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Year : 2014  |  Volume : 51  |  Issue : 3  |  Page : 315--318

Elevated chromogranin A serum levels in ovarian carcinoma patients

M Malaguarnera1, M Uccello1, S Bellanca2, B La Rosa2, M Vacante1, E Cristaldi1, A Biondi3, F Basile3, L Malaguarnera4,  
1 Department of Senescence, Urological and Neurological Sciences, Cannizzaro Hospital, Via Messina 829, University of Catania, I 95126 Catania, Italy
2 Department of Obstetrics and Gynaecology, Policlinico Hospital, Via S. Sofia 78, University of Catania, I-95123 Catania, Italy
3 Department of General Surgery, Section of General Surgery and Oncology, Vittorio Emanuele Hospital, Via Plebiscito 628, University of Catania, I-95123 Catania, Italy
4 Department of Biomedical Sciences, Via Androne 83, University of Catania, I-95124 Catania, Italy

Correspondence Address:
M Malaguarnera
Department of Senescence, Urological and Neurological Sciences, Cannizzaro Hospital, Via Messina 829, University of Catania, I 95126 Catania


Background: The observation of neuroendocrine activity during clinical course of ovarian cancer, suggested the use of neuroendocrine serum markers to detect this tumor. Aim: To evaluate the usefulness of serum measurements of chromogranin A (CgA) in the various stages of ovarian cancer. Materials and Methods: We measured serum concentrations of CgA and cancer antigen 125 (CA125) in 79 women at different clinical stages of ovarian cancer, enrolled between 2000 and 2007, and in a control group of 50 female volunteers. Results: CgA showed increased levels in patients with ovarian cancer as compared with healthy subjects, as it has been seen for CA125 serum levels. We also observed significant increase in CgA and CA125 serum levels when comparing patients with ovarian cancer in stage I versus stage II (P < 0.001); stage I versus stage III (P < 0.001); stage I versus stage IV (P < 0.001); stage II versus stage III (P < 0.001); stage II versus stage IV (P < 0.001). In patients with ovarian carcinoma in stage IV we observed a correlation between CgA and CA125 with a difference of 0.718 (P < 0.001). Conclusions: CgA serum levels were elevated in ovarian cancer and increased with the stage. Further studies are needed to elucidate the role of CgA as a prognostic indicator during treatment for ovarian cancer.

How to cite this article:
Malaguarnera M, Uccello M, Bellanca S, La Rosa B, Vacante M, Cristaldi E, Biondi A, Basile F, Malaguarnera L. Elevated chromogranin A serum levels in ovarian carcinoma patients.Indian J Cancer 2014;51:315-318

How to cite this URL:
Malaguarnera M, Uccello M, Bellanca S, La Rosa B, Vacante M, Cristaldi E, Biondi A, Basile F, Malaguarnera L. Elevated chromogranin A serum levels in ovarian carcinoma patients. Indian J Cancer [serial online] 2014 [cited 2020 Mar 31 ];51:315-318
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Ovarian cancer is the fifth most common malignancy in women, with the majority of patients presenting with advanced-stage disease. [1] During 2006, there were projected to be over 20,180 new cases of ovarian cancer in the US, resulting in 15,310 deaths as estimated by the American Cancer Society. [2] A number of tumor-associated antigens detectable in the serum of patients with ovarian cancer have been described, the most useful one is cancer antigen 125(CA125), a mucin-like glycoprotein. CA125 serum levels increase in response to changes of the celomic epithelium. This marker is most closely associated with ovarian carcinoma. [3] Because of the difficulty in accurately assessing tumor response in a neoplasm often confined to the peritoneal cavity, interest has developed in defining ways to use CA125 levels to determine response. [4] Current proposals focus on definitions based on a 50% or 75% decrease of CA125 levels during the treatment and they are under review by a committee of the Gynaecologic Cancer Intergroup. [5],[6] CA125, antigen of surface of the ovarian serous epithelial cells, represents the most reliable serum tumor marker. In fact, CA125 levels are higher in more than 90% of the cases in advanced stage, but only the 50% of the cases at an early stage. CA125 also raises in the presence of a few benign pathologies (endometriosis) or of other peritoneal irritation conditions. Chromogranin A (CgA) is a 49-kilodalton acidic glycoprotein widely expressed in neuroendocrine cells, where it constitutes one of the most abundant components of secretory granules and it is present in serum of patients with neuroendocrine tumors. [7],[8],[9] CgA is the major member of the chromogranin family. High serum levels of CgA have also been demonstrated in patients with various epithelial malignancies such as pancreas, [10] prostate, [11] lung, [12] colon, [12] and liver carcinomas. [13],[14] As it occurs in several epithelial tumors, ovarian carcinomas may undergo neuroendocrine differentiation. [15],[16] However, it is unclear whether neuroendocrine differentiation correlates with the clinical outcome of ovarian cancer. CgA appears to be the best overall tissue and serum marker of neuroendocrine differentiation. [9] Therefore, the aim of this present study was to evaluate the potential clinical usefulness of plasma CgA levels in ovarian cancer patients, through measurements in the various stages of the disease.

 Materials and Methods

A total of 79 females with ovarian cancer were enrolled between 2000 and 2007 [Table 1]. In the same time 50 women, who represented the control group, were randomly selected from applicants for an annual health check-up and then they were examined. They were judged as normal on the basis of the results of physical examination and laboratory findings. All patients and controls were screened for interfering factors on CgA. Patients with heart failure, kidney failure, type A chronic atrophic gastritis, autoimmune diseases, and concomitant use of proton pump inhibitors were not included since these conditions are associated with increased levels of CgA. The diagnosis of ovarian cancer was suspected on the clinical symptoms and serological features, on markedly elevated serum CA125 levels, and typical findings on dynamic computed tomography. The diagnosis of ovarian cancer was confirmed by histology. The International Federation of Gynecology and Obstetrics (FIGO) classification of ovarian cancer was used to classify the tumors. [17] The patients were divided into four groups: 21 patients being at stage I and 20 patients at stage II and 20 at stage III and 18 at stage IV. Written informed consent was obtained from each patient. The study was approved by the local ethics committee.{Table 1}

Serum collection and storage

Blood samples were taken from the patients and sera were immediately frozen and stored at −20΀C until analysis. A commercial solid-phase two-site immunoradiometric assay was used to detect serum CgA (CgA- RIA CT, CIS Bio international ORIS Group, GIF-SUR-Yvette, France). Two monoclonal antibodies were prepared against sterically remote sites on the CgA molecule. The first was coated in to the solid phase (coated tube), the second radiolabeled with iodine 125 and used as a tracer. CgA present in the standards or the samples to be tested are sandwiched between the two antibodies. Following the formation of the coated antibody, antigen-iodinated antibody sandwich, the unbound tracer is easily removed by a washing step. The radioactivity bound to the tube is proportional to the concentration of CgA in the sample. The normal range for serum levels of CgA in a control population is reported as 20-100 ng/ml. The coefficient of variation between and within assay were 6.4% and 4.1% respectively. CA125 was measured using an immunoradiometric analysis based on two monoclonal antibodies, one of which was labeled with I 125 , while the other was combed to magnetisable mono-dispersed polymer particles. Bound radioactivity was counted in Wallac Wizard 1470 Automatic Gamma Counter. The between and within assay coefficient of variation was 6.5% and 4.4% respectively. The sensitivity, specificity and accuracy of CgA and CA125 assay were calculated as previously described, [18] using as cut-off the upper reference limits of our healthy subjects. For sensitivity and specificity 95% confidence intervals (C.I.) were also determined. Clinical chemistry tests were performed in the medical center laboratory using standard methods. Fasting blood samples were taken at enrolment from the participants.

Statistical analyses

All data are presented as mean ΁ standard deviation. Discrete and continuous variables were compared using either Student's test or the Wilcoxon Mann-Whitney non-parametric test for unpaired data. Categorical variables were compared with either the χ square test or the Fisher exact test when requested. The Spearman's rank correlation co-efficient test was used to test for univariate relationships between variables. The following tests at P < 0.05 level significance were used to evaluate the results and was considered statistically significant. Data were analyzed using the statistical package SPSS for Windows 7.5 (SPSS Inc. Chicago, Il, USA).


The results are summarized in [Table 2]. The upper reference limits for CgA and CA125, defined as 2 SD above the mean levels of healthy subjects, were 35 ng/ml and 14 U/ml, respectively. CgA levels were significantly higher in ovarian cancer than in healthy subjects; CgA values were above the upper reference limit in 68.2% of ovarian cancer patients. CA125 levels were significantly higher in ovarian cancer patients compared to healthy subjects; CA125 values were above the upper reference limit in 76% of ovarian cancer patients.{Table 2}

Comparison between healthy subjects and patients with ovarian cancer

The comparison of patients with ovarian cancer in stage I (FIGO) versus healthy subjects showed a significant difference in CgA −17.71 ng/ml (P < 0.05; C.I. −33.57 to −1.85) and in CA125 -32.57 U/ml (P < 0.001; C.I. −41.83 to −22.31). The comparison between the stage II and healthy subjects showed a significant difference in CgA −75.60 ng/ml (P < 0.001; C.I. −100.72 to −50.48) and in CA125 -109.30 U/ml (P < 0.001; C.I. −149.99 to −68.61). When comparing the stage III versus healthy subjects the difference in CgA was −137.80 ng/ml (P < 0.001; C.I. −165.06 to −110.54) and in CA125 was −248.85 U/ml (P < 0.001; C.I. −282.92 to −214.78). Finally, the comparison between the stage IV versus healthy subjects showed a significant difference in CgA −166.89 ng/ml (P < 0.001; C.I. −212.94 to −120.84) and in CA125 -268.40 U/ml (P < 0.001; C.I. −322.31 to −214.49).

Comparison between FIGO stages of ovarian cancer

As concerns CgA levels, significant differences were observed in the following comparisons: Stage I versus stage II −57.89 ng/ml (P < 0.001; C.I. −84.92 to −30.86); stage I versus stage III −120.09 ng/ml (P < 0.001; C.I. −149.02 to −91.16); stage I versus stage IV −149.18 ng/ml (P < 0.001; C.I. −195.65 to −102.71); stage II versus stage III −62.20 ng/ml (P < 0.001; C.I. −97.52 to −26.88); stage II versus stage IV −91.29 ng/ml (P < 0.001; C.I. −143.10 to −39.48). As concerns CA125 levels, significant differences were observed in the following comparisons: Stage I versus stage II −34.95 U/ml (P < 0.001; C.I. −47.38 to −22.52); stage I versus stage III −216.27 U/ml (P < 0.001; C.I. −250.48 to −182.08); stage I versus stage IV −235.83 U/ml (P < 0.001; C.I. −289.06 to −182.60); stage II versus Stage III −139.55 U/ml (P < 0.001; C.I. −192.44 to −86.66); stage II versus stage IV −159.10 U/ml (P < 0.001; C.I. −227.91 to −90.29). In the ovarian carcinoma CA125 and CgA were correlated in stage IV with a difference of 0.718 (P < 0.001). Considering a cut-off of 35 ng/ml, the overall diagnostic accuracy for ovarian cancer of CgA was 73% with a sensitivity of 68% and a specificity of 64%. Considering a cut-off of 14 U/ml the diagnostic accuracy of CA125 was 91%, with a sensitivity of 78% and a specificity of 81%. The area under receiver operating characteristic (ROC) curve for CgA was 0.72 compared to 0.87 for CA125.


The present study showed the presence of elevated plasma levels of CgA at various stages of ovarian cancer. CgA is a member of the granin family and is co-stored with catecholamines in adrenal medullary and sympathetic neuronal vesicles. Its release occurs with catecholamines during sympathoadrenal activations in humans. [19],[20] CgA acts as a pre-hormon with multiple proteolytic sites, then allowing production of multiple peptides with various physiological functions. [21] It is also present in the widespread neuroendocrine system of the bronchial and gastrointestinal tracts and of the skin (Merkel cells). [22] Although the biological functions of CgA are not well established, several clinical applications are already in use as marker for neuroendocrine tumors or are being developed. Serum CgA levels have been also used as marker for other tumors, such as neuroblastoma, phaeochromocytoma, small cell lung cancer, and the carcinoids. [23],[24] Recently, the cellular replies with morphological and functional neuroendocrine features occurred in no endocrine tumors and the high serum levels CgA were described in patients with carcinoma of breast, liver, and ovary. [25] The morphological classification of the ovarian tumors reflects the current knowledge on embryogenesis and histogenesis of this complex organ. It consists of four main types responsible of a neoplastic variety: Surface epithelium or celomatic; germinal cells; sexual cords; specialized ovarian struma. The ovarian surface epithelium, when involved in metaplastic or neoplastic conditions, meets a mόllerian differentiation. Therefore, the histopathologic varieties of this group of neoplasia are: Serous, mucinous, endometrioid, clear cells, transitional and squamous cells, sometimes they have mixed and hybrid tumors. Other tumors are so scantily differentiated, thus, they cannot be inserted in some of these categories and are defined undifferentiated. The epithelial tumors of ovary represent over the 90% of the malignant forms; the remaining share is formed by the germinal and struma neoplasia. [1],[2],[3] The growth of tumor cell clones, expressing neuroendocrine markers during the process of de-differentiation is not only a common feature of colon, breast, and prostate cancer but an important finding in ovarian cancer. [26] Bosman [27] noted that neuroendocrine differentiation could occur in carcinomas that lack neuroendocrine cells in their normal epithelial counter parts, such as mucinous cystadenocarcinoma of the ovary, ovarian teratoma and ovarian carcinoma. In breast and prostate cancer, neuroendocrine differentiation has been extensively investigated, and there is a consensus that such differentiation is associated with poorer prognosis. [11] Oshita et al., [28] described 4 encountered cases and evaluated the clinic-pathological features of ovarian large-cell neuroendocrine carcinoma from 33 primary cases. The prognosis of ovarian large-cell neuroendocrine carcinoma is extremely poor. [29] Newly researchers showed the presence of hormonal positive and amine peptides in cells of ovarian mucinous tumors as gastrin, calcitonin, serotonin, and neurotensin. These substances are like those found in the fore-gut carcinoid. [30],[31] CgA had a low diagnostic accuracy in detecting ovarian cancer, being the overall accuracy inadequate to support this marker in a screening program. Circulating CgA levels in ovarian cancer patients could reflect CgA expression in ovarian tissues and acquisition of the neuroendocrine phenotype. [19],[20],[27] Human malignancies demonstrate a high degree of cellular heterogeneity and at different points in time, tumor progression. In spite of the biological interest of this phenomenon, its clinical significance remains an open question. [32],[33] Several investigators found that tumors with neuroendocrine differentiation behave more aggressively than tumors without such differentiation. [9] Strategies aimed at developing expression profile panels at potential use for either early disease detection or prognostication, which have so far been largely based on comparing profiles of tumor cells to that of normal coelomic epithelium. This would likely lead to a better understanding of the mechanism underlying disease, which in turn could lead to the development of better strategies for cancer treatment. Further studies are needed to ascertain the usefulness of circulating CgA as a prognostic marker in ovarian cancer.


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