Human Epididymis Protein 4 Reference Intervals in a Multiethnic Asian Women Population

  • Mokhtar, N.M. (Department of Pathology, Faculty of Medicine, University Malaya) ;
  • Thevarajah, M. (Department of Pathology, Faculty of Medicine, University Malaya) ;
  • M.A., Noorazmi (Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya) ;
  • M., Isahak (Centre for Occupational and Environmental Health, Faculty of Medicine, University Malaya)
  • Published : 2012.12.31


Background: Ovarian cancer is ranked as the fifth most common cause of cancer death in women. In Malaysia, it is the fourth most common cancer in females. CA125 has been the tumor marker of choice in ovarian cancer but its diagnostic specificity in early stages is only 50%. Hence, there is a critical need to identify an alternative tumor marker that is capable of detecting detect ovarian cancer at an early stage. HE4 is a new tumor marker proposed for the early diagnosis of ovarian cancer and disease recurrence. Currently, none of the normal ranges of HE4 quoted in the literature are based on data for a multiethnic Asian population. Therefore, the aim of this study was to determine reference intervals for HE4 in an Asian population presenting in University Malaya Medical Centre, a tertiary reference hospital. Materials and Methods: 300 healthy women were recruited comprising 150 premenopausal and 150 postmenopausal women, aged from 20-76 years. All women were subjected to a pelvic ultrasonograph and were confirmed to be free from ovarian pathology on recruitment. Serum HE4 levels were determined by chemiluminescent microparticle immunoassay (CMIA, Abbott Architect). The reference intervals were determined following CLSI guidelines (C28-A2) using a non-parametric method. Results: The upper limits of the $95^{th}$ percentile reference interval (90%CI) for all the women collectively were 64.6 pmol/L, and 58.4 pmol/L for premenopausal) and 69.0 pmol/L for postmenopausal. The concentration of HE4 was noted to increase with age especially in women who were more than 50 years old. We also noted that our proposed reference limit was lower compared to the level given by manufacturer Abbott Architect HE4 kit insert (58.4 vs 70 pmol/L for premenopausal group and 69.0 vs 140 pmol/L in the postmenopausal group). The study also showed a significant difference in HE4 concentrations between ethnic groups (Malays and Indians). The levels of HE4 in Indians appeared higher than in Malays (p<0.05), while no significant differences were noted between the Malays and Chinese ethnic groups. Conclusions: More data are needed to establish a reference interval that will better represent the multiethnic Malaysian population. Probably a larger sampling size of equal representation of the Malay, Chinese, Indians as well as the other native ethnic communities will give us a greater confidence on whether genetics plays a role in reference interval determination.


Ovarian cancer;biomarker;HE4;Asian women;ethnic groups


  1. Anastasi E, Granato T, Marchei GG, et al (2010). Ovarian tumor marker HE4 is differently expressed during the phases of the menstrual cycle in healthy young women. Tumor Biol, 31, 411-5.
  2. Anastasi E, Marchei GG, Viggiani V, et al (2010). HE4: a new potential early biomarker for the recurrence of ovarian cancer. Tumor Biol, 31, 113-9.
  3. Bast Jr RC, Badgwell D, Lu Z (2005). New tumour markers: CA125 and beyond. Int J Gynecol Cancer, 15, 274-81.
  4. Bingle L, Singleton V, Bingle CD (2002). The putative ovarian tumor marker gene HE4 (WFDC2), is expressed in normal tissues and undergoes complex alternative splicing to yield multiple protein is form. Ontogeny, 21, 2768-73.
  5. Bolstad N, Oijordsbakken M, Nustad K (2012). Human epididymis protein 4 reference limits and natural variation in a Nordic reference population. Tumor Biol, 33, 141-8.
  6. Buamah P (2000). Benign conditions associated with raised serum CA125 concentration. J Surg Oncol, 75, 264-5.<264::AID-JSO7>3.0.CO;2-Q
  7. Escudero JM, Auge JM, Filella X, et al (2011). Comparison of serum human epididymis protein 4 with cancer antigen 125 as a tumor marker in patients with malignant and nonmalignant diseases. Clin Chem, 57, 1534-44.
  8. Fuith LC, Daxenbichler G, Dapunt O (1987). CA125 in the serum and tissue of patients wth gynecological disease. Arch Gynecol Obstet, 241, 157-64.
  9. Hellstrom I, Hellstrom KE (2008). SMRP and HE4 as biomarkers for ovarian carcinoma when used alone and in combination with CA125 and/or each other. Adv Exp Med Biol, 622, 15-21.
  10. Hellstrom I, Raycraft J, Hayden-Ledbetter M, et al (2003). The HE4 (WFDC2) protein is a biomarker for ovarian carcinoma. Cancer Res, 63, 3695-700.
  11. Kirchhoff C (1998). Molecular characterization of epididymal proteins. Rev Reprod, 3, 86-95.
  12. Malaysian Cancer Statistics - Data and Figure (2007).
  13. Meden H, Fattahi-Meibodi A (1998). CA125 in benign gynecological conditions. Int J Biol Markers, 13, 231-7.
  14. Menon U, Gentry-Maharaj A, Hallett R (2009). Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: results of the prevalence screen of the UK collaborative trial of ovarian cancer screening (UKCTOCS). Lancet Oncol, 10, 327-40.
  15. Moore RG, Brown AK, Miller MC, et al (2008). The use of multiple novel tumor biomarkers for the detection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol, 108, 402-8.
  16. Moore RG, McMeekin DS, Brown AK, et al (2009). A novel multiple marker bioassay utilizing HE4 and CA125 for the prediction of ovarian cancer in patients with a pelvic mass. Gynecol. Oncol, 112, 40-6.
  17. Moore RG, Miller MC, Eklund EE, et al (2012). Serum levels of the ovarian cancer biomarker HE4 are decreased in pregnancy and increase with age. Am J Obstet Gynecol, 206, 1-7.
  18. Montagnana M, Danese E, Giudici S, et al (2011). HE4 in ovarian Cancer: from discover to clinical application. Adv Clin Chem, 55, 1-20.
  19. NCCLS document C28-A2. How to define and determine reference interval in the Clinical Laboratory; Approved Guideline - Second edition.
  20. Niloff JM, Knapp RC, Schaetzl E, et al (1984). CA125 antigen levels in obstetric and gynecologic patients. Obstet Gynecol, 64, 703-7.
  21. Park Y, Kim Y, Lee EY, et al (2012). Reference ranges for HE4 and CA125 in large Asian population by automated assay and diagnostic performances for ovarian cancer. Int J Cancer, 130, 1136-44.
  22. Sturgeon CM, Duffy MJ (2008). National Academy of Clinical Biochemistry laboratory medicine practice guidelines for use of tumour markers in testicular, prostate, colorectal, breast and ovarian cancer. Clin Chem, 54, 11-79.

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