REVIEW ARTICLE

The Role of Inhibins B and Antimüllerian Hormone for

Diagnosis and Follow-up of Granulosa Cell Tumors
Inge Geerts,* Ingnace Vergote,Þ Patrick Neven,Þ and Jaak Billen*

Abstract: The peptide hormones inhibin and antimüllerian hormone (AMH), both pro-
duced by the granulosa cells, are potential candidates for diagnosis and follow-up of
granulosa cell tumors (GCTs). The objective was to evaluate the usefulness of serum levels
of inhibin B and AMH in the diagnosis and follow-up of GCT. The review summarizes
and discusses the value and limitations of the laboratory tests of these hormones by in-
vestigating the performance characteristics of the serum analyses. A search in PubMed
database was accomplished to find articles describing serum inhibin and/or AMH as a
diagnostic test or for follow-up of GCT. The literature search included articles published
between 1989 and September 2008. The sensitivity of inhibin B and AMH for diagnos-
ing patients with a progressive disease is rather equivalent. Antimüllerian hormone is a
more specific serum parameter than inhibin, because inhibin may also increase in some
(mucinous) epithelial ovarian tumors. Nowadays, specific and ultrasensitive assays are
commercially available as well for inhibin B as for AMH, so that early detection of GCT
might be possible. For patients with elevated levels of inhibin B and/or AMH at initial
diagnosis of GCT, inhibin B and/or AMH seemed to be reliable markers during follow-up
for early detection of residual or recurrent disease. Elevated concentrations of these hor-
mones predict relapse earlier than clinical symptoms, which leads to less morbidity of the
patients. In conclusion, inhibin B and AMH are both useful serum markers for diagnosis
and especially for follow-up of patients with a GCT. Currently, there is no evidence-based
preference for inhibin B or AMH as tumor marker.
Key Words: Inhibin, Antimüllerian hormone, Granulosa cell tumor
(Int J Gynecol Cancer 2009;19: 847Y855)

until the age of 30 years.3 The estimated incidence of GCT in the

O varian cancer is the most lethal gynecologic malignancy and
the fifth leading cause of cancer mortality.1 Ovarian tumors
are mainly of epithelial origin (90%), and the remaining 10% are
mostly classified as sex-cord stromal (2%Y5%) or germ cell tumors.
Granulosa cell tumors (GCTs) represent the majority of the sex-cord
stromal tumors. This neoplasm is divided into 2 subtypes, the most
common adult type and juvenile type, based on different clinical and
histopathologic features. Granulosa cell tumor, in principle, can
occur at any age, but the median age of diagnosis is between 50 and
54 years in most series.2 About 5% of the GCT are of the juvenile
type, and they usually occur in premenarchal girls and young women
*Laboratory Medicine and †Department of Obstetrics and Gynaecology,
Division of Gynecologic Oncology, University Hospitals Leuven, Belgium.
Received October 21, 2008, and in revised form March 18, 2009.
Accepted for publication March 25, 2009.
Address correspondence and reprint requests to Jaak Billen, Laboratory
Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven,
Belgium. E-mail: jaak.billen@uz.kuleuven.be.
Copyright * 2009 by IGCS and ESGO
ISSN: 1048-891X
DOI: 10.1111/IGC.0b013e3181a702d1
United States is 1 in 100,000, whereas the reported incidence in
other developed countries ranges from 0.4 to 1.7 in 100,000.2
Some women with a GCT are asymptomatic, or if symptoms
are present, they are often vague. Clinical symptoms associated with
GCT are an enlarged adnexal mass and not infrequently related to the
endocrine effects of these tumors. Most GCTs produce estrogens;
rarely, they are androgenic. The tumor may cause frequent vaginal
bleeding or sometimes signs of virilization. Combined transvaginal
and abdominal ultrasonography enables the clinician to visualize the
adnexal mass with a good predictive value to distinguish a GCT
from other adnexal masses.4 Histopathologic examination remains
the criterion standard to confirm the diagnosis of GCT. Proper
staging of GCT according to the International Federation of
Gynecology and Obstetrics classification is essential. Because of
the nonspecific clinical symptoms, most women (60%Y65%) with
ovarian cancer are diagnosed in the later stage of the disease when
the cancer has spread beyond the ovaries. Screening for ovarian
cancer to find the disease at an early stage has not been proven
beneficial.5 The 5-year life expectancy is 20% to 40%. When the
cancer is detected early, the life expectancy increases to more than
85%.1 Some forms of ovarian cancers have a much better prognostic

International Journal of Gynecological Cancer & Volume 19, Number 5, July 2009 847

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Geerts et al International Journal of Gynecological Cancer
outcome, and GCT is among one of these. These tumors are
characterized by slow growth and late recurrence. If these tumors do
relapse, the median time to relapse is 4 to 6 years after the initial
diagnosis.2 In general, approximately 50% of the patients with GCT
relapse, and 80% of these patients will eventually die of their
disease.6 Because of the GCT’s tendency to recur years after the
initial diagnosis, prolonged surveillance is essential.
The lack of diagnostic tools for early detection of primary
tumors and recurrent disease and serum parameters to follow
patients on therapy for disseminated disease underline the need of
tumor markers. Direct detection of inhibin and antimüllerian
hormone (AMH), both produced by the granulosa cells, is potential
candidates for diagnosis and follow-up of GCT.
Both inhibin and AMH are members of the TGF-A family of
growth factors. Antimüllerian hormone is a homodimeric glycopro-
tein. Inhibin is heterodimeric and consists of an >-subunit linked to
either a AA-subunit or a AB-subunit, forming inhibins A and B,
respectively. Developing follicles produce inhibin B and AMH. In-
hibin A is produced by the dominant follicle and corpus luteum.
Inhibin regulates pituitary follicle-stimulating hormone (FSH). Serum
inhibins A and B levels fluctuate during the menstrual cycle. In
contrast, the AMH concentrations are constant during the menstrual
cycle. Antimüllerian hormone modulates the follicle growth by
playing a role in the initial recruitment and selection of the dominant
follicle and reduces the responsiveness of follicles for the stimulating
FSH signal. After the menopause, with the depletion of the ovarian
follicle pool, inhibins A and B and AMH decrease to very low or
undetectable levels.
We aimed to review the usefulness of serum levels of inhibin
B and AMH in the diagnosis and follow-up of GCT. The
performance characteristics of the serum analyses of these 2 peptide
hormones were investigated to understand the value and the
limitations of these laboratory tests.
METHODS
A search in PubMed database was consulted with the
following search terms (MeSH terms): Granulosa Cell Tumor +
inhibins and Granulosa Cell Tumor + Anti-Mullerian Hormone for
the period from 1989 to September 2008.
In most studies, inhibin and AMH were evaluated in the di-
agnosis or follow-up of GCT separately, and in other studies, inhibin
and AMH are compared with each other or with other markers, such
as activin and CA-125. Because these studies all have different study
designs/conditions and examine small populations, because of the
rareness of the tumor, a meta-analysis is not possible.
RESULTS
Inhibin and/or AMH in serum were evaluated in different
studies as a diagnostic test or for follow-up of GCT (Refs. 3,7Y18). An
overview is shown in Table 1.
DISCUSSION
Inhibin as a Diagnostic Marker
Lappohn et al3 in 1989 and Healy et al7 in 1993 reported,
respectively, elevated serum inhibin levels in patients with GCT
and epithelial ovarian tumor (EOT) of mucinous type. Those 2
observations initiated a series of studies.
Study Design and Analytical Considerations
Most reports studying the value of inhibin in ovarian cancer
consider women as menopausal based on menopausal symptoms,
848
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& Volume 19, Number 5, July 2009
age, FSH level, or after bilateral salpingo-oophorectomy.9Y12,15 Two
studies included premenopausal and postmenopausal women in their
study population.8,13 The premenopausal fluctuation of inhibin
levels might complicate the use of inhibin in preoperative setting.
Nevertheless, this is not a burden in most cases, because the serum
levels in patients with GCTs are mostly elevated drastically. The
literature described an upper limit of 150 ng/L for inhibin A and
200 ng/L for inhibin B in normal premenopausal women. Values of
5 ng/L or less for inhibin A and 15 ng/L or less for inhibin B in
postmenopausal women were considered normal.13 In the study of
Mom et al,13 which studied premenopausal and postmenopausal
women, inhibin B in patients with a preoperative GCT ranges from
327 to 22 520 ng/L. The diagnosis of ovarian cancer and the stage
of disease (International Federation of Gynecology and Obstetrics)
are confirmed by histopathologic examination in each of the men-
tioned studies (Table 1).
With the exception of the study by Jobling et al,8 the studies
have a retrospective, single-center study design. The earliest studies
used a radioimmunosorbent assay (RIA). This technique could not
determine the difference between inhibin A, inhibin B, precursor
forms, and the free circulating >-subunit. More recent studies have
used the more specific immunoassays for both inhibins A and B,
forms that can be recognized separately. In the study by Robertson
et al,11 RIA is compared with specific enzyme-linked immunosor-
bent assay (ELISA), and in another study conducted by the same
research group,12 an immunofluorometric assay (IFMA) is com-
pared with RIA (Table 1). Nowadays, immunoassays for inhibins
A and B are commercially available and manufactured by
Diagnostic Systems Laboratories (DSL; Webster, Tex) and Oxford
Bio-innovation Ltd (Oxford, UK). The calibrators in these kits
are traceable to the World Health Organization International
Reference Reagent.
Inhibin B seems to be the predominant molecular form of the
inhibin family proteins, produced by malignant granulosa cells.
Most patients presented also a moderate increase in serum inhibin
A.11 However, analysis of inhibin B simultaneously to the
measurement of inhibin A on the same samples indicates that the
concentrations of inhibin B are more extensively increased than
inhibin A levels (60-fold elevation for inhibin B compared with 6- to
7-fold increase in case of inhibin A) in patients with progressive
disease. Therefore, inhibin B seems to be best form of inhibin to
measure in patients with GCT, and it seems to be more closely
associated with the disease status than serum inhibin A.16,18,19
Epithelial ovarian tumors can also cause an increase in the
inhibin level. Some authors assumed that these epithelial tumors
mainly secrete inhibin peptides related to the >-subunit.7,11
Robertson et al11 compared different techniques to detect inhibin
in postmenopausal women with a GCT; an EOT of the serous,
mucinous, or miscellaneous subtypes; and nonovarian cancers. The
specific ELISAs for inhibins A and B failed to detect the epithelial
malignancies. Radioimmunoassay, which detects all inhibin forms
containing the >-subunit, provided the best results for detecting the
mucinous and serous subtypes of EOT (Table 1).7,11,12,15,20
Diagnostic Performance Characteristics
Inhibin as Individual Marker. The performance character-
istics of the specific ELISA tests for inhibins A and B for the
diagnosis of GCT are investigated in different studies.9,11,13 The
sensitivity of inhibin B changes according to the study and varies
between 89% and 100%. On the other hand, the sensitivity of
inhibin A changes between 67% and 77%. The specificity for
inhibins A and B was 100% in these studies.9,13
The risk for false-negative results is real, due to the relatively
poor sensitivity of inhibin in some studies. A normal inhibin value
cannot with certainty rule out a malignancy.13
* 2009 IGCS and ESGO
 TABLE 1. Different studies with performance characteristics of serum inhibin and/or AMH for the diagnosis and follow-up of GCT and/or epithelial tumors (1989Y2007)
Reference Population/Study Design Assay and Cutoff * Performance GCT Performance EOT Remarks
3
Lappohn et al : Retrospective, single-center Total inhibin: RIA (after 3 Women after operation: The presence of inhibin
inhibin study (Groningen, the bilateral oophorectomy: (a) 2/3: Residual disease of and low levels FSH in
Netherlands) inhibin levels fall to recurrence, elevated serum inhibin serum samples of

* 2009 IGCS and ESGO

6 Women with GCT 0 U/L; healthy women: (b) 1/3: Disease-free for 11 y, women who had
3 Women: hysterectomy follicular phase: 314 T undetectable inhibin level undergone
and bilateral 45 U/L; midfollicular 3 Women with amenorrhea and ovariectomy and had
salpingo-oophorectomy phase: 379 T 45 U/L; infertility growing GCT
3 women: amenorrhea luteal phase: 772 T 38 After removal of the tumors, the confirms the ability of
and infertility, due to U/L; midluteal phase: inhibin levels became normal and the GCT to secrete
a GCT 1666 T 91 U/L) fertility returned inhibin
Follow-up: during 3Y11 y All 3 women conceived after a few
International Journal of Gynecological Cancer

months (4Y10 mo after operation)

Healy et al7: Retrospective, single-center
inhibin study (Melbourne,
Australia)
212 Postmenopausal women
with suspected ovarian
cancer
143 Women: proved
ovarian cancer, of
which 3 are GCT
23 Postmenopausal
women with
nongynecologic cancer
Follow-up: 1 wk after surgery
for all women
(1) Total inhibin: RIA 3/143 of the ovarian cancers 140 Histologically proven
(122 U/L) were GCT ovarian cancers: 41 (29%)
(2) FSH: RIA Sensitivity: 100% had elevated inhibin values
(3) CA-125: RIA (Abbott Sensitivity:
Diagnostics, Sydney) Mucinous EOT: 82%
(4) Estradiol: RIA Serous EOT: 17%
Clear-cell EOT: 17%
Undifferentiated EOT: 15%
Other ovarian cancers: 19%
Specificity:
Nonovarian pelvic cancer: 7%
Benign ovarian disease: 27%
Nongynecologic cancer: 4%
Inhibin is elevated in the
majority of mucinous
EOT, CA-125 not very
useful in this case (only
7/22 elevated levels)
After surgery the inhibin
level drop below
122 U/L in GCT and
mucinous EOT
& Volume 19, Number 5, July 2009

GCT: 2/3 women with GCT

studied, 2 wk and 1
woman 3 wk after surgery
Jobling et al8: Prospective, single-center
inhibin study (Melbourne,
Australia)
27 Consecutive women with
GCT (4 premenopausal and
23 postmenopausal)
6 Women underwent
an operation
(1) Total inhibin: RIA Elevated inhibin levels 13/16 Disease-free
(122 U/L) Sensitivity: patients had normal
(2) FSH: RIA *Primary operation (6), 100% inhibin levels during
(3) CA-125: RIA (Abbott *Secondary operation (5), 100% 3 y of follow-up
Diagnostics, Sydney) *Recurrence/residual disease
(4) Estradiol: RIA (3/16), 100%
(Diagnostics Products, Specificity:
Sydney) *Clinical disease-free

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5 Women underwent (13/16), 100%
extra procedures
16 Women underwent
regularly inhibin analysis
Follow-up: during 3 y
(Continued on next page)
Inhibin B/Antimüllerian Hormone and GCTs

849
 TABLE 1. Continued
850
Reference Population/Study Design
Rey et al16: Retrospective, single-center
AMH study (Villejuif, France)
16 Women with AGCT
9 Women: preoperative and
postoperative samples
7 Women: only
postoperative samples
Women with adenocarcinoma
of the ovary (20), benign
ovarian cysts (7),
extraovarian cancer (48),
and Sertoli-Leydig tumor (1)
Longitudinal study: serum
AMH levels were serially
measured in 11 patients with
recurrent GCT
Follow-up: during 6Y47 mo
Boggess Retrospective, single-center
et al10: study (Seattle, Wash)
inhibin 15 Women with AGCT
Samples collected at random
after bilateral oophorectomy (2) FSH: RIA
Follow-up: during 9Y53 mo
Petraglia et al9: Retrospective, single-center (1) Inhibin A: ELISA
inhibin, study (Udine, Italy)
AMH 13 Women with AGCT
11 Women with EOT
Follow-up: not performed
Copyright @ 2009 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
* 2009 IGCS and ESGO
Assay and Cutoff* Performance GCT Performance EOT Remarks
Geerts et al
(1) AMH: ELISA (G2 Kg/L) Sensitivity: AMH In 1 patient, all 3
(2) >-Inhibin: RIA Preoperative with progressive hormones were within
(G50 U/L) GCT: 88% normal values,
(3) Estradiol: direct Specificity: AMH although a recurrent
solid-phase RIA Normal values in patients with EOT, tumor was confirmed
cysts, and extraovarian cancer: 100%
Clinical remission:
AMH is normal in 10/11 (specificity:
91%) patients
Longitudinal study: in 9/11 patients,
serum AMH demonstrated a good
correlation with the evolution of the
disease during follow-up
(1) Total inhibin: RIA (after 15 Patients with GCT: follow-up: Elevated inhibin levels
bilateral oophorectomy, (a) 4 Patients with measurable recurrent after surgery detect
inhibin levels fall to disease had elevated inhibin levels early recurrence and
0 U/L in normal women) that correlated directly with tumor identify patients who
burden (r 2 = 0.96) would benefit from
(3) Estradiol: RIA (b) 4 Patients in clinical remission with adjuvant chemotherapy
elevated inhibin levels predating to decrease the risk of
recurrence recurrence
(c) 7 Patients without recurrence, 2/7:
inhibin level fell to 1 U/L, 2/7 were
treated with adjuvant chemotherapy
for disseminated disease, 3/7 had
elevated inhibin levels, suggestive
of occult disease
International Journal of Gynecological Cancer
(1) Inhibin A sensitivity: 71% (1) Inhibin A: elevated in Inhibin B and AMH are
(Serotec, Oxford, UK) (2) Inhibin B (in 9 progressive progressive as well as in both elevated in most
(8.7 T 1.7 pg/mL) GCTs); sensitivity: 88.8%; remission patients with
(2) Inhibin B: ELISA specificity: 100% (all patients in (2) Inhibin B: no significant progressive GCT, but
(Serotec) (5.3 T clinical remission had normal values) elevation no correlation has been
0.9 pg/mL) (3) Activin A sensitivity: 84.6% (3) Activin A: all patients with found
(3) Activin A: ELISA (4) AMH (in 12 progressive GCTs active disease, as well as A discrepancy in AMH
measured) sensitivity: 91% patients in remission have and inhibin B level was
(Serotec) (0.52 T
0.01 ng/mL) One patient with GCT had a normal elevated levels found in 2 patients; a
(4) AMH (12 patients with value of AMH and high level of (4) CA-125: all patients had combination of these 2
GCT): ELISA (2.76 T inhibin B; another one with normal elevated levels markers may improve
0.80 ng/mL) inhibins A and B and activin A, the diagnostic
(5) CA-125: kryptor- presented an increased level of AMH performance
CA125II assay (Cis Bio
& Volume 19, Number 5, July 2009
International, France)
 Robertson Retrospective, single-center
et al11: study (Melbourne,
inhibin Australia)
143 Postmenopausal women
with ovarian cancer
(11 AGCT)
23 Nonovarian cancer
Preoperative samples collected
(1) Total inhibin: RIA Sensitivity: Sensitivity: One of the 23 nonovarian
(122 U/L) (1+ 4) RIA and inhibin B ELISA: 100% *Mucinous cancer had an elevated
(2) Pro->C: ELISA (2) Pro->C ELISA: 90% RIA: 70% inhibin B level
(92 ng/L), (3) Inhibin A ELISA: 77% Inhibin B ELISA: 60% (false-positive result)
(3) Inhibin A: ELISA Pro->C ELISA: 55% None of the controls
(13 ng/L) Inhibin A ELISA: 20% (normal) had an
(4) Inhibin B: ELISA *Serous elevated inhibin B,
(30 ng/L) RIA: 35% but in 3 controls, the

* 2009 IGCS and ESGO

Follow-up: not performed (5) FSH: ELISA Other assays: G15% inhibin A level was
*Miscellaneous above the cutoff value
RIA: 41%
Other assays: G30%
Specificity:
Nonovarian cancer (and
controls)
RIA: 22% (3%)
International Journal of Gynecological Cancer

Inhibin B ELISA: 4% (0%)

Pro->C ELISA: 13% (13%)
Inhibin A ELISA: 4% (8%)
Robertson Retrospective, single-center (1) Total inhibin: RIA Sensitivity: (1) Total inhibin (CA-125) The percentage of all
et al12: study (Melbourne, (122 U/L) (1) Total inhibin: RIA: 100% Sensitivity: ovarian cancers
inhibin Australia) (2) >C-subunit: IFMA (2) >C-subunit: IFMA: 100% *Mucinous (45%) detected at 95%
154 Women with ovarian (154 ng/L) (3) CA-125: IEA: 43% RIA: 71% (90%) specificity for
cancer (11 AGCT) (3) CA-125: IEA >C IFMA: 90% the combination of the
23 Women without ovarian (AIA-PACK CA125, *Serous (89%) inhibin assay (>C
cancer TOSOH) RIA: 33% IFMA) and the
Follow-up: not performed >C IFMA: 29% CA-125 assay is 89Y90
*Miscellaneous (74%) (91Y93)%
RIA: 35%
>C IFMA: 35%
*All ovarian cancer (75%)
& Volume 19, Number 5, July 2009

RIA: 44%
>C IFMA: 45%
*Nonovarian (75%)
RIA: 22%
>C IFMA: 17%
All ovarian cancers with
specificity of 95% (90%)
Total inhibin (>C IFMA):
50% (56%)
CA-125: 80% (84%)
Lane et al17: Retrospective, single-center AMH: ELISA (9highest Diagnosis-preoperative The elevations of AMH

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AMH study (Boston, Mass) value according to Sensitivity: at initial diagnosis or
17 Women with the age) JGCT: 75% during recurrence do
GCTVpreoperative samples AGCT: 78% not correlate with the
8 JGCT All GCTs: 76% stage of the tumor
9 AGCT

(Continued on next page)

Inhibin B/Antimüllerian Hormone and GCTs

851
 TABLE 1. Continued
852
Reference Population/Study Design
Follow-up: 56 women with
GCT, postoperative samples
Clinical follow-up possible in
36 patients with known
postoperative AMH levels
Follow-up period not specified
Long et al18: Retrospective, single-center AMH
AMH study (Villejuif, France)
31 patients (27 AGCT + 4
JGCT):
16 Samples after bilateral
oophorectomy in remission
15 Patients including:
8 Cases after bilateral
oophorectomy, samples
during progressive disease
and remission
2 Cases after unilateral
oophorectomy, samples
during progressive disease
and remission
4 Cases progressive disease
after bilateral
oophorectomy + chemo +
radiotherapy
1 Case: progressive GCT
Follow-up: during 7 y
Tsigkou et al15: Retrospective, single-center (1) Total inhibin: ELISA
inhibin study (Siena, Italy)
Postmenopausal women with: (2) CA-125: Cobas Core
89: EOT stage IYIII
( preoperative and
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postoperative serum
samples)
25 Benign ovarian cancer
30 Nongynecologic cancer
(10: breast cancer, 10:
colon cancer, 10: stomach
cancer)
* 2009 IGCS and ESGO
Assay and Cutoff* Performance GCT Performance EOT Remarks
Geerts et al
Postoperative
40/56 Normal concentration
(21 clinical info)
16/56 Elevated concentration
(15 clinical info)
9/15: Clinical detectable tumor
(5 slightly elevated and 4
persistently elevated and increased
slowly, suggestive of slow growth of
the tumor)
6/15: No complete tumor resection
or recurrence
AMH during follow-up: During follow-up of the
Traditional assay 15/16 Patients: AMH undetectable 16 ovariectomized
AMH/MIS ELISA 1/16 Patients: elevated AMH without patients, there was 1
(Immunotech-Coulter, evidence of recurrence false-positive result
Marscillas, France) Recurrent GCT In 1 case (1/15), AMH
(13.7 T 18.8 pmol/L) 14/15: Elevated AMH was undetectable,
Sensitivity: 93% despite a progressive
PPV: 93% disease (false-negative
Remission after bilateral ovariectomy result)
(16 + 8) 6/31 Samples, with both
23/24: Undetectable AMH methods analyzed,
Specificity: 96% showed a discrepancy
NPV: 96%
International Journal of Gynecological Cancer
With 95% specificity, In the 4 women who
(Oxford) (10 pg/mL) total inhibin assay were followed up,
Sensitivity: recurrence was
CA-125 Serous EOT: 93% associated to an
enzyme-immunoassay Mucinous EOT: 94% increase of total
analysis kit (Roche, All EOT inhibin levels
Switzerland) Total inhibin: spec.:
95% sens.: 84%
CA-125: spec: 95%
sens.: 87%
& Volume 19, Number 5, July 2009
International Journal of Gynecological Cancer & Volume 19, Number 5, July 2009 Inhibin B/Antimüllerian Hormone and GCTs

without recurrence had

Combination of Inhibin and CA-125. CA-125 assay readily

elevated inhibin levels

None of the 17 patients detects most EOTs, particularly serous carcinomas. Ninety-two per-

1 Patient: no elevated
cent of the patients with a serous tumor, included in the study of

diagnosis and at
inhibin levels at
Robertson et al,12 had an elevated value for CA-125 (specificity,
95%). This marker has some drawbacks. On the one hand, the

recurrence
specificity and the ability of the assay to detect the disease at an early
stage are questioned, because of the probable increase of CA-125 in
benign conditions such as pelvic inflammatory disease, pregnancy,
endometriosis, and liver cirrhosis. On the other hand, this marker
is less effective to detect GCTs and mucinous carcinomas.7 The
Monash assay (RIA) demonstrated that increased inhibin levels
could be found in 80% of the patients with a mucinous tumor. These
findings suggest the possible complementarity of inhibin and CA-
125. The combination of these 2 markers can diagnose most ovarian
cancers. Robertson et al12,20 concluded that 90% of all ovarian
cancers (GCTs and EOTs) can be detected with a specificity of 95%
when both parameters are analyzed (Fig. 1). Individual analysis of
CA-125 or total inhibin reveals a sensitivity of 80% and 50%,
respectively, with a specificity of 95%.12 Tsigkou et al15 even
mentioned a sensitivity of 99% with a specificity of 95% for the
combination of inhibin and CA-125.
AGCT, adult granulose cell tumor; JGCT, juvenile granulose cell tumor; NPV, negative predictive value; PPV, positive predictive value.

Inhibin as a Tumor Marker for Follow-up

B: 7/9 (78%), inhibin A: 3/9 (33%)
13 Patients, during the whole period of
Relapse (13/30), elevated inhibin levels:
9 Patients, primary recurrence: inhibin

follow-up: inhibin B: 1/13 (85%),

In normal circumstances, inhibin levels decrease significantly

after surgery. Consequently, patients in clinical remission have very
low to undetectable inhibin values.8,9 In contrast, CA-125 remains
Preoperative (17/30); elevated

Inhibin A sensitivity: 67%,

Inhibin B sensitivity: 89%,

elevated as long as 6 weeks after surgery. When persistent elevated

in non gynecologic cancer

inhibin A: 7/12 (58%)

inhibin concentrations are found, this is suggestive of occult disease.

spec.: 95% sens.: 99%
Total inhibin + CA-125:

No elevation of inhibin

If inhibin concentrations keep rising, relapse is most probable.

Elevated inhibin levels predict relapse earlier than clinical symptoms
specificity: 100%

specificity: 100%

with a median time of 11 months.10,13 Other studies report even a

inhibin levels:

lead time of 2 years.3,8 In a case of a prolonged history of ovarian

GCT, a patient was followed up with serial computed tomography
(CT) scans and serum inhibin levels. Despite CT scans showing
stable disease, the patient’s inhibin levels steadily increased, and
Postmenopausal: e15 ng/L
Premenopausal: 150 ng/L
Postmenopausal: e5 ng/L

Premenopausal: 200 ng/L

ELISA (Serotec)

ELISA (Serotec)
(1) Inhibin A

(2) Inhibin B

(pretherapy and posttherapy)

30 Consecutive women with

Add random serum samples

Retrospective, single-center
4 women with stage IIC

Follow-up: during 1Y31 y

Follow-up: during 5 y; in

study (Groningen, the

GCT (stage IYIII)

mucinous tumor

Netherlands)

*Cutoff value between brackets.

26 AGCT
4 JGCT
Mom et al13:

FIGURE 1. Receiver operating characteristic curve of the

inhibin

parameters CA-125, total inhibin, and the combination of

CA-125 and total inhibin for the detection of all ovarian
cancers.20

* 2009 IGCS and ESGO 853

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Geerts et al International Journal of Gynecological Cancer
eventually, metastases in the liver and lung were detected by CT
scan.21 Early detection of recurrent GCTs might be important as this
might facilitate radical surgery at the time of relapse.
Recurrence of GCTs is associated with a poor prognosis;
more specifically, the overall mortality for recurrent tumors is 73%,
with a mean survival of 5.6 years.22 When recurrences developed,
surgical resection, chemotherapy, and/or radiotherapy might still be
curative. Inhibin is also useful for following the response on
chemotherapy.10 The therapeutic consequences of early detection are
striking: if recurrences are detected early, they may still be amenable
to surgical resection, possibly followed by radiotherapy or chemo-
therapy. Less extensive surgical debulking leads to less morbidity.21
None of the studies investigated the influence of the use of inhibin
for follow-up on the mortality rate. The success of the treatment is
dependent on an early diagnosis of the recurrence, when complete
removal of the tumor is still possible. As mentioned in the preceding
part, inhibin may have the ability to contribute to a better outcome.
Although the overall rate of response to treatment is high, the overall
survival is unknown.19
AMH as a Diagnostic Marker
Antimüllerian hormone is also evaluated as a marker for GCT
in a few studies.16Y18,23 In 1992, Gustafson et al23 first demonstrated
elevated serum concentrations of AMH in the sera of women with
GCT. Antimüllerian hormone seemed to be undetectable in serum
from women with EOT.
Study Design and Analytical Considerations
In the study of Rey et al,16 patients with an adult GCT were
examined. All women were postmenopausal or underwent a bilateral
ovariectomy. Furthermore, women with other malignant and benign
tumors or cysts were included in the study to determine the
specificity of AMH as a serum marker for GCT. Preoperative and
postoperative samples were analyzed. In the survey of Petraglia
et al,9 antimüllerian hormone was also measured in sera of
patients with a progressive adult GCT. Finally, Lane et al17 studied
premenopausal and postmenopausal women with juvenile GCT
and adult GCT.
In all the studies, AMH is detected using a specific ELISA. In
the 1990s, ELISA was performed according to in-house protocols.
These methods were very labor-intensive and complex.9,16,17 In
2000, a new ultrasensitive ELISA was developed, the AMH/MIS
ELISA kit (Immunotech-Coulter, Marseilles, France). Nowadays, 2
different immunoassays for AMH are commercially available, one
from Immunotech and another from DSL. Immunotech states an
analytical sensitivity of 0.1 ng/mL, whereas DSL states 0.02 ng/mL.
There currently is no international reference standard for AMH, and
this is an obstacle to compare results using different assays.
However, a high correlation between values obtained with the 2
assays is observed.24
Diagnostic Performance Characteristics
An increased AMH level is very specific for GCT.16,23
Elevated AMH concentrations were not found in any ovarian
tumors besides GCT, benign cyst, or extraovarian cancer. The only
case in which elevated AMH levels were increased was in a
Sertoli cell tumor. This is self-evident, because these cells also
produce and secrete AMH. Rey et al16 found elevated AMH levels
in 8 (89%) of 9 patients with progressive GCT. In other studies,
the global sensitivity of serum AMH for diagnosing patients
with a progressive disease was 76% (13/17) and 91% (11/12).9,17
Besides, Petraglia et al9 reported a discrepancy in serum AMH
and inhibin B level in 2 patients with progressive GCT. Thus, it
must be kept in mind that false-negative results still occur and
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Copyright @ 2009 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
& Volume 19, Number 5, July 2009
may suggest the option to measure AMH and inhibin to improve
the detection rate of GCT (Table 1). At this moment, there are
no algorithms available to integrate several parameters for the
diagnosis of GCT. The magnitude of the increase in serum AMH
at initial diagnosis and recurrence do not correlate with the stage
of disease.17 There is no evidence to suggest a correlation between
inhibin and AMH in patients with progressive GCT.9
A study was carried out on 31 patients to compare the
traditional in-house method with the ultrasensitive AMH/MIS
ELISA kit (Immunotech-Coulter).18 This kit is able to measure
AMH concentrations as low as 0.1 ng/mL (0.7 pmol/L) (in contrast
with the traditional assay: 2 ng/mL [14 pmol/L]).16,18
AMH as a Tumor Marker for Follow-up
Gustafson et al23 described 6 disease-free women who had
undergone resection of GCT at 2 to 45 months before, and these
women had normal serum AMH levels. When treatment has been
successful, the AMH concentration decreases to an undetectable
level within a few days, which is similar to inhibin. Postoperative
serum AMH levels can be used to evaluate the completeness of the
tumor resection and to predict relapse. Elevated AMH levels are
suggestive of residual disease. In the study of Lane et al,17
56 women were followed up after surgery for a GCT. Fifteen of
56 showed elevated concentrations. In 9 cases, the increased
serum AMH was caused by a clinical detectable tumor. In the other 6
cases, there was residual or recurrent disease.17 Ninety-one percent
(10/11) of the cases in clinical remission, as studied by Rey et al,16
had normal serum AMH values. In 1 case, AMH was elevated,
although no evidence of recurrence was detected. Patients who
underwent bilateral ovariectomy for a GCT were followed up in
the study of Long et al.18 During the follow-up of 24 patients in
clinical remission, the AMH concentration was undetectable in 96%.
Fifteen patients had a relapse, and in 1 patient, the serum AMH
level was not increased.18 The performance characteristics of these
studies demonstrated that false-positive and false-negative AMH
results still occur16Y18 (Table 1).
The comparison between traditional in-house method with
the ultrasensitive AMH/MIS ELISA kit, described in the study of
Long et al, demonstrated a discrepancy in serum AMH in 6 of 31
patients.18 However, the clinical benefit of this ultrasensitive assay is
difficult to estimate as the study included only 1 patient with relapse
and 2 patients with residual disease after surgery. With the traditional
assay, these patients had an undetectable AMH concentration,
although the ultrasensitive assay warned the clinician with an
elevated value. This information is still based on a study population
that is too small and needs confirmation.
The analytical strength of the assay is an important factor; it
defines the usefulness of the parameter in the clinical practice. A
very low serum AMH concentration can be measured with a
qualified assay, so it becomes possible to predict early, preclinical
recurrence and to evaluate the results of treatment. The influence of
the use of AMH for follow-up on survival is likely, but has not yet
been proved.
Other Tumor Marker Candidates?
Activin and estradiol are also stated in several studies as
possible tumor markers for GCT. Activin is a dimer hormone and is
also secreted by the ovary and also by various nongonadal tissues. In
a small study of 3 patients who had been treated for a GCT, elevated
serum activin B levels were reported in 1 patient with relapse, while
this was not the case with the 2 disease-free patients.25 In another
study, serum activin A concentrations were elevated in patients with
EOT and in 11 of 13 patients with GCT. However, activin A did not
accurately reflect the course of disease in patients with GCT and
is not a possible tumor marker candidate.9
* 2009 IGCS and ESGO
International Journal of Gynecological Cancer & Volume 19, Number 5, July 2009
Estradiol values are also often elevated in patients with a GCT.
The values fluctuate in general with the progression of disease and
with response to or failure of therapy. A consistent correlation between
estradiol concentrations and tumor activity could not be established.13
Estradiol lacks sensitivity to be used as a tumor marker.3,16
CONCLUSION
In general, it should be considered that studies on the value
of inhibin and AMH in gynecologic cancers are hampered because
they are mostly retrospective and of poor methodological quality.
Nevertheless, this review of current literature provides some con-
cluding remarks.
The sensitivity of AMH and inhibin B as tumor markers for
GCT seems to be equivalent. Antimüllerian hormone is a more
specific circulating serum parameter than inhibin, because AMH is
only elevated in sex-cord stromal tumors, whereas inhibin may also
increase in some (mucinous) EOTs. For diagnosing ovarian
cancers, the lack of specificity of inhibin can be advantageous.
For EOTs, CA-125 remains the serum marker of choice. The pos-
sible complementarity of inhibin and CA-125 can therefore be
useful to diagnose an ovarian tumor. Nowadays, specific and ul-
trasensitive assays are used to analyze inhibin B and AMH, so that
early detection might be possible. In patients who presented with
elevated levels of inhibin B and/or AMH at initial diagnosis of
GCT, inhibin B and/or AMH seemed to be reliable markers during
follow-up for early detection of residual or recurrent disease. The
concentrations of these hormones increase significantly earlier than
clinical evidence of relapse. Because of the limitations (eg, false-
negative results) of the AMH as well as the inhibin assay, we assume
that the combination of these 2 markers may enhance diagnostic
performance. When an ovarian cancer is strongly suspected and the
tumors have large solid areas, we advise to measure both hormones.
With the current data, we prefer the determination of AMH in
relation to GCT, because of AMH’s excellent specificity. In our
laboratory (University Hospitals Leuven, Belgium), AMH assay was
implemented for this purpose. Besides the application of AMH as a
tumor marker, this hormone has a broad Bapplication window,[ for
instance, in the assisted reproductive technology as a marker of ovarian
reserve and response on in vitro fertilization therapy. Widespread
clinical use of AMH may await the availability of an international
standard for AMH so that results using different assays may be reliably
compared.
Serial inhibin B and/or AMH measurements are useful in
monitoring patients with GCT after therapy, but should be
interpreted together with the clinical and radiological findings
(CT). Late recurrences after more than 20 to 30 years are a hallmark
of GCT and emphasize the necessity for lifetime follow-up with
physical examinations and serum tumor markers.
There is, however, a need for more and larger studies that
compare AMH, total inhibin, and inhibin B to definitively determine
which is the most useful marker of disease progression of a GCT in
both premenopausal and postmenopausal women and whether 1 or
several markers should be used.
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