening

Not recommended for monitoring patients with known mucinous or germ cell subtype

Risk of Ovarian Malignancy Algorithm 2012618
Method: Quantitative Enzyme Immunoassay, Electrochemiluminescent Immunoassay


Should not be used without an independent clinical/radiological evaluation and is not intended to be a screening test or to determine whether a patient should proceed to surgery

Total Inhibin, Serum 2014109
Method: Quantitative Enzyme-Linked Immunosorbent Assay

Inhibin B 0070413
Method: Quantitative Enzyme-Linked Immunosorbent Assay

Estradiol, Adult Premenopausal Female, Serum or Plasma 0070045
Method: Quantitative Chemiluminescent Immunoassay

Alpha Fetoprotein, Serum (Tumor Marker) 0080428
Method: Quantitative Chemiluminescent Immunoassay

Neuron Specific Enolase 0098198
Method: Quantitative Enzyme-Linked Immunosorbent Assay

Lactate Dehydrogenase, Serum or Plasma 0020006
Method: Quantitative Enzymatic

Beta-hCG, Quantitative (Tumor Marker) 0070029
Method: Quantitative Electrochemiluminescent Immunoassay


Cannot be interpreted as absolute evidence of presence or absence of malignant disease

Result not interpretable as a tumor marker in pregnant females

Results obtained with different test methods or kits cannot be used interchangeably

Breast and Ovarian Hereditary Cancer Panel, Sequencing and Deletion/Duplication, 20 Genes 2012026
Method: Massively Parallel Sequencing/Exonic Oligonucleotide-based CGH Microarray


Deep intronic and regulatory variants, breakpoints for large deletions/duplications, sequence changes in EPCAM (exons 11-15 of CHEK2 will not be evaluated, with the exception of the c.1100delC variant), and deletions/duplications (exon 1 in CDH1MSH2, and RAD51D; exons 4, 6, 7 in STK11; exon 8 in PTEN; exon 12 in ATM) will not be determined or evaluated

Small deletions or insertions may not be detected

Diagnostic errors can occur due to rare sequence variations

Breast and Ovarian Hereditary Cancer Syndrome (BRCA1 and BRCA2) Sequencing and Deletion/Duplication 2011949
Method: Polymerase Chain Reaction/Sequencing/Multiplex Ligation-dependent Probe Amplification


Deep intronic and regulatory variants will not be detected

Breakpoints for large deletions/duplications will not be determined

Small deletions or insertions may not be detected

Diagnostic errors can occur due to rare sequence variations

Genes causing HBOC syndrome, other than BRCA1 and BRCA2, are not tested

Breast and Ovarian Hereditary Cancer Syndrome (BRCA1 and BRCA2) Sequencing 2011954
Method: Polymerase Chain Reaction/ Sequencing


Deep intronic and regulatory variants will not be detected

Breakpoints for large deletions/duplications will not be determined

Small deletions or insertions may not be detected

Diagnostic errors can occur due to rare sequence variations

p53 with Interpretation by Immunohistochemistry 0049250
Method: Immunohistochemistry

Wilms Tumor (WT-1), N-terminus by Immunohistochemistry 2004184
Method: Immunohistochemistry

p16 by Immunohistochemistry 2004064
Method: Immunohistochemistry

Estrogen/Progesterone Receptor with Interpretation by Immunohistochemistry 0049210
Method: Immunohistochemistry

Cytokeratin 7 (CK 7) by Immunohistochemistry 2003854
Method: Immunohistochemistry

Cytokeratin 20 (CK 20) by Immunohistochemistry 2003848
Method: Immunohistochemistry

CDX2 by Immunohistochemistry 2003821
Method: Immunohistochemistry

Beta-Catenin-1 by Immunohistochemistry 2003454
Method: Immunohistochemistry

Vimentin by Immunohistochemistry 2004181
Method: Immunohistochemistry

Calretinin by Immunohistochemistry 2003490
Method: Immunohistochemistry

Inhibin by Immunohistochemistry 2003969
Method: Immunohistochemistry

Carcinoembryonic Antigen, Monoclonal (CEA M) by Immunohistochemistry 2003824
Method: Immunohistochemistry

Carcinoembryonic Antigen, Polyclonal (CEA P) by Immunohistochemistry 2003827
Method: Immunohistochemistry

Sal-like 4 (SALL4) by Immunohistochemistry 2005432
Method: Immunohistochemistry

Smad4 by Immunohistochemistry 2006403
Method: Immunohistochemistry

PAX8 by Immunohistochemistry 2010787
Method: Immunohistochemistry

PD-L1 by Immunohistochemistry 2011158
Method: Immunohistochemistry


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Breast Cancer Risk Assessment Tool. National Cancer Institute. Bethesda, MD [Accessed: Nov 2017]

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General References

Buys SS, Partridge E, Black A, Johnson CC, Lamerato L, Isaacs C, Reding DJ, Greenlee RT, Yokochi LA, Kessel B, Crawford D, Church TR, Andriole GL, Weissfeld JL, Fouad MN, Chia D, O'Brien B, Ragard LR, Clapp JD, Rathmell JM, Riley TL, Hartge P, Pinsky PF, Zhu CS, Izmirlian G, Kramer BS, Miller AB, Xu J, Prorok PC, Gohagan JK, Berg CD, PLCO Project Team. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA. 2011; 305(22): 2295-303. PubMed

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References from the ARUP Institute for Clinical and Experimental Pathology®

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Medical Reviewers

Bayrak-Toydemir, Pinar, MD, PhD, Medical Director, Molecular Genetics and Genomics at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Best, Hunter, PhD, Medical Director, Molecular Genetics and Genomics; Co-Scientific Director, NGS and Biocomputing; Director, High Complexity Platforms-NGS, at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

Genzen, Jonathan R., MD, PhD, Laboratory Section Chief, Clinical Chemistry, and Medical Director, Automated Core Laboratory, at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Jarboe, Elke, MD, Staff Pathologist, Surgical Pathology and Cytopathology at ARUP Laboratories; Assistant Professor of Anatomic Pathology, Adjunct Assistant Professor, Obstetrics/Gynecology, University of Utah

McMillin, Gwendolyn A., PhD, Medical Director, Toxicology, and Medical Director, Pharmacogenetics, at ARUP Laboratories; Professor of Clinical Pathology, University of Utah

Miller, Christine E., MS, LCGC, Genetic Counselor, Molecular Genetics at ARUP Laboratories; Faculty, Graduate Program in Genetic Counseling, University of Utah

Salama, Mohamed E., MD, Laboratory Section Chief, Hematopathology, at ARUP Laboratories; Professor of Clinical Pathology, Chief of Hematopathology, and Director of the Hematopathology Fellowship Program, University of Utah

Samowitz, Wade S., MD, Medical Director, Solid Tumor Molecular Diagnostics and Histology, and Staff Pathologist, Anatomic Pathology at ARUP Laboratories; Professor of Anatomic Pathology, University of Utah

Straseski, Joely A., PhD, MS, MT(ASCP), DABCC, Medical Director, Endocrinology, and Co-Medical Director, Automated Core Laboratory, at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Last Update: December 2017