Multiple operations for recurrent colorectal cancer

Benefits of radioimmunoguided surgery for pelvic recurrence

AIM

Surgery for recurrent rectal cancer is usually traumatic and of questionable curative value. The use of radioimmunoguided surgery (RIGS) in enhancing the surgeon's assessment of the extent of disease in these patients was investigated.

METHODS

Twenty-one patients diagnosed with recurrent pelvic cancer were operated using the RIGS(O)system. Preoperative assessment included CTs of chest, abdomen and pelvis as well as colonoscopy. Patients were injected with CC49, a monoclonal antibody (MoAb) labelled with 125I. Surgical exploration was followed by survey with the gamma-detecting probe.

RESULTS

Surgical exploration identified eight intra-colorectal recurrences, nine extra-colonic pelvic recurrences and five extra-pelvic lymph node metastases. RIGS exploration confirmed all intra-colonic recurrences except for one (patient with no MoAb localization), identified 13 pelvic recurrences and 10 lymph node metastases. There were seven patients with occult findings (33%), resulting in a modified surgical procedure. Surgery included five abdomino-perineal resections, six low anterior resections, seven excisions of presacral tumour, eight total abdominal hysterectomy and bilateral salpingo-oophorectomy, one pelvic exenteration and one post-exenteration. There were no operative deaths. Eight patients had minor complications, and one patient had a major complication with reoperation due to urinary leak. The mean follow-up was 18 months. Ten patients died of disease.

CONCLUSION

Although not curative, RIGS can help the surgeon in the decision-making process through better disease staging.

Is carcino-embryonic antigen useful in the follow-up management of patients with colorectal liver metastases?

BACKGROUND

The role of carcino-embryonic antigen (CEA) in monitoring early detection of recurrent or metastatic colorectal cancer, and its impact on resectability rate and patient survival remains controversial. Our objective was to determine any association between the preoperative level of CEA and prognosis, and the resectability and survival by method of diagnosis of colorectal hepatic metastases.

METHODS

We analyzed patients who underwent exploration for hepatic resection for metastatic colorectal cancer over a 15-year period. The patient population consisted of those patients who had undergone primary colon or rectal resection and were followed up with serial CEA levels and of patients who were followed up with physical examination, liver function tests (LFTs) or computed tomography (CT) of the abdomen and pelvis that led to the diagnosis of liver metastases. Also included in the study were patients who were diagnosed with liver metastases at the time of the primary colon or rectal resection and underwent planned hepatic resection at a later time.

RESULTS

Three hundred and one (301) patients who underwent a total of 345 planned hepatic resections for metastatic colorectal cancer between January 1978 and December 1993 were included in this analysis. The median preoperative CEA level was 24.8 ng/mL in the resected group, 53.0 ng/mL in the incomplete resection group, and 49.1 ng/mL in the nonresected group (P = 0.02). More of the patients who had a preoperative CEA < or =30 ng/mL were in the resected group, while those who had a preoperative CEA >30 ng/mL were likely to be in the nonresected group (P = 0.002). The median survival was 25 months for patients with a preoperative CEA level < or =30 ng/mL and 17 months for patients with a preoperative CEA >30 ng/mL (P = 0.0005). The resectability rate and the survival of patients by method of diagnosing liver metastases-rising CEA versus history and physical, elevated LFTs, CT scan versus diagnosis at the time of primary resection-was not significant (P = 0.06 and P = 0.19, respectively). Given the nonstandardized retrospective nature of the study cohort and relative small groups of patients, the power to detect small differences in survival by method of diagnosis is limited. In the complete resection group of patients with unilobar liver disease (5-year survival of 28.8%) there was no difference in survival between those patients who had normal preoperative CEA and those who had elevated preoperative CEA, and approximately 90% of them had an abnormal preoperative serum CEA level.

CONCLUSIONS

CEA is useful in the preoperative evaluation of patients with hepatic colorectal metastases for assessing prognosis and is complimentary to history and physical examination in the diagnosis of liver metastases. Patients with colorectal liver metastases and preoperative CEA < or =30 ng/mL are more likely to be resectable, and they have the longest survival.

Radioimmunoguided surgery benefits in carcinoembryonic antigen-directed second-look surgery in the asymptomatic patient after curative resection of colorectal cancer

Radioimmunoguided surgery (RIGS) with radiolabeled monoclonal antibodies (MoAbs) has been reported as useful in second-look colorectal cancer procedures to improve surgical decision-making by helping avoid needless extensive surgery and expanding curative resection to sites of recurrence that have been missed previously. Sixteen asymptomatic patients with an history of colorectal cancer surgery underwent second-look surgery using the RIGS system, solely on the basis of rising serum levels of carcinoembryonic antigen (CEA). All patients were injected preoperatively with the anti-tumor-associated glycoprotein (TAG) 125I-labeled MoAb B72.3. Both traditional and RIGS exploration were used to determine the extension of a possible recurrence and its resectability for cure. Recurrent disease was observed in 14 of the 16 patients as the result of this combined exploration. Exploration alone showed the presence of recurrent disease in 9 of 16 patients (56.2%). Thus, RIGS found overlooked tumor in five patients (31.2%). All the additional RIGS-detected tumor sites were locoregional recurrences resectable for cure; conversely, no diagnostic improvements were shown in patients with liver metastases. Resection for cure was obtained by this approach in 9 of 16 patients (56.2%). Two patients without disease at the exploratory laparotomy recurred within 2 months at sites away from the abdomen. RIGS improved the results of colorectal cancer CEA-guided second-look procedures in asymptomatic patients by recruiting one-third of patients to curative resections.

Radioimmunoguided surgery benefits for recurrent colorectal cancer

BACKGROUND

Despite new adjuvant therapy, 50% of patients with colon cancer will have recurrent disease. This study investigated the use of a radiolabeled monoclonal antibody in locating occult tumor during surgery for recurrent colorectal cancer.

METHODS

Twenty-two patients with recurrent colorectal cancer underwent surgery using the radioimmunoguided surgery (RIGS) system. All patients were subjected to abdominal and chest computed tomography (CT). Before surgery, patients were injected with the CC49 monoclonal antibody (MoAb), anti-TAG antibody labeled with 125I. Ten patients with elevated carcinoembryonic antigen (CEA) levels and no CT findings had a scintigraphy scan with an anti-CEA MoAb labeled with 99Tc. Human antimouse antibody levels of these patients were within normal limits. Surgical exploration including liver ultrasound examination was followed by survey with a gamma-detecting probe (GDP).

RESULTS

There was MoAb tumor localization in 100% of the patients. CT found nine tumor sites, traditional surgical exploration 30, and the GDP 51, with 44 confirmed by pathology (hematoxylin and eosin). The RIGS system found occult tumor in 10 patients (45.4%) and resulted in major changes in surgical procedure in 11 patients. In the 10 patients who had scintigraphy scans, 10 tumor sites were identified, whereas RIGS found an additional eight sites.

CONCLUSION

RIGS technology offers a substantial benefit for patients undergoing surgery for recurrent colorectal cancer and a better chance of finding recurrent tumor intraoperatively in patients who have elevated CEA levels with no other CT findings.

N-terminal peptide of type III procollagen: a possible predictor of colorectal carcinoma recurrence

BACKGROUND

The first step of colorectal carcinoma spread depends on the ability of the tumor cells to degrade and invade the extracellular matrix (ECM). The objectives of the current study were to evaluate the serum pattern of laminin, C-terminal peptide of Type I (PIP), and N-terminal peptide of Type III (PIIIP) procollagens, markers of ECM synthesis, in the follow-up of patients after resection for colorectal carcinoma and to evaluate their role in predicting local recurrence or metastases.

METHODS

A total of 32 patients who had undergone resection for colorectal carcinoma were followed for a median period of 24 months (range, 6-36 months). Every 3 months, laminin, PIP, and PIIIP were measured in the sera together with the tumor markers carcinoembryonic antigen (CEA), CA 19-9, and tissue plasminogen activator (TPA). Twenty-one patients (Group 1) had no signs of recurrence, whereas the remaining 11 (Group 2) developed hepatic (n = 7) or pulmonary (n = 4) metastases.

RESULTS

No variations were observed in either group for laminin, CEA, CA 19-9, or TPA, whereas significant increases in PIP and PIIIP were observed in both groups 3 months after surgery. The increase in PIP and PIIIP at the 3-month follow-up was significantly greater in Group 1 than in Group 2. The difference between values at 3 months and basal values enabled a discrimination between Group 1 and Group 2, with a sensitivity of 36% and 91% and a specificity of 71% and 71% for PIP and PIIIP, respectively.

CONCLUSIONS

The authors believe PIIIP is useful as an early prognostic indicator of recurrence in the follow-up of patients who have undergone radical resection for colorectal carcinoma.

Role of carcinoembryonic antigen in predicting resectability of recurrent colorectal cancer

The reported low resectability rate for patients with recurrent colorectal cancer who have carcinoembryonic antigen (CEA) levels > 11 has led us to perform this study. One hundred twenty-four patients who underwent Radioimmunoguided Surgery (RIGS) procedures for recurrent colorectal cancer from 1986 to the present were studied. In surgery, all patients underwent a traditional exploration followed by survey with a hand-held, gamma-detecting probe to detect preinjected radiolabeled monoclonal antibodies attached to cancer cells. Sites of metastases included: 72 liver (58.1 percent), 23 pelvis (18.5 percent), 15 distant lymph nodes (12.1 percent), 2 anastomotic (1.6 percent), and 12 other sites (9.7 percent). The resectability rate was 43.5 percent (54 patients). The mean preoperative CEA level for patients with resectable disease was significantly lower than for patients with unresectable disease (P = 0.017): unresectable--mean, 87.1; SD, 141.0; minimum, 0.3; maximum, 501; resectable--mean, 36.6; SD, 59.3; minimum, 0.3; maximum, 329. The CEA level for patients with liver metastasis did not vary significantly from those patients without metastasis: 70 vs. 58.2 (P = 0.58). Those patients with resectable liver tumors had lower mean CEA levels than those with unresectable liver, approaching significance: 41.6 vs. 91.9 (P = 0.065). Other metastatic sites had a mean CEA level of: pelvic, 72.6; distant lymph nodes, 47.8; anastomotic, 2.7; and other sites, 53.8. These data suggest that there is a significant difference between the preoperative CEA level of the resectable and unresectable recurrent colorectal cancer patients, but the large standard deviation does not justify abandonment of exploration for any CEA level.