{'fraction_non_alphanumeric': 0.04479979694143029, 'fraction_numerical': 0.04270575544133511, 'mean_word_length': 5.054552439492893, 'pattern_counts': {'":': 0, '<': 9, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Significance of serum CA125 level in surgically resected cervical adenocarcinoma with adverse features

Objective Unlike cervical squamous cell carcinoma, there are no consensus criteria for serum tumor markers in cervical adenocarcinoma. This study aimed to identify the prognostic value of preoperative carbohydrate antigen 125 (CA125) levels in cervical adenocarcinoma patients with adverse pathologic features. Methods A total of 105 patients who underwent radical hysterectomy followed by adjuvant radiotherapy (RT) or concurrent chemoradiation therapy were included. Locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were evaluated using the Cox proportional hazard regression model. Results Using a cutoff value of 50 U/mL, 83 and 22 patients had low- and high-CA125, respectively. Patients with high-CA125 had a larger tumor size, more frequent parametrial extension, and more frequent lymph node metastasis than those with low-CA125. During a median follow-up of 59.3 (interquartile range, 32.7–97.8) months, patients with high-CA125 showed inferior 5-year LRFS, DMFS, and OS rates compared to those with low-CA125 (38.5% vs. 70.0%; 37.0% vs. 69.4%; 43.6% vs. 78.1%, respectively, all p<0.05). In multivariable analysis, the high-CA125 remained significant prognostic factor for LRFS, DMFS, and OS (all p<0.05). Furthermore, 12 patients with high-CA125 at recurrence exhibited lower 5-year OS rates than 21 patients with low-CA125 at recurrence (0.0% vs. 51.3%, p=0.003). Conclusion In this retrospective analysis, the serum CA125 level at diagnosis and recurrence was related to the extent of disease and prognosis of cervical adenocarcinoma with adverse pathologic features. A CA125 level of ≥50 U/mL may be a prognostic surrogate marker for cervical adenocarcinoma in patients with the presence of adverse factors.


INTRODUCTION
Although the incidence of cervical squamous cell carcinoma (SCC) has decreased, the incidence of cervical adenocarcinoma (ADC) has increased recently, accounting for 20%-25% of all cases of cervical cancer [1,2]. Although there are conflicting results regarding Despite the absence of consensus criteria for squamous cell carcinoma antigen (SCC-Ag), the prognostic value of SCC-Ag has been well known for cervical SCC [7]. A recent systematic review of 61 studies illustrated the significance of both pre-treatment SCC-Ag (range of cutoff level, 1.1-40.0 ng/mL) and post-treatment SCC-Ag (range of cutoff level, 1.5-2.0 ng/mL) for predictive survival outcomes [7]. In addition, a cohort study reported that the SCC-Ag level helped clinical decision making regarding the administration of post-operative radiotherapy (RT) in patients with SCC [8].
Regarding cervical ADC, limited reports are available for serum tumor markers, including carbohydrate antigen-125 (CA125), CA , and carcinoembryonic antigen [9][10][11][12]. Among aforementioned markers, CA125 has been established as an important marker in the diagnosis and monitoring of other gynecologic tumors, such as ovarian and endometrial cancer [12][13][14][15]. Although several reports have noted its significance in cervical cancer, the reports included heterogeneous groups of patients, including those with both ADC and adenosquamous cell carcinoma, and patients treated with either definitive RT or adjuvant RT.
Herein, we have investigated the role of CA125 in patients with cervical ADC treated with radical hysterectomy followed by adjuvant RT.

Patient population
After receiving Institutional Review Board approval of Samsung Medical Center (SMC 2020-10-052), we retrospectively reviewed data on patients with ADC treated with surgery and adjuvant RT between January 2001 and April 2018. Patients were excluded if an adenosquamous carcinoma component was discovered in the pathological specimen (n=31), if simple extrafascial hysterectomy or trachelectomy was performed (n=14), if the CA125 level at diagnosis or surgical pathology data were not available (n=11), if synchronous endometrial and cervical cancer was diagnosed (n=3), or if follow-up details were missing (n=2). Finally, 105 patients were included in the analysis (Fig. S1). The requirement for informed consent was waived due to the retrospective nature of the study.

Treatment
All patients were evaluated using diagnostic image modalities such as magnetic resonance imaging (n=105), or computed tomography (n=93), or 18F-Fludeoxyglucose positron emission tomography (n=57) before curative surgery. All patients underwent radical hysterectomy with pelvic lymph node (LN) dissection, and 36 (34.3%) patients underwent paraaortic LN dissection. The median number of dissected nodes was 19 (interquartile range [IQR]=13-26). Patients with two or more risk factors (intermediate-risk group), such as among tumor size ≥4 cm, depth of invasion ≥1/2 of the stroma, and positive lymphovascular invasion (LVI), received adjuvant RT. In addition, patients with positive parametrial extension, positive resection margins, or positive LNs were treated with concurrent chemoradiation therapy (CCRT; high-risk group). In total, 43 and 62 patients received adjuvant RT and CCRT, respectively. Except five patients who received intensity-modulated RT, standard four-field three-dimensional conformal RT with a median total dose of 50.4 Gy

Statistical analysis
The R package "MaxStat," which iteratively tests all possible cutoff points to find the one achieving the maximum rank statistic, was used to dichotomize the pre-operative CA125 level ( Fig. S2) [16]. Patients were then categorized into the high-CA125 (CA 125 levels ≥50 U/ mL, 22 patients) and low-CA125 (CA 125 levels <50 U/mL, 83 patients) groups. The baseline characteristics of patients in the high-and low-CA125 groups were compared using the Pearson chi-square test or Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) were calculated from the date of initial diagnosis to the date of each event or death from any cause, whichever occurred first. Overall survival (OS) was calculated from the date of initial diagnosis to death from any cause or the last follow-up. The Kaplan-Meier method was performed to estimate the LRFS, DMFS, and OS rates using the log-rank test to assess prognostic significance. A Cox regression model was used for multivariable analysis of factors affecting LRFS, DMFS, and OS; only factors with statistical significance in univariable analysis were included. In all analyses, a two-sided p-value of <0.05 was considered statistically significant. All statistical analyses were performed using R software (version 4.0.2; R Foundation for Statistical Computing, Vienna, Austria).

Baseline characteristics
The patient and tumor characteristics according to a preoperative CA125 level of 50 U/mL are summarized in Table 1. Using a median pre-operative CA125 level of 17.2 (IQR, 9.1-38.6) U/mL, the median CA125 levels in the high-CA125 and low-CA125 group were 91.0 (IQR, 77.7-174.3) U/mL and 12.2 (IQR, 7.8-21.8) U/mL, respectively. Patients with high-CA125 more frequently had FIGO stage III disease than those with low-CA125 at diagnosis (p<0.001). Pathological results revealed that patients in the high-CA125 group presented with larger tumors than those in the low-CA125 group (median, 5.0 cm vs. 4.0 cm, p=0.016); 45.5% and 12.0% patients in the high-CA125 and low-CA125 groups, respectively, had tumors measuring ≥6 cm (p=0.004). Regarding high-risk features, patients in the high-CA125 group more frequent had pathologically positive LNs than those in the low-CA125 group (median, 3 vs. 0, p<0.001). The rates of ≥1/2 stromal invasion, LVI, and parametrial extension were comparable between the high-CA125 and low-CA125 groups.

Patterns of failure
A total of 41 (39.0%) patients experienced disease progression after initial treatment; there were 24 (22.9%) and 35 (33.3%) locoregional failure and distant metastasis events, respectively ( Table 2). Overall, patients with high-CA125 more frequently experienced disease progression compared to those with low-CA125 (59.1% vs. 33.7%, p=0.045). The rate of locoregional recurrence differed significantly between the groups, favoring the low-CA125 group (low-CA125 vs. high-CA125 groups: 18.1% vs. 40.9%, p=0.047). In addition, the rate of distant metastasis was higher in the high-CA125 group than in the low-CA125 group, but the difference was not statistically significant (50.0% vs. 28.9%, p=0.107). The most frequent distant metastasis site was the lungs (n=17, 16.2%) in both groups.

Subgroup analysis according to risk groups
Since there were only three patients with high-CA125 in the intermediate-risk group, further statistical analysis was not performed. Subgroup analysis of patients in the high-risk group revealed that patients with high-CA125 showed inferior outcomes compared to those with low-CA125; the 5-year LRFS, DMFS, and OS rates for patients with high-CA125 and low-CA125 were 36.8% and 46.9% (p=0.012, Fig. S4

CA125 levels at recurrence
Among the 41 patients with progressive disease, CA125 levels at recurrence were evaluated in 33. The median CA125 level at recurrence was 19.4 (IQR=6.5-62.8) U/mL; patients with high preoperative CA125 levels had higher CA125 levels at recurrence than those with low preoperative CA125 levels (Table S1). Based on the cutoff value of 50 U/mL, 21 and 12 patients presented with CA125 levels <50 U/mL and CA125 levels ≥50 U/mL, respectively, at recurrence. There was no difference in the pattern of failure between these patients (Table S1). However, CA125 levels ≥50 U/mL at recurrence was associated with lower 5-year OS rates than CA125 levels <50 U/mL at recurrence (0.0% vs. 51.3%, p=0.003, Fig. 2

DISCUSSION
By analyzing the prognostic value of preoperative CA125 levels in surgically resected cervix ADC with either intermediate or high-risk features, we demonstrated a positive correlation between preoperative high-CA125 levels (≥50 U/mL) and the extent of disease, including tumor size, positive LNs, and pathological stage. In addition, high-CA125 was significantly associated with locoregional progression, distant metastasis, and inferior survival outcomes in comparison to low-CA125. We also found that CA125 levels ≥50 U/mL at recurrence were related to inferior survival outcomes in patients with CA125 levels <50 U/mL at recurrence.
Several studies have investigated various cutoff values for CA125 in cervical ADC. Tsai et al. discovered that CA125 level ≥26 U/mL was deemed as a predictive factor for LVI and deep stromal invasion in patients with early-stage cervical ADC treated with surgery [9]. Bender et al. [10] reported that CA125 level ≥30 U/mL was a significant unfavorable factor for survival in patients treated with definitive RT or surgery. In our study, we observed the effect of elevated CA125 levels in patients after radical hysterectomy and adjuvant RT on disease status and survival outcomes. We found that a higher CA125 levels (>50 U/mL) were significantly associated with an unfavorable pathological status and poor survival outcomes.
Since patients with ADC more frequently experience distant metastasis than those with SCC, early detection of relapse based on serum tumor markers is essential for improving treatment outcomes by eradicating microscopic metastatic disease. Although a standard cutoff level of 1.5 ng/mL for SCC-Ag can detect 70%-86% of relapses during surveillance, there is no useful criterion for CA125 in cervical ADC [17][18][19]. Although there was no difference in patterns of failure according to the CA125 level at recurrence, patients with high CA125 levels at recurrence had poorer OS than those with low CA125 levels at recurrence in our study. Elevated CA125 levels at recurrence could be a surrogate for tumor aggressiveness. There was no difference in patterns of recurrence between patients with high or low CA125 levels at recurrence, but rapid disease progression after initial recurrence may account for the low survival rate in patients with high CA125 levels at recurrence. Although a randomized trial in patients with ovarian cancer failed to prove the survival benefit of early intervention based on elevated CA125 levels during follow-up, detection of CA125 levels may help physicians to be preemptively informed of potential disease recurrence [20,21].
According to whole-exome sequencing and genotyping analysis, cervical ADC is characterized by distinct genomic alterations from those in cervical SCC [22,23]. Furthermore, revised classifications for cervical ADC endorsed by the International Endocervical Adenocarcinoma Criteria and the World Health Organization also highlight the heterogeneity of cervical ADC [24,25]. Recent studies based on the new categorization reported distinct clinical outcomes in patients with ADC [26][27][28]. However, there are no reports on the clinical implications of serum CA125 levels in various types of cervical ADC. Although we observed the detrimental effect of high-CA125 in ADC, appropriate serum tumor markers and cutoff values for detecting early recurrence in each ADC subtype need to be further analyzed.
Our study has several limitations. First, the lack of serial monitoring of CA125 levels after initial treatment provides limited information regarding the post-operative CA125 nadir and early detection of failure. Determining the dynamics of CA125 levels between pre-operative and post-operative assessment might allow more refined pre-operative estimation of the prognosis than conventional pathological parameters. Secondly, the information on profiles of CA125 in patients without adverse features was lacking in the current study. Since we only included patients with intermediate to high-risk pathologic features, current cutoff value of 50 U/mL possibly applied to specific subgroup of patients treated with radical surgery. However, the strength of this study is a large number of patients with ADC were treated homogeneously, including treatment with radical hysterectomy followed by adjuvant RT/ CCRT. A further study including both intermediate/high-risk and low-risk cervical cancer could help physicians to identify the prognostic impact of patients with cervical ADC. Lastly, due to the lack of pathological review of surgical specimens, we were unable to provide detailed information on the revised subgroups of ADC.
In summary, we demonstrated that preoperative high-CA125 directly relates to aggressive tumor features and poor outcomes in patients with cervical ADC presenting with adverse pathologic factors. In addition, CA125 level ≥50 U/mL at first recurrence was associated with poor survival outcomes in those patients. Preoperative high-CA125 may help stratify highrisk patients who require more intensive systematic treatment. In further investigations, the optimal cutoff value of CA125 in cervical ADC should be studied on a large scale because it is inconsistent and only a few reports have evaluated it thus far. In addition, the cutoff value of CA125 according to the subtype of cervical ADC might be needed to define its association with prognosis.

Table S1
Pre-operative CA125 level and patterns of failure stratified by CA 125 level at first recurrence Click here to view

Fig. S2
Results of maximally selected rank statistics regarding pre-operative CA125 level.

Fig. S3
Survival outcomes of the entire patients.

Fig. S4
Survival outcomes for patients in the high-risk group * according to CA125 elevation: Locoregional recurrence-free survival (A), distant metastasis-free survival (B), and overall survival (C).