# Utility of a Multimodal Biomarker Panel and Serum Proapoptotic Activity to Refine Diagnosis of Ovarian Adnexal Masses

## TL;DR

This study explores new blood-based biomarkers and apoptosis tests to better distinguish between benign and malignant ovarian masses, improving diagnostic accuracy beyond current methods.

## Contribution

The study introduces two novel multiparametric classifiers combining biomarkers and apoptosis data for improved ovarian mass diagnosis.

## Key findings

- Classifier 1 (CA125, HE4, MRP8/14, and apoptosis) outperformed ROMA in specificity and accuracy.
- Classifier 2 (including OPN, SAA, IL-6, IL-8, and IGFBP-4) showed even greater diagnostic performance.
- Malignant tumors were associated with older age, postmenopausal status, and larger tumor size.

## Abstract

Background/Objectives: Ovarian adnexal masses present diagnostic challenges due to their heterogeneous etiologies. Accurately differentiating these conditions is critical for timely and effective clinical intervention. This study evaluated circulating molecules and serum-induced apoptosis as complementary tools to conventional diagnostic methods (CA125, HE4, and the ROMA index) for distinguishing benign masses from malignant masses. Methods: A cohort of 136 participants (9 healthy controls, 87 women with benign ovarian adnexal masses and 40 with malignant ovarian adnexal masses) was analyzed. The induction of apoptosis in Jurkat cells by patient serum was assessed using flow cytometry. Serum concentrations of sFas/CD95, HE4, CA125, and additional molecules were measured by ELISA and LEGENDplex™. Clinical, ultrasonographic, and histopathological data were correlated with tumor malignancy. To improve diagnostic performance beyond individual biomarkers, we developed two multiparametric classifiers that integrate the dominant parameters identified through group divergence analysis and ROC evaluation across multiple clinical comparisons. Results: Malignant tumors were associated with older age (51.45 ± 8.35 years, p = 0.0002), postmenopausal status (61.1%, p = 0.0013), and larger tumor size (>10 cm). Ultrasonographic features of complexity were observed exclusively in malignant masses. Functional assays revealed reduced apoptosis in Jurkat cells exposed to malignant sera, suggesting tumor-mediated immune evasion. Although higher sFas levels were observed in tumors, no significant differences were identified between the groups. Among the circulating biomarkers, CA125, HE4, MRP8/14, OPN, and SAA levels were significantly higher in malignant tumors than in benign tumors and controls. Conclusions: The evaluation of CA125, HE4, MRP8/14, and apoptosis (Classifier 1) and, more prominently, the measurement of additional molecules: OPN, SAA, IL-6, IL-8, and IGFBP-4 (Classifier 2), systematically outperformed the ROMA. Both achieved superior specificity and balanced accuracy (Youden’s J index) across all clinical comparisons by capturing the biological diversity of malignancies.