Assessment of serial carcinoembryonic antigen: determinations to monitor the therapeutic progress and prognosis of metastatic liver disease treated by regional chemotherapy

Soluble intercellular adhesion molecule-1 is a prognostic marker in colorectal carcinoma

PURPOSE

Serological tumor markers are routinely used to monitor tumor onset and progression. In colorectal carcinoma (CRC), the carcinoembryonic antigen (CEA) is roughly elevated in 50% of patients at initial diagnosis. Soluble ICAM-1 (sICAM-1) is elevated in different cancers. The aim of this study was to evaluate the prognostic relevance of sICAM-1 combined with CEA in patients with CRC.

METHODS

In blood samples of 297 CRC patients, sICAM-1 was determined by ELISA and CEA by microparticle enzyme immunoassay the day before oncologic resection. Separation in patients with sICAM-1^high and sICAM-1^low was performed by minimum p value approach; separation in CEA normal and elevated was performed according to the established diagnostic cutoff. Clinical data were obtained from the prospective collected data from the Erlangen Registry for Colorectal Carcinomas.

RESULTS

Cancer-related 5-year survival rate of patients with sICAM-1^low (< 290 ng/ml, n = 208) was significantly increased (83.4%) as compared to that of patients with sICAM-1^high (≥ 290 ng/ml, n = 89) (66.2%; p < 0.001). Patients with normal CEA concentrations (n = 199; 90.8%) showed a significantly (p < 0.001) improved cancer-related 5-year survival rate compared to patients with elevated CEA concentrations (n = 98; 52.1%). Moreover, high sICAM-1 was an independent risk factor (hazard ratio 1.6) in multivariate analysis. Of note, increased sICAM-1 levels, either within normal or within elevated CEA, allowed to identify high-risk subgroups, both for overall (p < 0.001) and cancer-related survival (p < 0.001).

CONCLUSION

Application of a novel risk score combining CEA/sICAM-1 serum concentrations allows the identification of high-risk groups for poor survival in CRC patients.

Prognostic significance of the decreased rate of perioperative serum carcinoembryonic antigen level in the patients with colon cancer after a curative resection

Purpose

The serum level of carcinoembryonic antigen (CEA) is a clinical prognostic factor in the follow-up evaluation of patients with colon cancer. We aimed to evaluate the prognostic significance of the rate of decrease of the perioperative serum CEA level in patients with colon cancer after a curative resection.

Methods

A total of 605 patients who underwent a curative resection for colon cancer between January 2000 and December 2007 were enrolled retrospectively. The rate of decrease was calculated using the following equation: ([preoperative CEA - postoperative CEA]/[preoperative CEA] ×100).

Results

In the group with a preoperative serum CEA level of >5 ng/mL, the normalized group with a postoperative serum CEA level of ≤5 ng/mL showed a better overall survival (OS) rate and disease-free survival (DFS) rate than those of the non-normalized group (P ≤ 0.0001). The "cutoff values" of the rate of decrease in the perioperative serum CEA that determined the OS and the DFS were 48.9% and 50.8%, respectively. In the multivariate analysis of preoperative serum CEA levels >5 ng/mL, the prognostic factors for the OS and the DFS were the cutoff value (P < 0.0001) and the pN stage (P < 0.0001).

Conclusion

A rate of decrease of more than 50% in the perioperative serum CEA level, as well as the normalization of the postoperative serum CEA level, may be useful factors for determining a prognosis for colon cancer patients with high preoperative CEA levels.

Clinical significance of pre- to post-chemoradiotherapy s-CEA reduction ratio in rectal cancer patients treated with preoperative chemoradiotherapy and curative resection

PURPOSE

To evaluate the clinical significance of a reduction in serum carcinoembryonic antigen (s-CEA) concentration ratio from before to after preoperative chemoradiotherapy (CRT) in terms of recurrence and prognostic factors in rectal cancer patients.

METHODS

We retrospectively evaluated 333 rectal cancer patients who received preoperative CRT followed by surgery with curative intent between January 2000 and December 2006. Patients were divided into three groups: those with pre-CRT s-CEA≤6 ng/mL (group 1), those with pre-CRT s-CEA>6 mg/mL and post-CRT s-CEA≥70% lower than pre-CRT s-CEA (group 2), and those with pre-CRT s-CEA>6 mg/mL and post-CRT s-CEA<70% lower or higher than pre-CRT s-CEA (group 3).

RESULTS

The 5-year disease-free survival rate was similar in group 1 (76.0%) and group 2 (66.0%), but significantly lower in group 3 (39.5%) (p<0.001). Multivariate analysis showed that CEA group 3, ypT stage, ypN stage, and type of surgery were independent prognostic factors for disease-free survival.

CONCLUSIONS

The reduction ratio of pre- to post-CRT s-CEA concentration may be an independent prognostic factor for disease-free survival following preoperative CRT and surgery in rectal cancer patients with initial s-CEA>6 ng/mL.

The prognostic significant of percentage drop in serum CEA post curative resection for colon cancer

OBJECTIVE/BACKGROUND

This study aimed to analyze the hypothesis that increased percentage drop in serum CEA post curative resection for colon cancer is associated with improved survival.

METHODS

Five hundred thirty three patients who underwent colon resection with a curative intent were retrospectively analyzed for their pre- and postoperative CEA levels. The disease-free and overall survival curves were calculated using Kaplan Meier analysis to evaluate cancer related outcomes. For multivariate analysis, the Cox regression model was used.

RESULTS

The estimated 5-year overall survival for the preoperative serum CEA > 5 ng/mL group with respect to a postoperative CEA level drop rate of 40%, 50% and 60% were 72.9%, 80.9% and 81.8%, respectively. The estimated 5-year overall survival for the preoperative serum CEA ≤ 5 ng/mL group with respect to each postoperative CEA level drop rate were 86.6%, 97.1% and 97.7%, respectively (P = 0.257, P = 0.092 and P = 0.073, respectively). The prognostic factors for poor survival were the depth of invasion (p = 0.042, hazard ratio: 2.617, 95% CI = 1.021-3.012) and lymph node metastasis (p = 0.008, hazard ratio: 2.249, 95% CI = 1.231-4.111). A 60% drop of the CEA level was an independent prognostic factor for survival (p = 0.001, hazard ratio: 2.954, 95% CI = 1.686-5.176) for patients with a preoperative CEA level > 5 ng/mL.

CONCLUSION

Determining the preoperative CEA level and the early postoperative percent drop of the serum CEA level may be a helpful factor for the prognosis of colon cancer patients. However, the percent drop from the pre to postoperative CEA level from the normal range was not associated with survival difference.

Carcinoembryonic Antigen in the Staging and Follow-up of Patients with Colorectal Cancer

CEA is a complex glycoprotein produced by 90% of colorectal cancers and contributes to the malignant characteristics of a tumor. It can be measured in serum quantitatively, and its level in plasma can be useful as a marker of disease. Because of its lack of sensitivity in the early stages of colorectal cancer, CEA measurement is an unsuitable modality for population screening. An elevated preoperative CEA is a poor prognostic sign and correlates with reduced overall survival after surgical resection of colorectal carcinoma. A failure of the CEA to return to normal levels after surgical resection is indicative of inadequate resection of occult systemic disease. Frequent monitoring of CEA postoperatively may allow identification of patients with metastatic disease for whom surgical resection or other localized therapy might be potentially beneficial. To identify this group, serial CEA measurement appears to be more effective than clinical evaluation or any other diagnostic modality, although its sensitivity for detecting recurrent disease is not as high for locoregional or pulmonary metastases as it is for liver metastases. Several studies have shown that a small percentage of patients followed postoperatively with CEA monitoring and who undergo CEA-directed salvage surgery for metastatic disease will be alive and disease-free 5 years after surgery. Furthermore, CEA levels after salvage surgery do appear to predict survival in patients undergoing resection of liver or pulmonary metastases. However, several authors argue that CEA surveillance is not cost-effective in terms of lives saved. In support of this argument, there is no clear difference in survival after resection of metastatic disease with curative intent between patients in whom the second-look surgery was performed on the basis of elevated CEA levels and those with other laboratory or imaging abnormalities. There is also no clear consensus on the frequency or duration of CEA monitoring, although the ASCO guidelines currently recommend every 2-3 months for at least 2 years after diagnosis. In the follow-up of patients undergoing palliative therapy, the CEA level correlates well with response, and CEA is indicative of not only response but may also identify patients with stable disease for whom there is also a demonstrated benefit in survival and symptom relief with combination chemotherapy. More recently, scintigraphic imaging after administration of radiolabeled antibodies afforded an important radionuclide technique that adds clinically significant information in assessing the extent and location of disease in patients with colorectal cancer above and beyond or complementary to conventional imaging modalities. Immunotherapy based on CEA is a rapidly advancing area of clinical research demonstrating antibody and T-cell responses.

Applying Fong's CRS Liver Score in Patients with Colorectal Liver Metastases Treated by Cryotherapy

BACKGROUND

A significant proportion of patients with liver metastases from colorectal cancer have unresectable disease and we have used cytoablative treatment such as cryotherapy in some of these patients. We retrospectively reviewed patients who underwent hepatic cryotherapy for colorectal metastases and studied the effect of the clinical risk score (CRS) reported by Fong et al, which can predict survival following liver resection.

METHODS

A retrospective study was performed on patients who underwent hepatic cryotherapy between 1990 and 2000 in St George Hospital. There were 61 patients in this study and they were stratified into prognostic groups based on five preoperative CRS parameters: primary node positive, disease-free interval from primary to metastases < 12 months, number of hepatic tumours > 1, largest hepatic tumour > 5 cm and carcinoembryonic antigen level > 200 ng/mL. The median follow-up was 25 months.

RESULTS

The median survival was 26 months and the 3-year survival rate was 37%. Median survivals for patients with CRS scores 1 (13%), 2 (25%), 3 (53%), 4 (6%) and 5 (4%) were 37, 25, 30, 21 and 15 months, respectively (R2 = 0.81).

CONCLUSION

The CRS score can be used to predict outcome of hepatic cryotherapy, but the difference in survival between CRS 2, 3 and 4 is modest.

Prognostic effect of perioperative change of serum carcinoembryonic antigen level: a useful tool for detection of systemic recurrence in rectal cancer

BACKGROUND

The prognosis of patients even with the same stage of rectal cancer varies widely. We analyzed the capability of perioperative change of serum carcinoembryonic antigen (CEA) level for predicting recurrence and survival in rectal cancer patients.

METHODS

We reviewed 631 patients who underwent potentially curative resection for stage II or III rectal cancer. Patients were categorized into three groups according to their serum CEA concentrations on the seventh day before and on the seventh day after surgery: group A, normal CEA level (<or=5 ng/mL) in both periods; group B, increased preoperative and normal postoperative CEA; and group C, continuously increased CEA in both periods. The prognostic relevance of the CEA group was investigated by analyses of recurrence patterns and survival.

RESULTS

Stage III patients showed higher systemic recurrence (P = .001) and worse 5-year survival rates (P < .0001) for group C than for groups A and B. On multivariate analysis, the CEA group was a significant predictor for recurrence (P < .001; relative risk, 2.740; 95% confidence interval, 1.677-4.476) and survival (P = .001; relative risk, 2.174; 95% confidence interval, 1.556-3.308).

CONCLUSIONS

The perioperative serum CEA change was a useful prognostic indicator to predict for systemic recurrence and survival in stage III rectal cancer patients.

Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines

In recent years, numerous serum and cell/tissue-based markers have been described for colorectal cancer (CRC). The aim of this article was to provide guidelines for the routine clinical use of some of these markers. Lack of sensitivity and specificity preclude the use of any available serum markers such as carcinoembryonic antigen (CEA), CA 19-9, CA 242, CA 72-4, tissue polypeptide antigen (TPA) or tissue polypeptide-specific antigen (TPS) for the early detection of CRC. However, preoperative measurement of CEA is desirable as this may give independent prognostic information, help with surgical management and provide a baseline level for subsequent determinations. For patients with stage 2 (Dukes' B) and 3 (Dukes' C) disease who may be candidates for liver resection, CEA levels should be measured every 2-3 months for at least 3 years after diagnosis. For monitoring treatment of advanced disease, CEA should also be tested every 2-3 months. Insufficient evidence is presently available to recommend the routine use of other serum markers for monitoring purposes. Similarly, the new cell and tissue-based markers (e.g, ras, P53) cannot yet be recommended for routine clinical use.

CEA, CA 50 and CA 242 in patients surviving colorectal cancer without recurrent disease

AIMS

To establish a baseline and intraindividual fluctuations of the tumour markers CEA, CA 50 and CA 242 in patients cured from colorectal cancer, and to test the hypothesis that serum concentrations and intraindividual fluctuations do not differ from the concentrations in cancer-free individuals.

PATIENTS AND METHODS

Ninety patients with colorectal cancer, who had undergone surgery with curative intent, were still alive at least 5 years after surgery with no signs of recurrent disease. Serum levels of tumour markers CEA, CA 50 and CA 242 before and up to 2 years after surgery were analysed after the prospective study was terminated.

RESULTS

The pre-operative serum levels of CEA, CA 50 and CEA 242 were elevated in 36%, 16% and 20% of the patients. They were lowered after curative surgery. A small increase of CEA levels was found after the initial post-operative decrease. The intraindividual fluctuations for CA 50 and CA 242 did not exceed 15% but in 24% of the patients the serum levels of CA 50 were high and oscillating. The patients cured from Dukes >> C cancer had higher serum concentrations of CEA than patients who had a Dukes >> B cancer, which were higher than in patients who had Dukes >> A cancer. Concentrations of CA 242 were higher in patients cured from Dukes >> A than patients cured from Dukes>> B or C cancers.

CONCLUSIONS

During the first 2 years after curative surgery for colorectal cancer the serum levels of CEA did not differ from those levels in normal cancer-free subjects. The serum levels of CEA were related to Dukes >> staging whereas the levels of CA 242 were inversely related to Dukes >> staging.

Patterns of serum CEA fall after hepatic arterial chemotherapy as sole therapy and combined with cryotherapy for colorectal metastases

BACKGROUND

Hepatic artery chemotherapy (HAC) and cryoablation are treatments for unresectable liver metastases from colorectal carcinomas. Our centre has previously published data that describe survival statistics of patients after each of these treatments. It has also been established that serial serum carcinoembryonic antigen (CEA) concentrations may be used to monitor disease progress, and that the magnitude of fall is prognostic for both treatments. The pattern of fall of CEA following cryotherapy and regional chemotherapy has not previously been compared.

METHODS

In this study, we examined 26 HAC patients and 24 cryotherapy patients.

RESULTS

The mean percentage of the pre-treatment CEA concentration for the HAC group was 60.5% at 50 days and 29.4% at 150 days, and for the cryotherapy group 24.9% at 50 days and 24.3% at 150 days. Calculating the difference between means revealed a significantly different mean fall in the cryotherapy group at 50 days (P < 0.001) and a difference in mean fall at 150 days (P > 0.1) which was not significant. In patients who responded to hepatic artery chemotherapy, the eventual CEA fall was very similar in magnitude.

CONCLUSIONS

The pattern of fall of CEA differs in these two treatments.

Radiologically placed hepatic artery catheter allows selection of patients with high-volume liver metastases for regional chemotherapy

Regional chemotherapy has achieved high response rates in hepatic metastases from colorectal cancer and has been shown to improve survival significantly. The present paper reports the use of pre-operative regional therapy to establish marker response as a means of selection of patients for surgery. Fourteen patients underwent radiologically placed hepatic artery catheter (HAC) for chemotherapy. In the 11 patients with carcino-embryonic antigen (CEA) fall the patient proceeded to open surgical placement of HAC. The predictive effect of CEA fall following radiological HAC was good. Non-responding patients are clearly spared the discomfort and inconvenience and costs of an unnecessary operation.

Previous intravenous chemotherapy does not alter response rate or survival time of patients with hepatic metastases from colorectal cancer treated by hepatic artery chemotherapy

BACKGROUND

The present paper addressed the issue of whether pretreatment with intravenous (i.v.) chemotherapy affects response rate or survival in patients receiving hepatic artery chemotherapy (HAC).

METHODS

Case note reviews of 164 patients treated in a teaching hospital from June 1990 to July 1996 were carried out.

RESULTS

The response rate and carcino-embryonic antigen (CEA) fall in the two groups was almost identical. There was a nonsignificant survival advantage in the non-pretreatment group.

CONCLUSIONS

Previous administration of i.v. chemotherapy did not affect the CEA response of patients receiving HAC.

Monitoring palliative chemotherapy in advanced gastrointestinal cancer using serial tissue polypeptide specific antigen (TPS) measurements

Tissue polypeptide antigen specific (TPS) was analysed in serum taken prior to chemotherapy in 90 patients with advanced gastrointestinal cancer and prior to every treatment course in 68 of these patients in order to explore whether serial tumour marker measurements can be of importance in monitoring patients treated with palliative chemotherapy. Elevated TPS levels were seen in 83/90 (92%) patients (48/52 colorectal, 9/9 pancreatic, 9/11 biliary, 17/18 gastric). Baseline TPS level correlated with performance status, tumour response and survival. Based upon the change in TPS levels after the first two courses in relation to baseline, a decrease by >50% had a high sensitivity for a favourable treatment outcome (partial remission and prolonged stationary disease (90%) or a subjective response (100%)), whereas the specificity was lower (72% and 73% respectively). A similar result was seen when the TPS levels were analysed at the time of the response evaluation after 2 months (sensitivity 91 and 95%, specificity 74 and 75% for an objective or subjective response respectively). In 7 out of 15 patients with an initially favourable outcome, an increase in TPS levels of >50% at two occasions was seen 8-20 weeks prior to clinical disease progression. In advanced gastrointestinal cancer serial TPS measurements can with high accuracy early identify patients who will not benefit from the treatment. On the other hand, a response must be confirmed using other methods in the presence of a decrease, since this was also seen in non-responding patients.

Hepatic artery chemotherapy for colorectal liver metastases

Fifty per cent of patients with colorectal cancer develop hepatic metastases but only a minority are candidates for potentially curative surgical resection. Hepatic artery chemotherapy (HAC) has been used to treat patients with non-resectable metastases confined to the liver. Although response rates to HAC have been shown to be higher than response rates to systemic chemotherapy, the advantage in terms of survival has been debated. Furthermore, HAC requires surgical catheter placement which adds to the cost and morbidity of treatment. There have now been eight prospective randomized trials of HAC vs intravenous chemotherapy and/or supportive therapy. The present paper analyses the results of these trials with particular reference to survival. Surgical morbidity, treatment-related toxicity and cost are also discussed.

Pre- and postoperative carcinoembryonic antigen determinations in hepatic resection for colorectal metastases. Predictive value and implications for adjuvant treatment based on multivariate analysis

OBJECTIVE

The object of this study was to evaluate the prognostic significance of pre- and postoperative serum carcinoembryonic antigen (CEA) levels in the resectional treatment of colorectal hepatic metastases. The main question was whether postoperative CEA levels correlated with survival and the time to recurrence.

SUMMARY BACKGROUND DATA

Despite numerous investigations on prognostic factors in colorectal cancer, only sparse data are available to estimate the patient's individual risk for tumor recurrence postoperatively. It is controversial whether preoperative CEA values are of prognostic significance, and after observing the kinetics of CEA decline, elevated CEA levels postoperatively were found to be an ominous sign. CEA therefore could indicate the presence of a tumor burden after resection.

METHODS

One hundred sixty-six patients undergoing hepatic resection for colorectal metastases with curative intent were prospectively documented and underwent multivariate analysis for indicators of prognosis.

RESULTS

Abnormal preoperative CEA levels were not of prognostic significance compared with values within the normal range (survival, 36 vs. 30 months; p = 0.12; disease-free survival, 12 vs. 10 months; p = 0.82). The postoperative serum CEA level, however, was the most predictive factor with regard to survival and the disease-free interval. Patients in whom CEA levels were abnormal before surgery and returned into the normal range after resection had significantly better survival times (37 vs. 23 months, p = 0.0001) and disease-free survival times (12 vs. 6.2 months, p = 0.0001) compared with patients with persistently abnormal values.

CONCLUSIONS

Pre- and postoperative determination of the serum CEA level is mandatory to judge whether a curative resection has been performed and whether tumor has been left behind after the operation. Postoperative CEA levels also should be used as a stratification criterion in adjuvant treatment studies after hepatic resection to indicate patients with a high risk of tumor recurrence.

Elevated CA19-9 as the most significant prognostic factor in advanced colorectal carcinoma

Tumor markers such as carcinoembryonic antigen (CEA) and CA19-9 were analyzed as response indicators and prognostic factors in advanced colorectal carcinoma. Eighty-five patients participated in a phase II chemotherapy study from October 1984 to July 1990. A three-drug schedule was administered including low dose epirubicin and sequential methotrexate 5-fluorouracil, followed by leucovorin rescue. Serum specimens for CEA and CA19-9 were obtained prior to the initiation of chemotherapy, and subsequently at 4-6 weeks' intervals. In univariate analysis Karnofsky, the site of the primary tumor, the extent of metastases, the presence of abdominal or liver metastases, serum CEA (cut-off of 20 micrograms/l), and CA19-9 levels correlated with survival. In stepwise multivariate analysis an elevated CA19-9 level, a poor Karnofsky, and the presence of liver metastases were independent adverse prognostic factors. Tumors originating from the left colon had a better prognosis than the others. This was related to a higher response rate in this patient group. Serum CA19-9 level was the most significant prognostic factor whether it was entered as a continuous or as a dichotomized variable into the model. The median survival of patients with a normal CA19-9 level was 30.0 months (lower 95% confidence interval: 16.4 months; upper limit was not calculable), and with an elevated CA19-9 value 10.3 months (8.0-12.6 months, 95% confidence interval). Five of 85 patients had a complete response and 20 a partial response, the overall response rate being 29%. When compared with tumor shrinkage, "CEA response" and "CA19-9 response" had a sensitivity of 84% and 88% and specificity of 77% and 67%, respectively. In conclusion, serum CEA value seems to be the best tumor marker for response prediction, while CA19-9 level is one of the best available prognostic indicators in advanced colorectal carcinoma.

The effect of long acting somatostatin analogue SMS 201.995 therapy on tumour kinetic measurements and serum tumour marker concentrations in primary rectal cancer

Twelve patients with rectal carcinoma were treated for 2 weeks with the somatostatin analogue SMS 201.995. Effects of this therapy were assessed using serum marker concentration, Ki67 and gastrin-immunoreactivity of the primary tumour. In four out of 12 patients, a significant decrease in Ki67 immunoreactivity was seen during SMS 201.995 treatment while in the remaining eight patients there was no significant change in Ki67 expression. Four patients had elevated pretreatment serum carcinoembryonic antigen (CEA) levels. In two of these four patients, serum CEA levels fell modestly during SMS 201.995 therapy. This is the first clinical evidence that a somatostatin analogue can inhibit the growth of some colorectal cancers.