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  Sir,We read a published article by Qureshi et al  . in JCPSP2014, Vol. 24 (4): 232-235 with great interest. 1 In thisstudy, it was aimed to evaluate Cancer Antigen-125(CA-125) levels in patients with liver cirrhosis and theprobable relation between the high levels and theamount of ascites. In conclusion, a moderate correlationwas found between CA-125 levels and presence andamount of ascites. However, we would like to ask somequestions from authors and their comments on thisstudy.First, there are many studies found in literatureindicating elevation of CA-125 levels specific to ascitesin patients with liver cirrhosis. 2,3  Although encounteringdifferent CA-125 levels in patient groups of thesestudies, any cut-off value except 35 U/mLhas not beensuggested to predict severity of the diseases yet, asindicated in the original study, a level above 35 U/mLisconsidered abnormal. 4 In the methodology section of thesrcinal article, it is mentioned that patients were dividedinto four groups as between 35 - 100, 100 - 500, 500 -1000 and above 1000 U/L. However, any literatureand/or clinical reason is not specified in groupingpatients according to their CA-125 levels. Referring aliterature, if any, could increase the value and reliabilityof results.Second, after dividing cirrhotic patients into two groups,those with and without ascites, univariate logisticregression analysis should be performed to assumeCA-125 as a marker of ascites in patients with liver cirrhosis. Moreover, assessing power of CA-125 todetermine the severity of ascites by performing ordinallogistic regression analysis including all four groups of patients could provide more significant results. After performing these analyses you can conclude whether or not CA-125 is useful for the prediction of ascites.CA-125 may be a useful marker for the prediction of ascites, but regression analysis should be performed for this decision. REFERENCES 1.Qureshi MO, Dar FS, Khokhar N. Cancer antigen-125 as amarker of ascites in patients with liver cirrhosis. J Coll PhysiciansSurg Pak  2014; 24 :232-5. 2.Xiao WB, Liu YL. Elevation of serum and ascites cancer antigen-125 levels in patients with liver cirrhosis. J Gastroenterol Hepatol  2003; 18 :1315-6.3.Chowdhury MA, Xiubin Z, Wei H, Chenghao G. Cancer antigen-125 and ICAM-1 are together responsible for ascites in liver cirrhosis. Clin Lab 2014; 60 :653-8.4.Mayo Clinic, Mayo Medical Laboratories. Tests and procedures:cancer antigen-125 (CA-125) [Internet]. [cited June 06, 2014]. Available from: http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/9289 Authors Reply: We appreciate the thoughts shared on our study. Theaim of our study was to evaluate the correlation betweenCancer Antigen (CA-125) level with the amount of ascites in patients with liver cirrhosis. 1 We found thatthere was a moderate correlation between CA-125levels and amount of ascites. 1 We mentioned in our study that there are reports which showed that thepresence of ascites appears to play a key role in themechanism responsible for the increased levels of CA-125 in the patients of liver cirrhosis. 2 Few studies aresuggestive of correlation between ascites and increasedCA-125 levels. 3 However, will levels of CA-125 alsoincrease simultaneously with increasing amount of ascites? This question was answered in the presentstudy. 1 In previous studies, increases of CA-125 levels meantany value greater than 35 U/ml. 2,4 We also took valuesgreater than 35 U/ml as abnormal, but we also dividedCA-125 in four groups according to values between 35U/ml to 1000 U/ml. All groups have increased values inthe last group. After dividing in groups, we comparedthese values with the amount of ascites, and found abetter picture that would have not been possible bytaking all the patients as one group. For instance, wefound 14 patients of tense ascites with CA-125 levelsgreater than 500 U/ml, while only 3 patients had CA-125levels above 500 U/ml with mild ascites. Similarly, 10patients had CA-125 levels between 35 to 100 U/ml, andnone were in this range with severe ascites. 1Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24(11): 873-874  873 LETTER TO THE EDITOR Evaluation of RelationshipBetween CA-125 Levels andAscites in Patients with Liver Cirrhosis  Huseyin Kayadibi 1  , Erdim Sertoglu 2 and Metin Uyanik  31  Department of Medical Biochemistry, Adana Military Hospital, Adana, Turkey. 2  Department of Medical Biochemistry, Ankara Mevki Military Hospital, Anittepe Dispensary, Ankara, Turkey. 3  Department of Medical Biochemistry, Gulhane School of  Medicine, Ankara, Turkey.Correspondence: Dr. Huseyin Kayadibi, Adana Military Hospital, Department of Medical Biochemistry, 01150, Adana, Turkey. E-mail: mdkayadibi@yahoo.com Received: June 09, 2014; Accepted: June 26, 2014.  There are many aspects of this study, multipleinferences could be drawn by applying different test. Weapplied the tests according to our objectives. This is inaccordance with international literature. 3-5 However, thetests pointed out could be applied to extract moredetailed results out of this study. REFERENCES 1.Qureshi MO, Dar FS, Khokhar N. Cancer antigen-125 as amarker of ascites in patients with liver cirrhosis. J Coll PhysiciansSurg Pak  2014; 24 :232-5.2.Zuckerman E, Lanir A, Sabo E, Rosenvald-Zuckerman T,Matter I, Yeshurun D. Cancer antigen-125: a sensitive marker of ascites in patients with liver cirrhosis.  Am J Gastroenterol  1999; 94 :1613-8.3.Algan-öcal P, Aksahin A, Çetin T, Yildirim IS. Cancer antigen-125levels in patients with ascites. Turk J Gastroenterol 2003; 13 : 257.4. Devarbhavi H, Kaesi D, Williams AW, Rakelaaa J, Klee GG,Kamath PS. Cancer antigen-125 in patients with chornic liver disease. Mayo Clin Proc  2002; 77 :538-41.5.Jablkowski M, Bialkowska J, Koktysz R, Bartkowiak J,Stankiewicz W, Dworniak D. Cancer antigen-125 as a marker of ascites in patients with liver cirrhosis. Pol Merkur Lekarski  2004; 17 :149-52. Letter to the editor  874 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24(11): 873-874  Muhammad Omar Qureshi, Faisal Saud Dar and Nasir Khokhar  Department of Gastroenterology, Shifa International Hospital, Islamabad.Correspondence: Prof. Nasir Khokhar, Department of Gastroenterology, Shifa International Hospital, H-8/4, Islamabad. E-mail: drnkhokhar@yahoo.com
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