The monitoring role of plasma CEA alone and in association with other tumor markers in colorectal and mammary carcinoma

The role of tumour markers in improving the accuracy of conventional chest X-ray and liver echography in the post-operative detection of thoracic and liver metastases from breast cancer

The aim of this retrospective study was to assess the value of a serum tumour marker panel in selecting from among the patients with equivocal chest X-ray (CXR) or liver echography (LE) those with thoracic or liver metastases respectively. Between January 1984 and December 1999, 467 (341 non-relapsed and 126 metastatic) breast cancer patients were followed-up postoperatively. Among the 126 metastatic patients 36 showed thoracic (19 patients) or liver (17 patients) metastases, alone or in conjunction with other organs as the first evidence of distant spread. We focused on this series of 377 patients including 341 non-relapsed plus 36 with liver or thoracic metastases. The patients were followed-up after mastectomy with serial determinations of a panel of CEA-TPA-CA15.3 tumour markers, bone scintigraphy, CXR and LE. Up to December 1999, equivocal CXR occurred in 23 (6.1%) patients of whom 11 (47.8%) developed thoracic metastases; 14 (3.7%) patients showed an equivocal LE of whom 5 developed liver metastases. In the 37 patients with equivocal CXR or equivocal LE prolonged clinical and imaging follow-up over 41 +/- 36 months (mean +/- SD, range 3-163) was used to ascertain the presence or absence of thoracic or liver metastases. In the 23 patients with equivocal CXR the negative and positive predictive values of the tumour marker panel to predict thoracic metastases were 92% and 100% respectively. In the 14 patients with equivocal LE the negative and positive predictive values of the tumour marker panel for prediction of liver metastases were 90% and 100% respectively. This study shows that in breast cancer patients the CEA-TPA-CA15.3 tumour marker panel has a high value for selecting those patients at high risk of developing clinically evident pulmonary or liver metastases from amongst those subjects with equivocal CXR or equivocal LE.

CEA in tumors of other than colorectal origin

Carcinoembryonic antigen has been demonstrated to be a valuable clinical aid in the management of patients with colorectal carcinoma. Its elevation in the serum prior to evidence of clinical recurrence in up to 80% of patients highlights its utility. CEA has also been found to be elevated in the serum of patients with other epithelial malignancies, but these have not been as well studied as has colorectal carcinoma. In patients with breast cancer CEA elevations may be found in 40-73% of patients presenting with disease in stages I-IV. In addition, 80% of patients will have a CEA elevation 3-10 months prior to clinical symptoms of recurrence. Seventy-seven percent of patients with bronchogenic lung cancer will have an elevated preoperative value. However, cigarette smoking also causes an increase in the CEA assay level and, thus, differentiation between benign and malignant conditions is more difficult. In small cell carcinoma of the lung, CEA assay levels above 10 ng/ml correlate highly with metastatic disease, while values less than 2.5 ng/ml correlate with localized disease. Pancreatic and gastric malignancies demonstrate CEA level elevations in just over 50% of cases. But these, however, have not been clinically useful. Epithelial neoplasms of the female reproductive tract (cervix, uterus, and ovary) also produce CEA in 47-75% of cases and may correlate with stage of disease at diagnosis and level of cellular differentiation. CEA assay levels are elevated in a variety of tumors and correlate with tumor stage, degree of differentiation, and effectiveness of therapy; they may also be the earliest marker of recurrence.

Comparison of breast cancer mucin (BCM) and CA 15-3 in human breast cancer

The Breast Cancer Mucin (BCM) enzyme immunoassay utilizes two monoclonal antibodies (Mab), M85/34 and F36/22, for the identification of a mucin-like glycoprotein in serum of breast cancer patients. We have compared BCM with CA 15-3, another member of the human mammary epithelial antigen family. Serum BCM was evaluated in 151 and CA 15-3 in 134 patients with breast cancer, in 30 normal controls, in 9 pregnant women, and in 13 cancer patients (non-breast). Neither the normal controls nor the pregnant women had BCM levels greater than 25 U/ml. In contrast, 87 of 115 patients (75%) with metastatic breast cancer had BCM levels greater than 25 U/ml. All control persons had CA 15-3 levels less than 25 U/ml, but 2 out of 9 pregnant women (22%) had levels greater than 25 U/ml. Seventy-four out of 97 patients (76%) with metastatic breast cancer had CA 15-3 levels greater than 25 U/ml. A statistically significant correlation was found between BCM and CA 15-3 in the breast cancer patient group (r = 0.883, p less than 0.001, n = 134) and in the normal control group (r = 0.743, p less than 0.001, n = 30). BCM and CA 15.3 both showed no correlation with CEA in breast cancer patients (r = 0.060, n = 81; and r = 0.146, n = 78, respectively). BCM had a range of sensitivity similar to that of the CA 15-3 RIA. Our results suggest that BCM may be a useful new marker for monitoring the clinical course of patients with breast cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

A rational postoperative follow-up with carcinoembryonic antigen, tissue polypeptide antigen, and urinary hydroxyproline in breast cancer patients

Breast cancer patients (n = 224) aged 28 to 81 were postoperatively followed up with serial determinations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and urinary hydroxyproline (OHP). The clinical usefulness of these tumor markers to diagnose and monitor distant metastases was compared with that of the imaging techniques commonly used to monitor breast cancer patients (bone scanning [BS], liver echography [LE], chest radiograph, and skeletal radiograph). So far, 23 patients withdrew from the study, and distant metastases occurred in 33 patients. In 91% of the metastatic patients, constant elevation or progressive increase in serum CEA and/or TPA levels were the first pathologic findings of the relapse. Of the remaining 168 nonrelapsed patients, 122 were followed up longer than 24 months (43 +/- 17 months; mean +/- SD). In these 122 patients the false-positive results of CEA, TPA, and OHP were 0.8%, 2.4%, and 0%, respectively, when used simultaneously with clinical examination and the common laboratory examinations. BS and LE are the only imaging techniques that showed such a high sensitivity to be suitable in the postoperative follow-up of breast cancer patients. Nevertheless, because BS has a low specificity and is not harmless, it should be performed at longer intervals than tumor markers. Eventually, in the relapsed patients, TPA and OHP well reflected the response to treatment better than CEA and prevented useless radiologic examinations.

A mucinous-like carcinoma-associated antigen (MCA) in the tissue and blood of patients with primary breast cancer

The monoclonal antibody (MAb) b12 raised against human breast cancer cell lines was found to identify an epitope of a mucinous-like carcinoma associated antigen (MCA) that is strongly represented on breast tumor cells. The b12 MAb was used to develop an enzyme immunoassay (EIA) kit. MCA levels were measured with the EIA method in the cytosol of both breast cancer and normal breast tissue as well as in the blood of 147 patients with primary breast cancer and 92 healthy subjects. MCA cytosol levels were significantly higher in carcinoma than in normal breast tissue cytosol samples. Higher MCA levels were found in the cytosol of tumor without lymph nodal involvement. The 95th percentile of the MCA value distribution in the healthy control group (11.0 U/ml) was chosen as negative/positive cut-off level. The overall positivity rate in breast cancer group was 26.5% with MCA showing a trend toward higher levels in patients with more advanced disease. Significantly higher levels were found in patients with a higher number of positive lymph nodes.

Carcinoembryonic antigen in breast cancer. Clinical review

Carcinoembryonic antigen is widely used as a tumor marker for gastrointestinal neoplasms. Its role in the management of other tumors is poorly defined. This review considers the place of carcinoembryonic antigen measurement in the management of breast cancer and concludes that sufficient data exist to support its use in clinical practice. Of the many potential uses, the major role for carcinoembryonic antigen measurement in breast cancer is in following patients with advanced disease, especially patients with bone metastases.

Monitoring serum CEA in women with primary breast tumours positive for oestrogen receptor and with spread to lymph nodes

Serum carcinoembryonic antigen concentrations (serum CEA) in 80 patients with primary breast cancer were measured preoperatively, one month after operation, and thereafter serially every third month. These data were related to histological and morphometric features of the primary breast carcinoma and the lymph node metastases and to clinical follow up data. Analysis of the serum CEA values showed significant correlations with size of tumour, the presence of lymph node metastases, oestrogen receptor, and occurrence of distant metastases. Furthermore, the results indicated that serial determination of serum CEA in the first two years after operation may be useful in monitoring for the occurrence of distant metastases in patients with metastatic spread to lymph nodes and with large (greater than or equal to 2 cm) primary breast tumours positive for oestrogen receptor. In agreement with other studies, however, it was found that the predictive value of serum CEA concentrations in general is weak and costs may prohibit the implementation of the routine assessment of CEA concentrations.

Biological markers for breast carcinoma

During the last decade, there has been an intense search for biological markers for breast carcinoma. Many different types of materials have been found that may be elevated in the body fluids of patients with this disease. However, no markers specific for breast cancer have been discovered and those currently available lack the sensitivity and specificity for early detection of the disease or for determining when the tumor burden is low. Problems may also occur in the interpretation of marker data due to apparent biological variations in synthesis or secretion. Plasma carcinoembryonic antigen (CEA), elevated in 60%-70% of patients with metastases, has had the most extensive evaluation. For the latter patients with increased plasma CEA, the levels in general are proportional to tumor burden. Changes in level with therapy correlate with measurable clinical parameters of response or progression in the majority of these patients. Specific patterns of serial CEA measurements after mastectomy may be helpful for predicting those patients most likely to develop recurrent disease. More recent attention has focused on trials of combinations of markers and on tissue measurement. The search for a specific marker for breast cancer using monoclonal antibody techniques is a promising area of considerable research interest.

Carcinoembryonic antigen and interferon as tumor markers in breast cancer

A total of 239 determinations of CEA plasma levels were performed for 83 breast cancer patients during chemotherapy or follow-up. In addition, 137 plasma samples were assayed for interferon levels. Patient clinical status was carefully scored according to objective criteria and recorded at each evaluation. Liver function tests (LFT) were performed to establish a full clinical picture at each visit. The results obtained proved a 73 to 83% positivity rate when the results of the 4 tests were compared. The importance of routine CEA assays and careful clinical evaluation and LFT are stressed. An analysis of interferon levels defined 4 distinct groups that differed by the amount of interferon present and also by clinical status and CEA levels. The results are discussed in terms of tumor volume-dependent interferon production.

Tissue and plasma carcinoembryonic antigen in early breast cancer. A prognostic factor

A prospective study of plasma and tissue carcinoembryonic antigen (P-CEA and T-CEA) levels in 63 patients with early (Stage I and II) breast cancer was undertaken to determine if the presence of CEA in tissue and/or plasma at the time of primary surgery can be used as a prognostic factor. Thirty-two Stage I and 31 Stage II patients were evaluable with a median follow-up time of 26 months: 29/63 were T-CEA and/or P-CEA positive while 34/63 were T-CEA and P-CEA negative; 9/63 were both T-CEA and P-CEA positive; 13/63 were P-CEA positive alone, while 25/63 were T-CEA positive alone; 5/29 T-CEA and/or P-CEA positive showed disease progression with a mean DFI of 11.8 months, compared with 0/34 T-CEA and P-CEA negative patients (P less than 0.02); 2/9 T-CEA and P-CEA positive compared with 0/34 negative patients progressed (P less than 0.01). There was a significant difference (P less than 0.05) between P-CEA positive (3/13) patients with recurrence and P-CEA negative (2/50). When T-CEA positive patients (4/25) were compared with T-CEA negative (1/38), the difference approaches significance. When the recurrences were analyzed with respect to CEA, estrogen receptor (ER) and nodal status, only in the CEA + versus CEA - group was there a significant difference. The early data show that patients with positive T-CEA and/or P-CEA have a higher recurrence rate with probable poor prognosis. Prognosis correlates better with CEA status than with ER or nodal status.

The detection and evaluation of human tumor metastases

Many biochemical indices are purported to have clinical utility in the detection and management of neoplasia. Experience gained during the past decade tends to indicate their having a more important role in the detection and monitoring of metastases than of the primary lesion. From this present review of some of the commoner human tumours, it is concluded that such marker substances are important adjuncts in the management of germ cell and certain endocrine and endocrine-related tumours. The carcinoembryonic antigen (CEA) provides a marker for many gastrointestinal cancers, but there are no presently available substances with clinical usefulness for either breast or lung neoplasms. Alternative approaches to the detection of metastases are also presented. The particular use of antibody probes at an immunohistochemical level has been claimed to be able to detect micrometastastic disease in bone marrow or tumour-related monoclonal antibody probes may have application to other cancers in the future.

Carcinoembryonic antigen as a monitor of recurrent breast cancer

Carcinoembryonic antigen (CEA) test was performed at the time of diagnosis in 136 patients with early operable breast carcinoma (stage I = 65, stage II = 71). Only 4% had CEA levels greater than 5 ng/ml. Patients with axillary metastasis (stage II) had higher incidence of abnormal CEAs than those with disease localized to the breast (stage I). Follow-up CEA tests were performed on 243 patients after mastectomy. In this group, 50 patients developed recurrent disease and 48% had elevated CEA levels. Patients with chest-wall recurrences rarely had abnormal CEAs, while those with visceral metastasis had higher levels. Among the 193 patients known to be without recurrence, 10% also had elevated CEAs. Excluding inflammatory, hepatic, and renal diseases, the most common medical conditions which could explain such false elevations are diabetes, hypertension, and organic heart disease.

Carcinoembryonic antigen serum levels in patients with squamous cell carcinoma of the uterine cervix: clinical significance

In 114 patients with invasive cervical cancer of the squamous cell type pretreatment CEA levels were determined. An individual upper limit of the normal range was derived taking into account the smoking habits and the age of each patient. Pretreatment CEA levels exceeding the upper limit of normal concurred with a very poor prognosis, regardless of the stage of the tumor. Moreover, in 92 patients longitudinal CEA patterns were established. The median follow-up time of the nonrecurrence patients was four years. Three patients appeared to be exclusively associated with the presence of recurrent cancer. The median lead-time obtained in patients demonstrating such patterns, was 13 weeks. The clinical value and the possible therapeutic consequences of the findings presented are discussed in relation to the available knowledge of tumor growth in cervical cancer.

Biochemical evaluation of patients with breast cancer

Peripheral blood specimens were obtained from 50 patients with various stages of breast cancer (I-II = 7, III = 6, IV = 24, treated and NED = 13), and 20 biochemical tests were performed. There are significant differences of hemoglobin, LDH, SGPT, serum protein, albumin, and alpha globulin values between patients with early (I, II, NED) and late (III, IV) lesions. Among patients with stage IV diseases, those patients with bony metastases had significantly higher values of alkaline phosphatase, alpha-1 globulin, IgA, and C-reactive protein than those with nonosseous lesions. Neither CEA nor pregnancy-associated alpha-2 glycoprotein showed any correlation with different stages or sites of breast cancer in these small series of patients.

Markers of minimal residual disease

Current methods employing tumour markers to detect small amounts of residual disease are reviewed with respect to human germ cell, colorectal and breast neoplasms. It is concluded that the assay of tumour markers in body fluids has only limited clinical value. Alternative approaches, such as are afforded by radioimmunodetection and immunocytochemistry, are presented and critically appraised.