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Kim, Jeon, Park, Choi, Shin, Park, Seo, and Kim: Clinical Interpretation of Elevated CA 19–9 Levels in Obstructive Jaundice Following Benign and Malignant Pancreatobiliary Disease
Original Article

Korean J Gastroenterol 2017;70(2):96-102.

Published online: 4 October 2017

DOI: https://doi.org/10.4166/kjg.2017.70.2.96

Clinical Interpretation of Elevated CA 19–9 Levels in Obstructive Jaundice Following Benign and Malignant Pancreatobiliary Disease

Min Seong Kim, Tae Joo Jeon1, , Ji Young Park1, Jeongmin Choi1, Won Chang Shin1, Seong Eun Park1, Ji-Young Seo1, Young Moon Kim1

1Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Division of Gastroenterology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea

Correspondence to: Tae Joo Jeon, Division of Gastroenterology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine University, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea. Tel: +82-2-950-1341, Fax: +82-2-950-1955, E-mail: drjtj@paik.ac.kr

Received 10 February 2017       Accepted 30 April 2017

Copyright © 2017 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Elevated carbohydrate antigen (CA) 19–9 level may be unable to differentiate between benign and malignant pancreatobiliary disease with obstructive jaundice. The study aims to determine the clinical interpretation and the diagnostic value of CA 19–9 level in pancreatobiliary diseases with coexistent obstructive jaundice.

Methods

We retrospectively reviewed the data of 981 patients who underwent biliary drainage due to obstructive jaundice following pancreatobiliary disease at Sanggye Paik Hospital for 5 years. 114 patients with serial follow-up data for CA 19–9 level were included in this study (80 patients with malignancy and 34 patients with benign diseases). We compared the levels of CA 19–9 levels and the biochemical value before and after biliary drainage.

Results

The rate of CA 19–9 elevation (>37 U/mL) was significantly different between the benign group and the malignant group (59% vs. 90%, p=0.001). Despite the decrease in serum bilirubin after biliary drainage, CA 19–9 levels remained elevated in 12% of patients in the benign group and in 63% of patients in the malignant group (p<0.001). Finally, 12% of patients in the benign group turned out to have malignant disease. A receiver operating characteristic analysis provided a cut-off value of 38 U/mL for differentiating benign disease from malignant disease after biliary drainage (area under curve, 0.787; 95% confidence interval, 0.703 to 0.871; sensitivity, 62%; specificity, 88%).

Conclusions

This study suggested that we should consider the possibility of malignant causes if the CA 19–9 levels remain high or are more than 38 U/mL after resolution of biliary obstruction.

Keywords: CA 19–9 antigen, Obstructive jaundice, Malignancy, Neoplasms, benign, Drainage

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Fig. 1.
Study flowchart and enrollment. CA, carbohydrate antigen.
kjg-70-96f1.tif
Fig. 2.
The correlation between CA 19–9 and total bilirubin in benign diseases and malignant diseases. (A) Pre-drainage in benign diseases. (B) Post-drainage in benign diseases. (C) Pre-drainage in malignant diseases. (D) Post-drainage in malignant diseases. CA, carbohydrate antigen.
kjg-70-96f2.tif
Fig. 3.
The ROC and the cut-off level (pre-drainage: 240 U/mL, post-drainage: 38 U/mL) for CA 19–9 to distinguish between benign and malignant disease states. ROC, receiver operating characteristic; CA, carbohydrate antigen, BD, billiary drainage.
kjg-70-96f3.tif
Table 1.
Baseline Characteristics before Biliary Drainage for Obstructive Jaundice Treatment in the Malignant and Benign Pancreatobiliary Disease Groups
Characteristics Malignant (n=80) Benign (n=34) p-value
Gender 0.529
    Male 51 (63.7) 20 (58.8)
    Female 29 (36.3) 14 (41.2)  
Age, years 68±10 68±11 0.840
Median CA 19–9 (range, U/mL) 442.4 (0.6–10,000) 67.4 (0.6–5,066)  
Positive CA 19–9 (>37 U/mL) 72 (90) 20 (59) 0.001
Total bilirubin (mg/dL) 10.4±6.6 6.8±6.8 0.010
Alkaline phosphatase (U/L) 549±496 263±196 <0.001
γ-Glutamyl transferase (U/L) 829±638 428±304 <0.001
Biliary drainage method      
    EST: Stent: PCD 2: 57: 21 29: 3: 2 <0.001

Values are presented as mean± standard deviation, range or n (%).

CA, carbohydrate antigen; EST, endoscopic sphincterotomy; PCD, percutaneous catheter drainage.

Table 2.
CA 19–9 Level and Cholestasis Laboratory Findings after Successful Drainage
  Malignant (n=80) Benign (n=34) p-value
Median CA 19–9 (range, U/mL) 91.2 (0.6–10,000) 14.1 (0.6–258.5) N/A
Positive CA 19–9 (>37 U/mL) 50 (63) 4 (12) <0.001
Total bilirubin (mg/dL) 1.5±2.7 1.6±2.5 0.969
Alkaline phosphatase (U/L) 193±171 136±105 0.117
γ-Glutamyl transferase (U/L) 145±150 103±102 0.197

Values are presented as mean±standard deviation, range or n (%).

CA, carbohydrate antigen; N/A, not applicable.

Table 3.
Cases of Change in the Initial Diagnosis
Case (Sex/Age) Diagnosis CA 19–9 (U/mL) Total bilirubin (mg/dL)
Initial Final Initial Final Initial Final
F/67 CCC Benign stenosis 215.2 8.9 8.5 0.5
M/50 CCC Benign stenosis 27.8 5.5 6.9 0.7
F/67 Cancer invasion Benign stenosis 17.8 3.8 3.9 0.3
M/74 Calculous Dz CCC 587.3 499.9 7.3 1.0
M/64 Calculous Dz AOV cancer 198.3 644.8 6.9 0.5
M/64 Calculous Dz Cancer invasion 2,681 4,401 7.4 0.7
M/87 Benign stenosis CCC 5,946 3,196 18.9 1.9

CA, carbohydrate antigen; F, female; M, male; CCC, cholangiocarcinoma; Dz, disease; AOV, ampulla of vater.

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