Human Epididymis Protein 4

CPT: 86305
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Special Instructions

Values obtained with different assay methods should not be used interchangeably in serial testing. It is recommended that only one assay method be used consistently to monitor each patient's course of therapy. This procedure does not provide serial monitoring; it is intended for one-time use only. If serial monitoring is required, please order test 481700.

This test may exhibit interference when sample is collected from a person who is consuming a supplement with a high dose of biotin (also termed as vitamin B7 or B8, vitamin H, or coenzyme R). It is recommended to ask all patients who may be indicated for this test about biotin supplementation. Patients should be cautioned to stop biotin consumption at least 72 hours prior to the collection of a sample.

Expected Turnaround Time

1 - 3 days

Related Information

Related Documents

Specimen Requirements




0.8 mL

Minimum Volume

0.4 mL (Note: This volume does not allow for repeat testing.)


Red-top tube or gel-barrier tube


If red-top tube is used, transfer separated serum to a plastic transport tube.

Storage Instructions


Stability Requirements



Room temperature

5 days


14 days


14 days

Freeze/thaw cycles

Stable x3

Patient Preparation

No special patient preparations are required.

Causes for Rejection

Nonserum sample received

Test Details


The assay is used as an aid in monitoring recurrence or progressive disease in patients with epithelial ovarian cancer. Serial testing for patient HE4 assay values should be used in conjunction with other clinical findings used for monitoring ovarian cancer.


The HE4 assay should not be used as a cancer screening test.

HE4 levels tend to be higher in older women and in women who began menstruating at an older age, but these affects are small.1 Falsely elevated or depressed values of HE4 may occur in samples containing human antimouse antibodies.2 Levels of HE4 within the reference range do not preclude the presence of cancer, nor are elevated results an absolute indication of malignancy; thus, HE4 should not be used for cancer screening.2 HE4 should not be used for monitoring patients with mucinous or germ cell ovarian cancer. Results should be interpreted in conjunction with other clinical and laboratory findings.2

The measured HE4 value of a patient's sample can vary depending on the testing procedure used. The laboratory finding must therefore always contain a statement on the HE4 assay method used. HE4 values determined on patient samples by different testing procedures cannot be directly compared with one another and could be the cause of erroneous medical interpretations. If there is a change in the HE4 assay procedure used while monitoring therapy, then the HE4 values obtained upon changing over to the new procedure must be confirmed by parallel measurements with both methods.

There is no high dose hook effect at HE4 concentrations up to 40000 pmol/L.

Patients with confirmed ovarian cancer may have HE4 assay values in the same range as healthy women. Certain histological types of ovarian cancer (e.g. mucinous or germ cell tumors) rarely express HE4, therefore the use of the Elecsys HE4 assay is not recommended for monitoring of patients with known mucinous or germ cell ovarian cancer.3 Conversely, elevated levels of HE4 antigen may be present in individuals with renal, liver and non-malignant diseases.


Electrochemiluminescence Immunoassay (ECLIA)

Reference Interval


Range (pmol/L)


Not Established



0 to 39 years

0.0 – 61.2

40 to 49 years

0.0 – 63.6

50 to 59 years

0.0 – 105.2

60 to 69 years

0.0 – 96.5

>69 years

0.0 – 96.9

The distribution of HE4 levels determined in 1147 specimens is shown in the table.

Distribution of HE4 Assay Values

Number of Subjects

0−150 pMol

150.1−300 pMol

300.1−500 pMol

>500 pMol

Apparently Healthy

Female (premenopausal)






Female (postmenopausal)






Benign Conditions







Benign gynecological disease






Other benign disease













Ovarian cancer






Breast cancer






Lung cancer






Endometrial cancer






Gastrointestinal cancer






*In this study, 94.4% of the healthy female subjects had an HE4 assay value ≤150 pMol.

Monitoring of disease status in patients diagnosed with ovarian cancer.

The effectiveness of the HE4 EIA as an aid in monitoring of disease status in ovarian cancer patients was determined by assessing changes in HE4 levels in serial serum samples from 80 patients compared to changes in disease status. A study involving a total of 354 pairs of observations was undertaken with an average number of 4.4 observations per patient. A positive change in HE4 was defined as an increase in the value that was at least 25% greater than the previous value of the test. This level of change takes into account the variability of the assay and the biological variability. Sixty percent or 76/126 of the patient samples with a positive change correlated with the disease progression, while 75% or 171/228 of the patient serial samples with no significant change in HE4 value correlated with no progression. The total concordance was 70% or 247/354. The following table presents the data in a 2 x 2 format.

Change in Disease State per Sequential Pair

Increase in HE4 Concentration


No Progression














The following table shows the resulting sensitivities and specificities of the HE4 EIA compared to the disease status at various changes in HE4 EIA concentrations.

• Sensitivity is represented as a concordance of the HE4 EIA to progression of disease.

• Specificity is represented as a concordance of the HE4 EIA to no progression of disease.

Percent Change In HE4 Concentration





















Additional Information

Human epididymis protein 4 (HE4) was first identified in the epithelium of the distal epididymis and was originally predicted to be a protease inhibitor involved in sperm maturation.4,5 HE4 is the gene product of the WFDC2 gene that is located on chromosome 20q12-13.1. The WFDC2 gene is one of 14 homologous genes on this chromosome that encode proteins with WAP-type four disulphide core WFDC2) domains.6,7 HE4 belongs to the family of whey acidic four-disulfide core (WFDC2) proteins with suspected trypsin inhibitor properties.8 However, no biological function has so far been identified for HE4.8 The HE4 gene codes for a 13-kD protein, although in its mature glycosylated form the protein is approximately 20−25 kD, and consists of a single peptide and two WFDC domains.9

HE4 has been reported to be expressed in a number of normal tissues, including epithelia of respiratory and reproductive tissues.9,10 Elevated levels were found in several tumor cell lines, including ovarian, lung, colon, and breast cancer. A number of independent microarray studies have shown that the WFDC2 gene is overexpressed in patients with ovarian carcinoma relative to normal controls.10-14 In 2003, Hellstrom and coworkers showed that secreted HE4 was detected in high levels in the serum of ovarian cancer patients.15 This group found that measurement of HE4 showed sensitivity and specificity comparable to that of CA125 for differentiating postmenopausal women with ovarian cancer from normal controls.15 They suggested that the HE4 assay might be superior to CA125 in that it is less frequently positive in patients with nonmalignant disease.15

Drapkin and coworkers used immunohistochemical techniques to show that cortical inclusion cysts lined by metaplastic Müllerian epithelium abundantly expresses HE4 relative to normal surface epithelium.16 Using tissue microarrays, they showed that HE4 expression was restricted to certain histologic subtypes of epithelial ovarian carcinomas (EOC).16 HE4 was expressed in 93% of serous and 100% of endometrioid EOC expressed HE4, whereas only 50% and 0% of clear cell carcinomas and mucinous tumors, respectively, were found positive.16 This study also revealed that most nonovarian carcinomas do not express HE4, consistent with previous findings that HE4 protein expression is highly restricted in normal tissue of the reproductive tracts and respiratory epithelium.16

Moore and coworkers showed that HE4 had a slightly better sensitivity for detecting EOC than CA125.17,18 These researchers found that HE4 was particularly superior for detecting stage I disease, with no increase in sensitivity when combined with CA125 or any other marker.17,18 Overall they found that combining CA125 and HE4 provided a more accurate predictor of malignancy than either alone.19 Montagnana and coworkers found that receiver operating characteristics curve analysis on healthy controls and patients with ovarian cancers revealed that HE4 had a significantly higher area under the curve than CA125 (0.99 vs 0.91), with a sensitivity and specificity of 98% and 100%, respectively.20 Mean HE4 levels were found to be significantly higher in patients with endometrial or ovarian cancer than in patients with ovarian endometriomas or other types of endometriosis.20,21 These findings suggest that the HE4 test may be valuable in discriminating ovarian tumors from ovarian endometriotic cysts.20,21

Shaw and coworkers showed that the ability of serum HE4 levels to discriminate ovarian cancer cases from healthy and benign controls is not influenced by risk status.22 Several other studies have indicated that including HE4 in a multivariate analysis of ovarian cancer risk served to improve the accuracy of screening and/or disease monitoring.3,23-25


1. Ranganathan S, Simpson KJ, Shaw DC, et al. The whey acidic protein family: A new signature motif and three-dimensional structure by comparative modeling. J Mol Graph Model. 1999; 17(2):106-113, 134-136.10680116
2. Israeli O, Goldring-Aviram A, Rienstein S, et al. In silico chromosomal clustering of genes displaying altered expression patterns in ovarian cancer. Cancer Genet Cytogenet. 2005; 160(1):35-42.15949568
3. Human epididymal protein 4 (HE4) on Elecsys 1010/2010 and Modular Analytics E170, package insert 2015-10, V 3.0, Indianapolis, IN: Roche Diagnostics, 2006.
4. Bouchard D, Morisset D, Bourbonnais Y, et al. Proteins with whey acidic-protein motifs and cancer. Lancet Oncol. 2006; 7(2):167-174.16455481
5. Bingle L, Singleton V, Bingle CD. The putative ovarian tumour marker gene HE4 (WFDC2), is expressed in normal tissues and undergoes complex alternative splicing to yield multiple protein isoforms. Oncogene. 2002; 21(17):2768-2773.11965550
6. Galgano MT, Hampton GM, Frierson HF Jr. Comprehensive analysis of HE4 expression In normal and malignant human tissues. Mod Pathol. 2006; 19(6):847-853.16607372
7. Schummer M, Ng WV, Bumgarner RE, et al. Comparative hybridization of an array of 21,500 ovarian cDNAs for the discovery of genes overexpressed In ovarian carcinomas. Gene. 1999; 238(2):375-385.10570965
8. Hough CD, Sherman-Baust CA, Pizer ES, et al. Large-scale serial analysis of gene expression reveals genes differentially expressed In ovarian cancer. Cancer Res. 2000; 60(22):6281-6287.11103784
9. Ono K, Tanaka T, Tsunoda T, et al. Identification by cDNA microarray of genes involved In ovarian carcinogenesis. Cancer Res. 2000; 60(18):5007-5011.11016619
10. Welsh JB, Zarrinkar PP, Sapinoso LM, et al. Analysis of gene expression profiles in normal and neoplastic ovarian tissue samples identifies candidate molecular markers of epithelial ovarian cancer. Proc Natl Acad Sci USA. 2001; 98(3):1176-1181.11158614
11. Hellström I, Raycraft J, Hayden-Ledbetter M, et al. The HE4 (WFDC2) protein is a biomarker for ovarian carcinoma. Cancer Res. 2003; 63(13):3695-3700.12839961
12. Drapkin R, von Horsten HH, Lin Y, et al. Human endometrioid ovarian carcinomas. Cancer Res. 2005; 65(6):2162-2169.15781627
13. Moore RG, Brown AK, Miller MC, et al. Utility of a novel serum tumor biomarker HE4 in patients with endometrioid adenocarcinoma of the uterus. Gynecol Oncol. 2008; 110(2):196-201.18495222
14. Moore RG, Brown AK, Miller MC, et al. The use of multiple novel tumor biomarkers for the detection of detection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol. 2008; 108(2):402-408.18061248
15. Havrilesky LJ, Whitehead CM, Rubatt JM, et al. Evaluation of biomarker panels for early stage ovarian cancer detection and monitoring for disease recurrence. Gynecol Oncol. 2008; 110(3):374-382.18584856
16. Andersen MR, Goff BA, Lowe KA, et al. Use of a symptom index, CA125, and HE4 to predict ovarian cancer. Gynecol Oncol. 2010 Mar; 116(3):378-383.19945742
17. Montagnana M, Lippi G, Ruzzenente O, et al. The utility of serum human epididymis protein 4 (HE4) in patients with a pelvic mass. J Clin Lab Anal. 2009; 23(5):331-335.19774626
18. Huhtinen K, Suvitie P, Hiissa J, et al. Serum HE4 concentrations differentiates malignant ovarian tumours from ovarian endometriotic cysts. Br J Cancer. 2009; 21:100(8):1315-1319.19337252
19. Hellstrom I, Hellstrom KE. SMRP and HE4 as biomarkers for ovarian carcinoma when used alone and in combination with CA125 and/or each other. Adv Exp Med Biol. 2008; 622:15-21.18546615
20. Li J, Dowdy S, Tipton T, Podratz K, et al. HE4 as a biomarker for ovarian and endometrial cancer management. Expert Rev Mol Diagn. 2009; 9(6):555-556.19732003
21. Moore RG, McMeekin DS, Brown AK, et al. A novel multiple marker bioassay utilizing HE4 and CA125 for the prediction of ovarian cancer In patients with a pelvic mass. Gynecol Oncol. 2009; 112(1):40-46.18851871
22. Shah CA, Lowe KA, Paley P, et al. Influence of ovarian cancer risk status on the diagnostic performance of the serum biomarkers mesothelin, HE4, and CA125. Cancer Epidemiol Biomarkers Prev. 2009; 18(5):1365-1372.19423517
23. Lowe KA, Shah C, Wallace E, et al. Effects of personal characteristics on serum CA125, mesothelin, and HE4 levels in healthy postmenopausal women at high-risk for ovarian cancer. Cancer Epidemiol Biomarkers Prev. 2008; 17(9):2480-2487.18768519
24. Kirchhoff C, Habben I, Ivell R, et al. A major human epididymis-specific cDNA encodes a protein with sequence homology to extracellular protease inhibitors. Biol Reprod. 1991; 45(2):350-357.1686187
25. Kirchhoff C. Molecular characterization of epididymal proteins. Rev Reprod. 1998; 3(2):86-95.9685187


Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
081700 Human Epididymis Protein 4 55180-4 081750 HE4 pmol/L 55180-4

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