Tumor markers produced by neoplastic and embryonal cells
were originally studied in an attempt to develop a screening
test for early diagnosis of cancer. However, low specificity for
malignancy, high levels in benign conditions is limitations for
their usage. CA 19-9 can be found in 15-36% of patients with
benign processes, such as acute pancreatitis, chronic
pancreatitis, chronic liver disease, Mirizzi’s syndrome, and
inflammatory liver pseudotumor. However, marked elevations
are essentially limited to cirrhosis and acute cholangitis
5-9.
Kim et al. reported a serum level of > 37 U/ml in only 157 of
20,035 cases (0.78 %)
10. Extremely high levels of CA 19-9
are observed rarely and there have been some case reports.
Akdogan et al
2 reported a patient who had cholangitis and a
pancreatic pseudocyst with an elevated CA 19-9 level up to
35,500 u/ml. Katsanos et al
9 have reported four cases with
elevated serum CA 19-9 levels in benign biliary tract diseases.
These abnormal CA 19-9 levels, especially the highest ones,
are reported to return to normal about 3 weeks after the therapeutic intervention. Lin et al
11 reported Mirizzi’s
syndrome with high CA 19-9 levels (44 000 U/ml), which
returned to normal 15 days later. In the setting of acute
inflammatory processes, elevated values generally return to
normal after the inflammatory process resolves
5-9.
The case with elevated CA 19-9 levels in a benign biliary
tract disease with gallstone presented cholecystitis is reported
here. Interestingly, clinical and biochemical findings were not
so prominent in our case. Elevated levels of CA 19-9 were
prompted us to perform further evaluation to exclude
malignancy. Other tests for malignancy of gastrointestinal tract
were found negative. In our case, CEA was within normal
limits. These abnormal CA 19-9 values returned to normal 18
days after cholecystectomy. Although marked elevations have
been reported in the presence of cholangitis, no sign of
cholangitis was found in our case 7,12. The elevation of CA
19-9 levels seen in cholecystitis may be due to increased
production of it from the inflamed epithelial cells and its
decreased hepatobiliary clearance. Thus, serum CA 19-9 levels
decrease when infection resolves 7,12. In such cases CA 19-9
should be nearly followed-up.
High levels of CA 19-9 could mislead to the diagnosis of
pancreatic or biliary malignancy, despite the lack of
radiological, surgical and endoscopic evidences. This case
emphasizes the need for caution in the interpretation of an
elevated serum CA 19-9 level as a marker for malignancy. In
our patient, the elevation was due to cholecystitis rather than a
malignant process. The level of CA 19-9 should never be
regarded as a gold standard but rather as a helpful indicator
when searching for malignancy.
