Diagnostic Value of Serum Prolactin in Ovarian Cancer

IBBJ Original Article Autumn 2018, Vol 4, No 4 Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 Diagnostic Value of Serum Prolactin in Ovarian Cancer Rimaz Alhag Gurashi1*, Moawia Elsadig Hummeida2, Faisal Galal Abdelaziz3 1. Clinical Chemistry Department, Faculty of Medical Laboratory Sciences, Al- Neelain University, Sudan. 2. Department of Obstetrics and Gynecology, Faculty of Medicine, Al Neelain University, Sudan. 3. Military Hospital, Omdurman, Sudan. Submitted 29 Dec 2018; Accepted 29 Jan 2019; Published 4 May 2019 Ovarian cancer ranks fifth in cancer deaths among women, and causes more deaths than any other cancer of the female reproductive system. Since diagnosis at an early stage is associated with improved survival rate, an effective screening strategy that detects early stage ovarian cancer could have a significant impact on mortality from this disease. Cancer antigen 125 (CA125) is an established biomarker for ovarian cancer detection. As CA125 effectiveness in the identification of the malignancy is threatened by its low diagnostic specificity, measurement of prolactin (PRL) in serum have been proposed for improving the sensitivity and specificity of disease identification. The aim of the present study was to assess the level of serum PRL among healthy and ovarian cancer women at Khartoum state, Sudan. 90 Sudanese ladies with age range (16-80) years old who attended the gynecological oncology clinic in Omdurman Military hospital were enrolled in this study. Blood samples were collected, and quantitative determination of serum prolactin (PRL) levels was performed by immunoassay. Epithelial ovarian cancer was the most common ovarian cancer type followed by germ cell tumors. PRL serum levels were within the reference range in both control and study groups. No significant difference in PRL levels was observed when considering the parity or the stage of cancer (P > 0.05). Investigating different isoforms of PRL may help to better understand the mechanism of action of this hormone in ovarian cancer induction. Keywords: Ovarian cancer, serum biomarker, prolactin O varian cancer has been called the "silent strategy to detect early-stage disease. Ovarian killer" because symptoms often become cancer presents with very few, if any, specific apparent only when the cancer has spread and is symptoms. Twenty percent of patients are diagnosed harder to treat. It’s the fifth leading cause of cancer- at stage I and II when the disease is still confined to related death in women in the United States and is the ovary. In patients diagnosed with advanced the leading cause of gynecologic cancer deaths. disease, the 5-year survival rate ranges from 20% to Despite being one-tenth as common as breast 25%, depending on the stage and grade of tumor cancer, it is three times more lethal, and carries a differentiation (2). Of these patients, 80% to 90% 1:70 lifetime risk. It was estimated that in 2018, will initially respond to chemotherapy, but less than approximately 22,240 women would be diagnosed 10-15% will remain in permanent remission (2). with ovarian cancer, and 14,070 would die from the Approximately 90% of ovarian cancers are disease in USA (1). The high mortality rate of carcinomas, and based ovarian cancer is due to the lack of a screening immunohistochemistry, and on histopathology, molecular *Correspondence: Clinical Chemistry Department, Faculty of Medical Laboratory Sciences, Al- Neelain University, Sudan. E-mail: [email protected] genetic Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 Gurashi RA et al. analysis, at least five main types are currently bleeding in rare cases,. These symptoms usually do distinguished: high-grade serous carcinoma (70%); not become apparent until the later stages of the endometrioid clear-cell disease when the cancer mass is large enough to carcinoma (10%); mucinous carcinoma (3%); and interfere with pelvic organs such as the bladder or low-grade serous carcinoma (<5%) (3, 4). These rectum, or after the cancer has metastasized to the tumor types which account for 98% of ovarian abdominal cavity. Obtaining a personal obstetric and carcinomas can be reproducibly diagnosed by light gynecologic history and a family history of microscopy, and are inherently different diseases (3, gynecologic disease may be important in diagnosis 4). Much less common are malignant germ cell (8). A number of case–control studies investigating tumors and potentially malignant sex cord-stromal symptoms in women with ovarian cancer and tumors. Several studies have suggested that the comparing them to symptoms in women without ovarian cancer risk is associated with parity and oral ovarian cancer demonstrated that patients with contraceptive. Parity women have a lower risk of ovarian cancer are symptomatic for a variable period ovarian cancer development in comparison with before diagnosis and challenge the perception of nulliparity women. The risk goes down with each ovarian cancer as the "silent killer" (Network SIG, full-term pregnancy, and women who have their first 2013) (9). carcinoma (10%); full-term pregnancy after age 35 have a higher risk of ovarian cancer (5). The polypeptide hormone prolactin (PRL) has numerous functions in addition to its important role Also, it appears that breastfeeding protects in lactation, including a role in reproduction by against ovarian cancer. Correspondingly, it was maintaining normal ovarian function, modulating shown that the risk of ovarian cancer development the effects of gonadotropins, and modulating is reduced by 37% in women who have breastfed for immune function. Though PRL is primarily a year or more (6) Women who have used oral or an produced in the pituitary gland it is also produced in injectable contraceptive have a lower risk of ovarian other tissues, including the ovaries. The PRL cancer, and the risk is lower the longer the receptor is expressed in normal ovarian and contraceptives are used (7). Tubal ligation may fallopian tube tissues, the primary sites of origin for reduce the chance of developing ovarian cancer by ovarian tumors. There are several ways that PRL up to two-thirds, and hysterectomy also seems to could influence ovarian cancer development. reduce the risk of getting ovarian cancer by about Animal and in vitro studies have shown that PRL one-third (5). promotes the growth of ovarian surface epithelial About 5 to 10% of ovarian cancers are a part cells, inhibits apoptosis, and increases ovarian of family cancer syndromes resulting from inherited cancer cells survival. Furthermore, PRL levels mutations. Symptoms in early-stage disease are increase in response to psychosocial and physical either absent or vague, and may resemble stresses, which was associated with greater tumor menopausal symptoms and intestinal illnesses. burden and tumor invasiveness in a mouse model of Individuals in later stages may report indigestion, ovarian cancer (10, 11). gas, nausea, vomiting, loss of appetite, a feeling of In a cross-sectional study, nulliparity and fullness after small meals, pelvic or abdominal pain, endometriosis which are known risk factors for swelling, increased frequency or urgency of ovarian cancer were associated with higher PRL urination, unexplained change in bowel habits, levels, which suggests that PRL may be part of the unexplained weight gain or loss, pain during underlying mechanism through which these factors intercourse, ongoing fatigue, lower back pain, influence the disease (12). PRL receptor expression shortness of breath, and, postmenopausal vaginal and circulating PRL levels have been shown to be Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4 184 Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 Serum Prolactin in Ovarian Cancer higher among women with ovarian cancer versus Five to 10 ml blood samples were collected benign-condition or healthy controls (10, 13). from each participant. Sera were separated, and then However, a major limitation of these retrospective stored at -20 studies is that PRL levels may have been affected by concentration of PRL was evaluated quantitatively the presence of the tumor and/or the stress by AIA-600 II automated immunoassay system associated with cancer diagnosis or treatment. In this (Tosoh Bioscience). o C for subsequent testing. The study, we aimed to evaluate the diagnostic The ST AIA-PACK PRL was a two – site performance of serum biomarker from patients immune enzymometric assay which was performed presenting with ovarian cancer. We especially entirely in the ST AIA- PACK PRL test cups. PRL desired to investigate PRL levels for possible present in the tested sample was pound with the assistance in screening, diagnosis, and follow-up of monoclonal antibodies immobilized on magnetic ovarian cancer patients. solid phase and enzyme- labeled monoclonal antibodies in test cups. The magnetic beads were Materials and methods washed to remove unbound enzyme. Labeled Patients monoclonal antibodies were then incubated with a A total of 90 Sudanese ladies age range (16-80) fluorogenic substrate, 4-methylelumbelliferyl years attending gynecological oncology clinics in phosphate (4MUP). The amount of enzyme- labeled Omdurman Military hospitals, Khartoum state from monoclonal antibodies that were bound to the beads May 2015 to December 2016 were included in the was directly proportional to the cancer antigen 125 study. This was an analytical comparative cross- (OVCA125), PRL, and 17-beta-estradiol (E2) sectional study. The sample population was divided concentration in the test sample. into two main groups; study group including 53 The calibrator of the PRL was prepared (58.9%) ovarian cancer patients with an age of 16 to gravimetrically and compared to internal reference 80 years, and control group including 37 (41.1%) standard and stability of the curve up to 90 days, age matched apparently healthy individuals. Patients which diagnosed with other cancer types rather than performance and was dependent on proper reagent ovarian cancer were excluded from the study. handling and TOSHO AIA system maintenance History and background data were collected from according to manufacturer’s instructions. participants using verbal interviews and pre- Statistical analysis was monitored by quality control presentation Raw data were entered into a spread sheet of included an enlarged ovary on a pelvic exam, and SPSS statistical package program. Descriptive ascites. Informed and written consents were analysis was performed to all study variables. designed questionnaire. Clinical obtained from all participants prior to involvement Data was analyzed using SPSS version 21. The in the study. Ethical release to proceed in the study results were expressed as mean, standard deviation, was obtained from the ethical committee of the median, frequency and percentage. Descriptive Faculty of Medical statistic was performed to obtain the frequencies and Laboratory Sciences at Alneelain University. percentages of the study variables and clinical data. Histological evaluation Independent–sample T-test was used to compare the Histopathological examinations were perform- mean concentration of PRL in ovarian cancer versus ed to assess the tumor type, ovarian cancer type, and healthy individuals. Graphs were done using staging of the disease. The metastatic status of the Microsoft excel and Graph Pad Prism version 6. P cancer was also evaluated. value ≤ 0.05 was considered as significant. All Serum prolactin level evaluation statistics tests were done in 95% confidence interval. 185 Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4 Gurashi RA et al. Results confirmed by ultrasonography that also revealed the Clinical evaluation percentage of left, right, and bilateral ovarian mass as 19%, 34%, and 47%, respectively. Ninety Sudanese ladies were enrolled in this Histopathological results Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 study. They were distributed into two groups: study group including 53 (58.8%) newly diagnosed About 97% of the ovarian cancers were ovarian cancer patients with age ranging from 16 to epithelial cell origin and only 3 % were germ cell 80 years, and control group including 37 (31.2%) origin. Figure 1 shows the stage distribution among age matched apparently healthy individuals. Study ovarian cancer patients with stage 4 being the most group included 32% in the reproductive age (< 40 prevalent. years). Serum prolactin analysis The frequency and percentage of signs and Table 2 and figure 2 represent the serum PRL symptoms are summarized in Table 1. Accordingly, levels in case and control groups. Accordingly, no abdominal pain was the most prevalent symptom statistical difference was observed between the 2 with 85% prevalence, followed by abdominal groups. Similarly, no statistical difference was bloating (79%), increased abdominal size (70%), observed among different parity groups or different frequent urination (68%), loss of appetite (62%), and cancer stages (Tables 3 and 4). irregular bowel movement (57%). About 51% of the The sensitivity of serum PRL assessment was study group were para and multi-parous compared 65%), the specificity was 64%) while positive and with 49% nulliparous. 45% of the study group negative predictive values were 62% and 61%, patients were suffering from ascites when clinical respectively. examination was done. The presence of ascites was Table 1. Frequency and percentage of common symptoms among ovarian cancer patients Variables Frequency Percentage (%) Abdominal bloating 42 79% Loss of appetite 33 62% Frequent urination 36 68% Irregular bowel movement 30 57% Increased abdominal size 37 70% Abdominal pain 45 85% History of ovarian cancer 0 0% Use of contraceptive pills 7 13% Use of estrogen 2 4% Caesarean section 4 8% Ascites 24 45% Table 2. Prolactin serum levels among study and control groups Parameter Case (Mean±SD) Median Control (Mean±SD) Median P-value Prolactin (ng/ml) 20.40±2.28 12.50 20.21±3.65 10.35 0.966 Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4 186 Serum Prolactin in Ovarian Cancer 57.00% 60.00% Percentage (%) 40.00% 30.00% 19.00% 20.00% 13.00% 11.00% 10.00% 0.00% Stage 1 Stage 2 Stage 3 Stage 4 Figure 1. Staging of ovarian cancer among study group. Table 3. Prolactin serum levels among parity subgroups Parameter Para/ multi parity (Mean±SD) Nulliparous (Mean±SD) P-value Prolactin (ng/ml) 22.45±3.58 18.26±2.79 0.141 Table 4. Prolactin serum levels among different ovarian cancer staging groups Parameter Prolactin (ng/ml) Stage 1 (Mean±SD) Stage 2 (Mean±SD) Stage 3 (Mean±SD) Stage 4 (Mean±SD) P-value 23.23±5.51 28.17±19.73 14.72±10.60 19.91±17.88 0.416 P -v a lu e 0 .9 6 6 100 P r o la c tin ( n g /m l) Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 50.00% 80 60 40 20 0 -2 0 C ase C o n tro l G rou p s Figure 2. Variation of prolactin levels among ovarian cancer patients and healthy subjects. 187 Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4 Gurashi RA et al. Gynecologists, 2007). Ovarian epithelial cell was Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 Discussion Amongst all gynecological cancers, ovarian the most common form which was present in cancer is the most lethal malignancy worldwide. different age ranges. Germ cell neoplasm was less Aggressive local invasion and the lack of sensitive frequent, and was observed among younger age early screening methods, are the most important patients., Relatively, Kancherla et al. reported that barriers to early diagnosis. Furthermore, its high surface epithelial tumors were most common (80%) mortality rate has made it one of the most followed by germ cell tumors (16%) (18). investigated fields in gynecological oncology. Grosdemouge et al. found a significant During 2016 ovarian cancer ranked fifth in cancer difference in PRL level between ovarian cancer and deaths among women in USA (14). A woman's risk normal individuals (22). Levina et al. found that of getting ovarian cancer during her lifetime is about there was elevated levels of serum PRL in ovarian 1.5%, and there is 1% lifetime chance of dying from cancer (13). Several studies reported that higher ovarian cancer (1). levels of circulating PRL among women with Even though ovarian cancer mainly develops ovarian cancer vs. benign condition or healthy in older women, younger age range was reported by controls suggest that PRL may be associated with Adam et al. (15). Among Sudanese ovarian cancer increased risk of ovarian cancer (10, 13) while patients who agreed to participate to the present Clendenen et al. found a non-significant association study 32% were within reproductive age. between circulating PRL levels and ovarian cancer Around 57% of all ovarian cancers included in (10) which is similar to the results obtained in the this study were diagnosed at an advanced stage, and present study. The reason for this discrepancy is not only 11% were in early stage. The five-year survival clear from the data presented, but it may be due to rate for patients with clinically advanced ovarian the presence of several PRL receptor isoforms that cancer was reported to be only -15-20%, in striking have been identified in the ovaries and the fact that contrast to a five-year survival rate of over 90% for varied expression and dimerization of these patients with stage 1 disease (16, 17). receptors may influence the effects of the PRL In the present study, we found the common ligand on ovarian cancer risk. Studies have shown symptoms among ovarian cancer patients which that there are also several variant forms of PRL. Our were abdominal bloating, pelvic pain, abdominal immunoassay was not able to distinguish between pain, increased abdominal size, and vaginal different isoforms or structural variants of PRL discharge, while vaginal bleeding was observed at a which may have different bio-availabilities and low frequency. These findings are similar to cancer biological actions (10). facts published in 2017 by American cancer society. Further studies are needed to elucidate the Ultrasonography as a non-invasive diagnostic test in mechanisms of action of PRL in ovarian cancer women with pelvic, bilateral, and ascites is helpful induction. in predicting the malignant likelihood of the mass Conflict of interest (18). Ovarian tumors were unilateral in 53% of cases The authors declared no conflict of interest. and bilateral in 47% with right side predominance. This also corroborates with the findings of References Kancherla et al. (19). 1. Torre L A, Trabert B, Desantis C E, et al. Ovarian cancer Histopathological distribution in our study statistics, 2018. CA Cancer J Clin. 2018;68:284-96. group is similar to many published works (20, 21) 2. Schwartz P E. Current diagnosis and treatment modalities for (US Preventive Services Task Force, 2014; ovarian cancer. Cancer Treat Res. 2002;107:99-118. American 3. Kurman R J, Carcangiu M L, Herrington C S, et al., WHO college of Obstetricians and Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4 188 Downloaded from ibbj.org at 2:27 +0330 on Monday November 29th 2021 Serum Prolactin in Ovarian Cancer classification of tumors of female reproductive organs. 4 ed. factors and family history of breast cancer in relation to plasma Lyon: International Agency for Research on Cancer. 2014. prolactin levels in premenopausal and postmenopausal women. 4. Prat J. Ovarian carcinomas: five distinct diseases with different Int J Cancer. 2007;120:1536-41. origins, genetic alterations, and clinicopathological features. 13. Levina V V, Nolen B, Su Y, et al. Biological significance of Virchows Arch. 2012;460:237-49. prolactin in gynecologic cancers. Cancer Res. 2009;69:5226-33. 5. Mcguire V, Hartge P, Liao L M, et al. Parity and Oral 14. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence Contraceptive Use in Relation to Ovarian Cancer Risk in Older and mortality worldwide: sources, methods and major patterns in Women. Cancer Epidemiol Biomarkers Prev. 2016;25:1059-63. GLOBOCAN 2012. Int J Cancer. 2015;136:E359-86. 6. Chowdhury R, Sinha B, Sankar M J, et al. Breastfeeding and 15. Adam W, Gurashi R A, Humida M A, et al. Ovarian Cancer maternal health outcomes: a systematic review and meta-analysis. in Sudan. Journal of Medical and Biological Science Research. Acta Paediatr. 2015;104:96-113. 2017;3:37-41. 7. Beral V, Doll R, Hermon C, et al. Ovarian cancer and oral 16. Lee J-Y, Kim S, Kim Y T, et al. Changes in ovarian cancer contraceptives: collaborative reanalysis of data from 45 survival during the 20 years before the era of targeted therapy. epidemiological studies including 23,257 women with ovarian BMC Cancer. 2018;18:601. cancer and 87,303 controls. Lancet. 2008;371:303-14. 17. Protani M M, Nagle C M, Webb P M. Obesity and ovarian 8. Azrak S. Hereditary Ovarian Cancer and Germline Mutations: cancer survival: a systematic review and meta-analysis. Cancer Review Article. Journal of Genetics and Genetic Engineering. Prev Res (Phila). 2012;5:901-10. 2017;1:31-42. 18. Feliciano M a R, Uscategui R a R, Maronezi M C, et al. 9. Goff B A, Mandel L S, Drescher C W, et al. Development of Ultrasonography methods for predicting malignancy in canine an ovarian cancer symptom index: possibilities for earlier mammary tumors. PLOS ONE. 2017;12:e0178143. detection. Cancer. 2007;109:221-7. 19. Kancherla J, Kalahasti R, Sekhar C. Histomorphological 10. Clendenen T V, Arslan A A, Lokshin A E, et al. Circulating Study of Ovarian Tumors: An Institutional Experience of 2 Years. prolactin levels and risk of epithelial ovarian cancer. Cancer Int J Sci Study. 2017;5:1400-03. Causes Control. 2013;24:741-8. 20. American college of Obstetricians and Gynecologists. (2007). 11. Egli M, Leeners B, Kruger T H. Prolactin secretion patterns: Practice bulletin no. 83: management of Adnexal masses. basic mechanisms and clinical implications for reproduction. 21. Grosdemouge I, Bachelot A, Lucas A, et al. Effects of Reproduction. 2010;140:643-54. deletion of the prolactin receptor on ovarian gene expression. 12. Eliassen A H, Tworoger S S, Hankinson S E. Reproductive Reprod Biol Endocrinol. 2003;1:12. 189 Int. Biol. Biomed. J. Autumn 2018; Vol 4, No 4