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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 262-266

The role of thiol–disulfide and ischemia-modified albumin in the differential diagnosis of ovarian pathologies in children

1 Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey
2 Department of Biochemistry, Medical Faculty, Ankara Yildirim Beyazit University, Ankara, Turkey
3 Pediatric Surgery Clinic, Ankara City Hospital, Ankara, Turkey
4 Pediatric Clinic, Ankara City Hospital, Ankara, Turkey
5 Department of Pediatric Surgery, Yildirim Beyazit University, Ankara, Turkey

Date of Submission09-Jan-2020
Date of Decision10-Apr-2020
Date of Acceptance15-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Can Ihsan Oztorun
İrfan Baştuğ Avenue, Kurtdereli Street, Altindağ, Ankara 06130
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_8_20

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Introduction: The aim of this study was to evaluate the association between ovarian pathologies and oxidative stress in children via the new method of thiol/disulfide homeostasis. Materials and Methods: The study was conducted in our clinic and included 24 cases of ovarian cysts (OCs) followed by us and 23 cases of operated OC or torsion and monitored by pediatric surgical intensive care unit. The control group consisted of 24 girls who admitted to the pediatric surgery outpatient clinic because of not-incarcerated inguinal hernia. Serum native thiol, total thiol, dynamic disulfide, albumin, and ischemia-modified albumin (IMA) levels of the patients and healthy volunteers were evaluated. Results: Native thiol (P = 0.41), total thiol (P = 0.57), dynamic disulfide (P = 0.98), albumin (P = 0.54), and IMA (P = 0.98) levels of the patients with OC were found similar with the ovarian torsion (OT) group. However, there were statistically significant differences in native thiol (P < 0.001), total thiol (P < 0.001), albumin (P < 0.001), and IMA (P < 0.001) levels of OT group compared to the controls, whereas dynamic disulfide levels (P = 0.63) were not statistically different from that of controls. Conclusions: In children, the evaluation thiol/disulfide homeostasis might be helpful in the diagnosis of ovarian pathology. Nonetheless, it could not be helpful in the differential diagnosis of OT, which requires emergency surgery from the other ovarian pathologies. Measuring of IMA levels as well as thiol/disulfide homeostasis could increase the specificity of the test. Further studies with larger samples are needed to clarify this issue.

Keywords: Children, ischemia-modified albumin, ovarian cyst, oxidative stress, thiol–disulfide, torsion

How to cite this article:
Oztorun CI, Gok G, Erturk A, Demir S, Guney D, Akman AO, Neselioglu S, Azili MN, Senel E. The role of thiol–disulfide and ischemia-modified albumin in the differential diagnosis of ovarian pathologies in children. J Nat Sci Med 2020;3:262-6

How to cite this URL:
Oztorun CI, Gok G, Erturk A, Demir S, Guney D, Akman AO, Neselioglu S, Azili MN, Senel E. The role of thiol–disulfide and ischemia-modified albumin in the differential diagnosis of ovarian pathologies in children. J Nat Sci Med [serial online] 2020 [cited 2021 Oct 16];3:262-6. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/262/289806

  Introduction Top

Childhood ovarian masses are different from adults in terms of clinical, histopathology, and prognostic characteristics. The diagnosis and treatment options of childhood ovarian masses are planned in relation to clinical, biochemical, and imaging findings.[1],[2] Although laboratory findings are nonspecific in ovarian pathologies, they help in differential diagnosis of other causes of abdominal pain.[3] Ovarian torsion (OT) is one of the most important emergencies of ovarian pathologies, which requires urgent surgical intervention. The treatment of OT is detorsion or detorsion–oophorectomy in certain circumstances; however, this issue is still controversial.

For the differential diagnosis of ovarian pathologies, ultrasonography, computed tomography, and tumor markers (AFP, HCG, and CA125) are utilized. However, tumor markers are not specific in demonstrating malignancy, and none of the imaging techniques or laboratory tests do not fully diagnose OT, as well. Delay in diagnosis and accordingly delayed treatment may result in loss of ovary despite surgical intervention. Therefore, it is critical to have a specific test for differential diagnosis and optimizing treatment method.

Oxidative stress

Free radicals formed during normal cell metabolism are highly reactive molecules containing one or more noncoupled electrons. The balance between the production of free radicals and antioxidant defense is important for the survival of living organisms.[4],[5] Oxidative stress (OS) occurs as a result of shifting of equilibrium to oxidative side. Thus, increased free oxygen radicals damage cellular structures, nucleic acids, lipids, and proteins in the living organism. In inflammatory reactions, the activation of neutrophils and macrophages reproduces excess free oxygen radicals, which causes lipid peroxidation in cell membranes.[6],[7],[8] These changes in cell membrane increase microvascular permeability, edema, infiltration of inflammatory cells, activation of neutrophils, and finally cell death.[7]

Thiol/disulfide homeostasis

Thiols, also known as mercaptans, are organic compounds consisting of a sulfur atom attached to a carbon atom, a hydrogen atom, and containing the sulfhydryl group (-SH).[9] Thiol compounds present in the plasma are eliminated by binding free radicals (scavenger) and thus display a function of antioxidants.[10] Thiols (RSH) react with free radicals in the organism to form disulfide (RSSR) bonds. The resulting disulfide bonds are reduced back to the thiol groups with the help of antioxidant compounds. Thus, the organism's dynamic thiol–disulfide homeostasis is maintained in equilibrium.[9] Plasma thiol pool is mainly formed by low-molecular-weight thiols such as albumin thiols, protein thiols, and small amounts of cysteine (Cys), cysteinylglycine, glutathione, homocysteine, and gamma-glutamylcysteine.[9] The state of the dynamic thiol–disulfide balance plays a critical role in antioxidant protection, detoxification, signal transduction, apoptosis, the regulation of enzymatic activity, transcription factors, and cellular signaling mechanisms.[11] In addition, the distortions in the dynamic thiol–disulfide balance and consequent OS have been shown to play a role in the pathogenesis of many diseases including diabetes, cardiovascular diseases, cancer, rheumatoid arthritis, chronic kidney disease, AIDS, Parkinson's disease, Alzheimer's disease, Friedreich's ataxia, multiple sclerosis, amyotrophic lateral sclerosis, and liver diseases.[9],[12] Therefore, establishing the dynamic thiol/disulfide balance can provide valuable information about various normal or abnormal biochemical processes.[9]

Evaluation of OS in humans is carried out either by analyzing the final products (radicals) or by identifying the antioxidant defense capacity of the organism.[13] Lipid peroxidation due to oxidative damage in organism results in the formation of malonyl-dialdehit (MDA) and thiobarbituric acid-reactive substances (TBARS). For these reasons, the levels of OS have been determined by measuring the level of these biochemical markers (SOD, CAT, MDA, and TBARS).[14],[15],[16] Recently, Erel et al. developed a new method for detecting OS by measuring the level of OS in the body of thiol/disulfide homeostasis.[15] This method has the advantages of lower cost rate, less time-consuming, and less complexity. It produces a thiol/disulfide homeostasis in the plasma by completely consuming and removing the unused reductant NaBH4 using formaldehyde solution.

Since we think that it may be a novel method, and may help in the differential diagnosis of ovarian pathologies, in this study, we investigated the relationship of OS in childhood ovarian pathologies, in order to make a contribution to those studies.

Ischemia-modified albumin

Ischemia-modified albumin (IMA) is a FDA-approved test among the recently investigated cardiac markers.[17] The principle of the test is based on measuring the cobalt-binding capacity of albumin, leading to chemical changes in the albumin during oxidation. This new albumin molecule is called IMA. The formation of this new albumin molecule that has lost its ability to cobalt is one of the earliest markers of ischemia.[18] However, recent studies suggest that IMA, which stands out as a marker of cardiac ischemia, may increase in various pathologies.[19],[20],[21]

  Materials and Methods Top

After obtaining institutional review board approval (IRB No. 2016/065), we designed a prospective study at a tertiary children's hospital, between March 2017 and September 2017. Girls aged 0–18 years who were admitted to pediatric surgery outpatient clinic or pediatric surgery intensive care unit with ovarian pathology were included in this study. The cohort included a total of 71 cases which were grouped as OT (n = 23), ovarian cyst (OC, n = 24), and control (n = 24) groups.

Informed consent was obtained from the parents of the patients in both study and control groups who were included in this study. Twenty-four cases with OC who were admitted to pediatric surgery outpatient clinic and followed-up for cyst regression and 23 patients who were hospitalized in pediatric surgery clinic or pediatric surgery intensive care unit and operated with the prediagnosis of torsion of ovarian were included in the study. The control group of the study included 24 girls with incarcerated inguinal hernia. As per the study protocol, 2 mL of blood samples was obtained preoperative and postoperative day 2 from the patients who underwent surgery, and for the follow-up OC, patients' blood samples were obtained during outpatient clinic admission. All blood samples were collected in yellow cap jell-tubes (BD Vacutainer plastic SST II Tube®), centrifuged at 3600 rpm for 10 min and kept at −80°C in plasma storage freezer.

As soon as all the samples were collected, they were thawed at the same time, and the blood thiol–disulfide levels were determined with a novel automated measurement method described by Erel and Neselioglu[9] and IMA levels were analyzed with the colorimetric method (Roche Hitachi Cobas c501 automatic analyzer) described by Bar-Or et al.[22] in a referral biochemistry laboratory. Native thiol (-SH), total thiol (SH + SS), dynamic disulfide (SS), albumin, and IMA levels were recorded and evaluated.

Statistical analyses

Statistical analyses were performed with the software SPSS Statistics for windows version 17.0 (Chicago: SPSS INC.: 2008). Groups were analyzed by one-way ANOVA test. Preoperative and postoperative day 2 dynamic disulfide (SS), native thiol, total thiol, IMA, and albumin values were analyzed by paired correlation test. P < 0.05 was considered statistically significant.

  Results Top

In this study, 23 girl patients who underwent surgery for ovarian pathologies along with 24 girl patients followed-up for OC were evaluated, and their data were compared with 24 girl control patients.


The mean age of the patients was 14.29 ± 2.19 (range, 9–17) years in the control group, 14.83 ± 1.80 (range, 9–17) years in the OT group, and 13.70 ± 3.86 (range, 11–17) years in the OC group. There was not any significant difference among all groups, in terms of age (P = 0.59) [Table 1].
Table 1: Demographics variables of the groups

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Laboratory findings

The IMA, native thiol (SH), total thiol (SH + SS), dynamic disulfide (SS), and albumin levels of OC, OT, and control groups are summarized in [Table 2]. The statistical analysis results of those are summarized in [Table 3].
Table 2: Laboratory findings of the variables in the groups

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Table 3: The comparison of the laboratory variables among three groups

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There were no statistically significant differences between OC and OT groups, in terms of native thiol (P = 0.41), total thiol (P = 0.57), dynamic disulfide (P = 0.98), albumin (P = 0.54), and IMA (P = 0.98) levels. However, there was statistically significant decrease in native thiol (P < 0.001), total thiol (P < 0.001), dynamic disulfide (P < 0.03), and albumin (P < 0.001) levels and an increase in IMA (P < 0.001) levels in group OC as compared to the control group. In addition, there was statistically significant difference between OC and control groups, in terms of native thiol (P < 0.001), total thiol (P < 0.001), albumin (P < 0.001), and IMA (P < 0.001) levels; however, dynamic disulfide levels were similar (P = 0.63).

[Table 4] demonstrates the preoperative and postoperative day 2 serum native thiol, total thiol, dynamic disulfide, albumin, and IMA mean levels of 8 patients in the OT group and statistical comparison of preoperative and postoperative day 2 blood sample mean levels of those parameters.
Table 4: Preoperative and at the second day of postoperative laboratory findings of the ovarian torsion subjects

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There was no significant difference between preoperative and postoperative day 2 OS biomarker levels [for all variables, P > 0.05, [Table 4].

There was also no correlation between ovarian sizes or ovarian pathology localization determined by USG and OS markers of native thiol (P = 0.115), total thiol (P = 0.097), dynamic disulfide (P = 0.165), albumin (P = 0.099), and IMA (P = 0.325) levels of the patients in the OC and OT groups (ANOVA).

  Discussion Top

Among the childhood ovarian pathologies, there is no specific laboratory and grayscale ultrasonography or Doppler flow finding in the diagnosis of over torsion which requires urgent surgical exploration.[23] Therefore, its diagnosis is specifically difficult. Since laparoscopy and laparotomy provide direct visualization, they can be used for definitive diagnosis.[24] Delay in diagnosis and treatment may lead to ovarian hemorrhagic infarction, organ loss, or peritonitis, as well. Therefore, studies on the early diagnosis of OT are very important to prevent serious complications such as infertility. Currently, there are no biochemical markers which can be used reliably in the differential diagnosis of OT.[25]

Many studies have focused on OS markers and its relationship with various diseases. To date, however, there is no study that concerned the relationship between ovarian pathologies and OS in children. Therefore, this study is first to evaluate whether thiol–disulfide and IMA levels differentiate childhood ovarian pathologies. Regarding thiol/disulfide homeostasis, the levels of total thiol, native thiol, dynamic disulfide, and albumin levels were significantly decreased, and IMA level was increased in the OC group as compare to the control group. Similarly, total thiol, native thiol, and albumin levels were significantly decreased, and IMA level was increased in the OT group when compared with controls. Although the dynamic disulfide (-S-S-) level was higher in the OT group as compared to the control group, the difference was not statistically significant (P = 0.63). There was also no statistically significant difference between OC and OT groups, in terms of total thiol, native thiol, dynamic disulfide, albumin, and IMA levels. These results indicate that the OS in the ovarian pathology groups is shifting in favor of the oxidant side, pointing an increase in OS. However, there was no difference in the thiol/disulfide balance between OC and OT cases. This result exhibits that the thiol/disulfide balance and IMA levels cannot be used as markers in the differential diagnosis of OT and OC.

Of the 8 cases in the OT group, although preoperative and postoperative day 2 measurements of serum total thiol, native thiol, and albumin levels were increased, and dynamic disulfide and IMA levels were decreased, the differences were not statistically significant. As a result, it was observed that OS did not decrease statistically after ovary detorsion, but due to limited number of cases in this study, this state should be supported by extensive studies.

In our study, albumin levels were decreased and IMA levels were increased in patients with ovarian pathology as compared to the control group. Of the total thiol pool in serum, 70% is albumin-induced. In case of ischemia, the structure of the albumin converts to IMA and the level of IMA increases as albumin levels decrease. Elevation of IMA level occurs after ischemic event reaches the detection limit in serum in approximately 10 min and returns to normal values approximately 6 h after termination of ischemia.[26]

In circumstances where the OS increases, the modification of the albumin also increases. There is only one experimental study on IMA, which demonstrates that the level of IMA significantly increases in ovarian tissue, concluding that IMA could be used as a marker for early diagnosis.[27] In recent studies, IMA has emerged as both OS and ischemic marker and has been reported to be increased in some ischemic diseases such as OT and acute ischemic stroke.[27],[28],[29],[30],[31],[32],[33],[34] In our study, IMA levels were found to be higher in the OC and OT groups than that of the control group.

  Conclusion Top

It is difficult to make a differential diagnosis of ovarian pathologies in children. The lack of a specific diagnostic laboratory tests makes it difficult to diagnose. Accordingly, studies concerning specific laboratory tests have been conducted to make a differential diagnosis for ovarian pathologies. Development of a specific test will help prevent unnecessary surgical interventions, as well as identify situations that require immediate intervention, such as OT. Besides physical examination findings, imaging methods, and current laboratory tests, the diagnosis of thiol/disulfide homeostasis and detection of changes in favor of OS might be helpful in the diagnosis of ovarian pathologies. In addition to thiol/disulfide homeostasis, evaluating IMA levels may also increase the specificity of the test. More extensive further clinical studies with higher number of patients are needed to verify these results.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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