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Schellerer VS, Langheinrich MC, Zver V, Grützmann R, Stürzl M, Gefeller O, Naschberger E, Merkel S. Soluble intercellular adhesion molecule-1 is a prognostic marker in colorectal carcinoma. Int J Colorectal Dis 2019; 34:309-317. [PMID: 30470940 PMCID: PMC6331741 DOI: 10.1007/s00384-018-3198-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 02/04/2023]
Abstract
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-1high and sICAM-1low 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-1low (< 290 ng/ml, n = 208) was significantly increased (83.4%) as compared to that of patients with sICAM-1high (≥ 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.
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Affiliation(s)
- Vera S. Schellerer
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
| | - Melanie C. Langheinrich
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
| | - Veronika Zver
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
| | - Michael Stürzl
- Division of Molecular and Experimental Surgery, Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Olaf Gefeller
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander- University of Erlangen-Nürnberg, Erlangen, Germany
| | - Elisabeth Naschberger
- Division of Molecular and Experimental Surgery, Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
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Kim SB, Fernandes LC, Saad SS, Matos D. Assessment of the Value of Preoperative Serum Levels of CA 242 and CEA in the Staging and Postoperative Survival of Colorectal Adenocarcinoma Patients. Int J Biol Markers 2018; 18:182-7. [PMID: 14535588 DOI: 10.1177/172460080301800305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction CEA is the most frequently used tumor marker in colorectal cancer. There may be an improvement in its efficacy when used in association with CA 242. Aim The purpose of this study was to evaluate the efficacy of preoperative serum levels of the tumor markers CA 242 and CEA in the staging and postoperative follow-up of colorectal adenocarcinoma patients. Patients and Methods Of a series of 134 patients with colorectal adenocarcinomas 90 underwent radical surgery and 44 palliative surgery. The control group consisted of 22 organ donors. The cutoff serum levels utilized were 5 ng/mL for CEA and 20 U/mL for CA 242. The mortality during follow-up was recorded in order to determine the duration of survival. The data were submitted to statistical analysis using diagnostic tests, the chi-square test, survival analysis (Kaplan and Meier) and ROC curves. A significance level of p ≤ 0.05 was applied. Results The sensitivity of CEA in Dukes’ stages A, B, C and D was 27.8%, 32.4%, 32.1% and 66.7%, respectively. The sensitivity of CA 242 was 11.1%, 16.2%, 30.8% and 50%. When both markers were combined, the sensitivity was 33.3%, 48.6%, 40.7% and 72.5%. In the group of patients who underwent radical surgery the mean survival was 60.47 months for those with high preoperative CEA levels, 52.22 months for those with high preoperative CA 242 levels, and 44.80 months for those with elevated levels of both markers. There was a statistically significant difference in survival between patients undergoing radical surgery with elevated CA 242 levels, especially when CEA was also elevated, and patients without elevated CA 242. Conclusion Preoperative serum levels of CA 242 showed less efficacy than CEA levels for the staging of colorectal adenocarcinoma patients. Elevated preoperative serum levels of CA 242 alone were related to poor survival, especially in association with high levels of CEA.
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Affiliation(s)
- S B Kim
- Surgical Gastroenterology Division, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
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Incorporation of CEA Improves Risk Stratification in Stage II Colon Cancer. J Gastrointest Surg 2017; 21:770-777. [PMID: 28290141 DOI: 10.1007/s11605-017-3391-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/28/2017] [Indexed: 01/31/2023]
Abstract
High-risk features are used to direct adjuvant therapy for stage II colon cancer. Currently, high-risk features are identified postoperatively, limiting preoperative risk stratification. We hypothesized carcinoembryonic antigen (CEA) can improve preoperative risk stratification for stage II colon cancer. The National Cancer Database (NCDB 2004-2009) was reviewed for stage II colon adenocarcinoma patients undergoing curative intent resection. A novel risk stratification including both traditional high-risk features (T4 lesion, <12 lymph nodes sampled, and poor differentiation) and elevated CEA was developed. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyzed overall survival. Concordance Probability Estimates (CPE) assessed discrimination. Seventy-four thousand nine hundred forty-five patients were identified; 40,844 (54.5%) had CEA levels reported and were included. Chemotherapy administration was similar between normal and elevated CEA groups (23.8 vs. 25.1%, p = 0.003). Compared to patients with CEA elevation, 5-year overall survival in patients with normal CEA was improved (74.5 vs. 63.4%, p < 0.001). Restratification incorporating CEA resulted in reclassification of 6912 patients (16.9%) from average to high risk. CPE increased for novel risk stratification (0.634 vs. 0.612, SE = 0.005). The routinely available CEA test improved risk stratification for stage II colon cancer. CEA not only may improve staging of colon cancer but may also help guide additional therapy.
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Tarantino I, Warschkow R, Schmied BM, Güller U, Mieth M, Cerny T, Büchler MW, Ulrich A. Predictive Value of CEA for Survival in Stage I Rectal Cancer: a Population-Based Propensity Score-Matched Analysis. J Gastrointest Surg 2016; 20:1213-22. [PMID: 27067235 DOI: 10.1007/s11605-016-3137-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/21/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of the study was to assess whether preoperative carcinoembryonic antigen (CEA) level is an independent predictor of overall- and cancer-specific survival in stage I rectal cancer. METHODS Stage I rectal cancer patients were identified in the Surveillance, Epidemiology, and End Results database between 2004 and 2011. The impact of an elevated preoperative CEA level (C1-stage) compared with a normal CEA level (C0-stage) on overall and cancer-specific survival was assessed using risk-adjusted Cox proportional hazard regression models and propensity score methods. RESULTS Overall, 1932 stage I rectal cancer patients were included, of which 328 (17 %) patients had C1-stage. The 5-year overall and cancer-specific survival for patients with C0-stage were 85.7 % (95 % CI 83.2-88.2 %) and 94.7 % (95 % CI 93.1-96.3 %), versus 76.8 % (95 % CI 70.9-83.1 %) and 88.1 % (95 % CI 83.3-93.2 %) for patients with C1-stage (P < 0.001 and P = 0.001). The negative impact of C1-stage on overall and cancer-specific survival was confirmed by risk-adjusted Cox proportional hazard regression analysis (hazard ratio [HR] = 1.57, 95 % CI = 1.15-2.16, P = 0.007 and 2.04, 95 % CI = 1.25-3.33, P = 0.006), and after propensity score matching (overall survival [OS]: HR = 1.46, 95 % CI = 1.02-2.08, P = 0.044 and cancer-specific survival [CSS]: HR = 3.28, 95 % CI = 1.78-6.03, P < 0.001). CONCLUSION This is the first population-based investigation of a large cohort of exclusively stage I rectal cancer patients providing compelling evidence that elevated preoperative CEA level is a strong predictor of worse overall and cancer-specific survival.
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Affiliation(s)
- Ignazio Tarantino
- Department of General, Abdominal and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, 69120, Heidelberg, Germany
| | - Bruno M Schmied
- Department of Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Ulrich Güller
- Department of Medical Oncology and Hematology, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.,University Clinics for Visceral Surgery and Medicine, University Hospital Berne, 3010, Berne, Switzerland
| | - Markus Mieth
- Department of General, Abdominal and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Cerny
- Department of Medical Oncology and Hematology, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Markus W Büchler
- Department of General, Abdominal and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Abdominal and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Sørensen CG, Karlsson WK, Pommergaard HC, Burcharth J, Rosenberg J. The diagnostic accuracy of carcinoembryonic antigen to detect colorectal cancer recurrence - A systematic review. Int J Surg 2015; 25:134-44. [PMID: 26700203 DOI: 10.1016/j.ijsu.2015.11.065] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/29/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Carcinoembryonic Antigen (CEA) has been used as a tumor marker in the follow-up of colorectal cancer for more than 40 years. Controversy exists regarding its diagnostic applicability due to a relatively low sensitivity and a questionable effect on mortality. The aim of this review was to assess the diagnostic accuracy of CEA in detecting recurrence after intended curative surgery for primary colorectal cancer. METHODS Systematic literature searches were performed in PubMed, EMBASE and Cochrane databases, and articles were chosen based on predefined inclusion criteria. Reference lists from included articles were manually searched for additional publications of relevance. RESULTS Forty-two original studies with generally representative populations and long follow-up were included. Data were reported on outcomes from 9,834 CEA tests during follow-up. Reporting on the reference standards used was not optimal. Sensitivity of CEA ranged from 17.4 % to 100 %, specificity ranged from 66.1 % to 98.4 %, positive predictive value ranged from 45.8 % to 95.2% and negative predictive value ranged from 74.5 % to 100 %. CONCLUSION Results point toward a sensitivity of CEA ranging between 50 % and 80 %, and a specificity and negative predictive value above 80 %. Results on positive predictive value showed low reliability. Overall, CEA did not effectively detect treatable recurrences at an early stage, and a clinically relevant effect on patient mortality remains to be proven.
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Affiliation(s)
- Caspar G Sørensen
- Faculty of Health Sciences - University of Copenhagen, Blegdamsvej 3 - 2200 København N, Denmark.
| | - William K Karlsson
- Faculty of Health Sciences - University of Copenhagen, Blegdamsvej 3 - 2200 København N, Denmark
| | - Hans-Christian Pommergaard
- Hvidovre Hospital - University of Copenhagen, Department of Surgery, Kettegård Alle 30 - 2650 Hvidovre, Denmark
| | - Jakob Burcharth
- Herlev Hospital - University of Copenhagen, Centre for Perioperative Optimization, Department of Surgery, Herlev Ringvej 75 - 2730 Herlev, Denmark
| | - Jacob Rosenberg
- Herlev Hospital - University of Copenhagen, Centre for Perioperative Optimization, Department of Surgery, Herlev Ringvej 75 - 2730 Herlev, Denmark
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Nicholson BD, Shinkins B, Pathiraja I, Roberts NW, James TJ, Mallett S, Perera R, Primrose JN, Mant D. Blood CEA levels for detecting recurrent colorectal cancer. Cochrane Database Syst Rev 2015; 2015:CD011134. [PMID: 26661580 PMCID: PMC7092609 DOI: 10.1002/14651858.cd011134.pub2] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Testing for carcino-embryonic antigen (CEA) in the blood is a recommended part of follow-up to detect recurrence of colorectal cancer following primary curative treatment. There is substantial clinical variation in the cut-off level applied to trigger further investigation. OBJECTIVES To determine the diagnostic performance of different blood CEA levels in identifying people with colorectal cancer recurrence in order to inform clinical practice. SEARCH METHODS We conducted all searches to January 29 2014. We applied no language limits to the searches, and translated non-English manuscripts. We searched for relevant reviews in the MEDLINE, EMBASE, MEDION and DARE databases. We searched for primary studies (including conference abstracts) in the Cochrane Central Register of Controlled Trials (CENTRAL), in MEDLINE, EMBASE, and the Science Citation Index & Conference Proceedings Citation Index - Science. We identified ongoing studies by searching WHO ICTRP and the ASCO meeting library. SELECTION CRITERIA We included cross-sectional diagnostic test accuracy studies, cohort studies, and randomised controlled trials (RCTs) of post-resection colorectal cancer follow-up that compared CEA to a reference standard. We included studies only if we could extract 2 x 2 accuracy data. We excluded case-control studies, as the ratio of cases to controls is determined by the study design, making the data unsuitable for assessing test accuracy. DATA COLLECTION AND ANALYSIS Two review authors (BDN, IP) assessed the quality of all articles independently, discussing any disagreements. Where we could not reach consensus, a third author (BS) acted as moderator. We assessed methodological quality against QUADAS-2 criteria. We extracted binary diagnostic accuracy data from all included studies as 2 x 2 tables. We conducted a bivariate meta-analysis. We used the xtmelogit command in Stata to produce the pooled estimates of sensitivity and specificity and we also produced hierarchical summary ROC plots. MAIN RESULTS In the 52 included studies, sensitivity ranged from 41% to 97% and specificity from 52% to 100%. In the seven studies reporting the impact of applying a threshold of 2.5 µg/L, pooled sensitivity was 82% (95% confidence interval (CI) 78% to 86%) and pooled specificity 80% (95% CI 59% to 92%). In the 23 studies reporting the impact of applying a threshold of 5 µg/L, pooled sensitivity was 71% (95% CI 64% to 76%) and pooled specificity 88% (95% CI 84% to 92%). In the seven studies reporting the impact of applying a threshold of 10 µg/L, pooled sensitivity was 68% (95% CI 53% to 79%) and pooled specificity 97% (95% CI 90% to 99%). AUTHORS' CONCLUSIONS CEA is insufficiently sensitive to be used alone, even with a low threshold. It is therefore essential to augment CEA monitoring with another diagnostic modality in order to avoid missed cases. Trying to improve sensitivity by adopting a low threshold is a poor strategy because of the high numbers of false alarms generated. We therefore recommend monitoring for colorectal cancer recurrence with more than one diagnostic modality but applying the highest CEA cut-off assessed (10 µg/L).
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Affiliation(s)
- Brian D Nicholson
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Bethany Shinkins
- University of LeedsAcademic Unit of Health Economics101 Clarendon RoadLeedsUKLS29LJ
| | - Indika Pathiraja
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Tim J James
- Oxford University Hospitals NHS TrustClinical BiochemistryHeadingtonOxfordUK
| | - Susan Mallett
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - John N Primrose
- University of SouthamptonDepartment of SurgerySouthampton General HospitalTremona RoadSouthamptonUKS0322AB
| | - David Mant
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Thirunavukarasu P, Talati C, Munjal S, Attwood K, Edge SB, Francescutti V. Effect of Incorporation of Pretreatment Serum Carcinoembryonic Antigen Levels Into AJCC Staging for Colon Cancer on 5-Year Survival. JAMA Surg 2015; 150:747-755. [DOI: 10.1001/jamasurg.2015.0871] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Chetasi Talati
- Department of Internal Medicine, University of Buffalo, Buffalo, New York
| | - Sumeet Munjal
- Department of Internal Medicine, University of Buffalo, Buffalo, New York
| | - Kris Attwood
- Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York
| | - Stephen B. Edge
- Department of Surgery, Baptist Memorial Health Care, Memphis, Tennessee
| | - Valerie Francescutti
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
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Usefulness of CEA concentration measurement and classic colonoscopy in follow-up after radical treatment of colorectal cancer. POLISH JOURNAL OF SURGERY 2012; 83:310-8. [PMID: 22166547 DOI: 10.2478/v10035-011-0048-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED There is always a certain rate of recurrence after radical treatment for cancer and to get on it an early detection of disease set back is crucial. MATERIAL AND METHODS Medical data of patients operated on for primarily detected colorectal cancer in years 1993-2002 was retrospectively reviewed. Usefulness of follow-up means such as physical examination, or CEA and endoscopic surveillance was analyzed. All mentioned above were applied to scheduled follow-up (in 3, 6 and 12 month intervals following an operation and annually after that by the year 5). RESULTS Complete and reliable data was obtained from 340 out of 502 follow-up intended subjects (67.7%). Elevated CEA was the most frequent predictor of recurrence within non-symptomatic subjects meeting follow-up appointments (60%). The cancer set back diagnosed by means of either physical or endoscopic examinations was the case only in one out of five patients (20.75% and 18.87% respectively). Clinical onset of recurrence making patients meet an unscheduled appointment was found increasing relative risk of nothing-but-palliative option either for them with local set back, or meta-static spread. Relative risk of onset of meta-chronous colonic cancer was significantly higher in patients being affected by synchronous advanced adenoma at time of surgery compared to those with one-fold changes. CONCLUSIONS CEA scheduled follow-up after treatment for colorectal cancer CRC seems adequate to provide a good outcome of treatment for recurrent tumors. CRC patients presenting with synchronous advanced adenomas at time of surgery are probably to be under more intensive endoscopic surveillance.
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Thirunavukarasu P, Sukumar S, Sathaiah M, Mahan M, Pragatheeshwar KD, Pingpank JF, Zeh H, Bartels CJ, Lee KKW, Bartlett DL. C-stage in colon cancer: implications of carcinoembryonic antigen biomarker in staging, prognosis, and management. J Natl Cancer Inst 2011; 103:689-97. [PMID: 21421861 DOI: 10.1093/jnci/djr078] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The American Joint Committee on Cancer (AJCC) has proposed the inclusion of pretreatment serum carcinoembryonic antigen (CEA) level (C-stage) into the conventional TNM staging system of colon cancer. We assessed the prognosis of various stages of colon cancer after such an inclusion. METHODS Data for all patients (N = 17 910) diagnosed with colonic adenocarcinoma (AJCC stages I, IIA, IIB, IIC, IIIA, IIIB, IIIC, and IV, based on TNM staging system) between January 1, 2004, and December 31, 2004, with a median follow-up of 27 months (range 0-35 months), were collected from the Surveillance, Epidemiology, and End Results database. C-stage (C0-stage = normal CEA level; C1-stage = elevated CEA level) was assigned to all patients with available CEA information (n = 9083). Multivariable analyses using Cox proportional hazards models were used to identify independent factors associated with prognosis. Prognosis of overall stages (AJCC stages I-IV and C0 or C1) was analyzed using Kaplan-Meier survival curves. All statistical tests were two-sided. RESULTS C1-stage was independently associated with a 60% increased risk of overall mortality (hazard ratio of death = 1.60, 95% confidence interval = 1.46 to 1.76, P < .001). Overall survival was decreased in patients with C1-stage cancer compared with C0-stage cancer of the respective overall stages (P < .05). Similarly, decreased overall survival was noted in patients with stage I C1 cancer compared with stage IIA C0 or stage IIIA C0 cancer (P < .001), in patients with stage IIA C1 cancer compared with stage IIIA C0 (P < .001), and in patients with stage IIB C1 or stage IIC C1 cancer compared with stage IIIB C0 cancer (P < .001). CONCLUSIONS C-stage was an independent prognostic factor for colon cancer. The results support routine preoperative CEA testing and C-staging upon diagnosis of colon cancer and the inclusion of C-stage in the conventional TNM staging of colon cancer.
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Abstract
Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.
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Affiliation(s)
- Michael D Hellinger
- Department of Surgery, Division of Colon and Rectal Surgery, University of Miami, Miller School of Medicine, Miami, FL 33136, USA.
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11
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Goldstein MJ, Mitchell EP. Carcinoembryonic Antigen in the Staging and Follow-up of Patients with Colorectal Cancer. Cancer Invest 2009; 23:338-51. [PMID: 16100946 DOI: 10.1081/cnv-58878] [Citation(s) in RCA: 273] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Mitchell J Goldstein
- Division of Neoplastic Diseases, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Cho N, Morré DJ. Early developmental expression of a normally tumor-associated and drug-inhibited cell surface-located NADH oxidase (ENOX2) in non-cancer cells. Cancer Immunol Immunother 2009; 58:547-52. [PMID: 18704408 PMCID: PMC11030580 DOI: 10.1007/s00262-008-0577-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/30/2008] [Indexed: 10/21/2022]
Abstract
Full length mRNA to a drug-inhibited cell surface NADH oxidase, tNOX or ENOX2, is present in both non-cancer and cancer cells but is translated only in cancer cells as alternatively spliced variants. ENOX2 is a growth-related protein of the external plasma membrane surface that is shed into the circulation and is inhibited by a series of quinone site inhibitors with anticancer activity. To test the possibility that ENOX2 expression might be important to early stages of non-cancer cell development, the expression of the protein was monitored in chicken embryos during their development. Polyclonal antisera to a 34 kDa human serum form of ENOX2 cross-immunoreactive with the drug-responsive NADH oxidase of chicken hepatoma cells was used. The protein was identified based on drug-responsive enzymatic activities and analyses by western blots. The drug-responsive activity was associated with plasma membranes and sera of early chicken embryos and with chicken hepatoma plasma membranes but was absent from plasma membranes prepared from livers or from sera of normal adult chickens and from late embryo stages. The findings suggest that ENOX2 may fulfill some functions essential to the growth of early embryos which are lost in late embryo stages and absent from normal adult cells but which then reappear in cancer.
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Affiliation(s)
- NaMi Cho
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, Hansen Life Sciences Research Building, 201 S. University Street, West Lafayette, IN 47907 USA
| | - D. James Morré
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, Hansen Life Sciences Research Building, 201 S. University Street, West Lafayette, IN 47907 USA
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Diagnostic precision of carcinoembryonic antigen in the detection of recurrence of colorectal cancer. Surg Oncol 2008; 18:15-24. [PMID: 18619834 DOI: 10.1016/j.suronc.2008.05.008] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 05/27/2008] [Accepted: 05/28/2008] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer. METHODS Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a 'positive' CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken. RESULTS The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61-0.67) and 0.90 (95% CI: 0.89-0.91), respectively. The area under the SROC curve was 0.75 (SE=0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94-28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving > or =100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC. CONCLUSION Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.
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Yao YF, Yang Z, Li ZF, Gu J. Immunoscintigraphy of local recurrent rectal cancer with 99mTc-labeled anti-CEA monoclonal antibody CL58. World J Gastroenterol 2007; 13:1841-6. [PMID: 17465478 PMCID: PMC4149964 DOI: 10.3748/wjg.v13.i12.1841] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore a specific diagnostic method for local recurrent rectal cancer.
METHODS: Immunoscintigraphy with 99mTc-labeled anti-CEA monoclonal antibody (MoAb) CL-58 was performed for patients suspected of having a postoperative local recurrent rectal cancer and the findings were compared with the results of conventional imaging and pathology.
RESULTS: A total of 36 patients with a suspected local recurrent rectal cancer underwent immunoscintigraphy with 99mTc-conjugated CL58. Local recurrence of rectal cancer was identified in 31 patients and established in 30 during operation, endoscopy and pathological examination. No local recurrence was found in 5 patients without specific accumulation of 99mTc during the follow-up. Immunoscintigraphy had a positive rate of 86.11%, a specificity of 83.33%, and a sensitivity of 100%.
CONCLUSION: Immunoscintigraphy has a highly specific and predictive value for detecting local recurrent rectal cancer, especially after abdominal perineal resection (APR).
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Affiliation(s)
- Yun-Feng Yao
- Peking University School of Oncology, Beijing 100036, China
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Bhattacharjya S, Aggarwal R, Davidson BR. Intensive follow-up after liver resection for colorectal liver metastases: results of combined serial tumour marker estimations and computed tomography of the chest and abdomen - a prospective study. Br J Cancer 2006; 95:21-6. [PMID: 16804525 PMCID: PMC2360492 DOI: 10.1038/sj.bjc.6603219] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/20/2006] [Accepted: 05/15/2006] [Indexed: 12/11/2022] Open
Abstract
The aim of the study was to prospectively evaluate an intensive follow-up programme using serial tumour marker estimations and contrast-enhanced computed tomography (CT) of the chest and abdomen in patients undergoing potentially curative resection of colorectal liver metastases. Seventy-six consecutive patients having undergone potentially curative resections of colorectal liver metastases in a single unit were followed up with a protocol of 3 monthly carcinoembryonic antigen and carbohydrate antigen 19-9 estimations and contrast-enhanced spiral CT of the chest, abdomen and pelvis for the first 2 years following surgery and 6 monthly thereafter. The median period of follow-up was 24 months (range 18-60). Recurrent tumour was classed as early if within 6 months of liver resection. Thirty-seven of the 76 patients (49%) developed recurrence on follow-up. Nineteen recurrences were in the liver alone (51%), 16 liver and extrahepatic (43%) and two extrahepatic alone (6%). Of the 19 patients with isolated liver recurrence, eight developed within 6 months of liver resection none of which were resectable. Of the 11 recurrences after 6 months, five (45%) were resectable. Of the 37 recurrences, CT indicated recurrence despite normal tumour markers in 19 patients. Tumour markers suggested recurrence before imaging in 12 and concurrently with imaging in 6. In the 12 patients who presented with elevated tumour markers before imaging, there was a median lag period of 3 months (range 1-21) in recurrence being detected on further serial imaging. Seventeen patients who developed recurrence had normal tumour markers before initial resection of their liver metastases. Of these 17, 10 (58%) had an elevation of tumour markers associated with recurrence. Over a median follow-up of 2 years following liver resection, the use of CT or tumour markers alone would have failed to demonstrate early recurrence in 12 and 18 patients respectively. A combination of tumour markers and CT detected significantly more (P < 0.05) recurrence than either modality alone. Tumour markers and CT should be used in combination in the follow-up of patients with resected colorectal liver metatases, including patients whose markers are normal at the time of initial liver resection.
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Affiliation(s)
- S Bhattacharjya
- Department of Surgery, Royal Free and University College School of Medicine, University College London, The Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - R Aggarwal
- Department of Surgery, Royal Free and University College School of Medicine, University College London, The Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - B R Davidson
- Department of Surgery, Royal Free and University College School of Medicine, University College London, The Royal Free Hospital, Pond Street, London NW3 2QG, UK
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Fernandes LC, Kim SB, Saad SS, Matos D. Value of carcinoembryonic antigen and cytokeratins for the detection of recurrent disease following curative resection of colorectal cancer. World J Gastroenterol 2006; 12:3891-4. [PMID: 16804977 PMCID: PMC4087940 DOI: 10.3748/wjg.v12.i24.3891] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of postoperative serial assay of carcinoembryonic antigen (CEA) and cytokeratins for the detection of recurrent disease in patients with colorectal adenocarcinoma after radical surgery.
METHODS: Between 1993 and 2000, 120 patients with colorectal adenocarcinoma underwent radical surgery in the Department of Surgical Gastroenterology, Federal University of São Paulo-Escola Paulista de Medicina, São Paulo, Brazil. Periodic postoperative evaluation was performed by assaying markers in peripheral serum, colonoscopy and imaging examination. Presence of CEA was detected using the Delfia® method with 5 μg/L threshold, and cytokeratins using the LIA-mat® TPA-M Prolifigen® method with 72 U/L threshold.
RESULTS: In the first postoperative year, patients without recurrent disease had normal levels of CEA (1.5 ± 0.9 μg/L) and monoclonal tissue polypeptide antigen-M (TPA-M, 64.4 ± 47.8 U/L), while patients with recurrences had high levels of CEA (6.9 ± 9.8 μg/L, P < 0.01) and TPA-M (192.2 ± 328.8 U/L, P < 0.05). During the second postoperative year, patients without tumor recurrence had normal levels of CEA (2.0 ± 1.8 μg/L) and TPA-M (50.8 ± 38.4 U/L), while patients with recurrence had high levels of CEA (66.3 ± 130.8 μg/L, P < 0.01) and TPA-M (442.7 ± 652.8 U/L, P < 0.05). The mean follow-up time was 22.3 mo. There was recurrence in 23 cases. Five reoperations were performed without achieving radical excision. Rises in tumor marker levels preceded identification of recurrences: CEA in seven (30%) and TPA-M in eleven individuals (48%).
CONCLUSION: Intensive follow-up by serial assay of CEA and cytokeratins allows early detection of colorectal neoplasm recurrence.
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Affiliation(s)
- Luis C Fernandes
- Department of Surgical Gastroenterology, Federal University of São Paulo-Escola Paulista de Medicina, Brazil.
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Paty PB, Wong WD. Preoperative evaluation and postoperative follow-up for patients with rectal cancer. ACTA ACUST UNITED AC 2005; 51:31-8. [PMID: 15771284 DOI: 10.2298/aci0402031p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Rectal cancer has a wide variety of presentations. In most cases, it is the surgeon who is faced with the challenge of determining the extent of disease and advising the patient how to proceed with treatment. Utilizing diagnostic tests of the highest accuracy and relevance will help in the selection of the best initial therapy, which is critical for achieving the highest cure rate while also avoiding over-treatment and unnecessary morbidity. Following curative treatment, surveillance testing for detection of recurrence is traditionally done, but the efficacy of this practice has been questioned. Surveillance will detect a number of asymptomatic recurrences that are treatable by potentially curative salvage surgery, but to what extent early detection improves salvage therapy is not well established. In this brief review, the goals, methods, and expected benefits of rectal cancer staging and surveillance are assessed.
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Affiliation(s)
- P B Paty
- Memorial Sloan-Kettering Cancer Center, New York, USA
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Fernandes LC, Kim SB, Matos D. Cytokeratins and carcinoembryonic antigen in diagnosis, staging and prognosis of colorectal adenocarcinoma. World J Gastroenterol 2005; 11:645-8. [PMID: 15655814 PMCID: PMC4250731 DOI: 10.3748/wjg.v11.i5.645] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the serum levels of cytokeratins and carcinoembryonic antigen (CEA) in diagnosis, staging and prognosis of patients with colorectal adenocarcinoma.
METHODS: The sample consisted of 169 patients. One hundred blood donors formed the control group. Radical surgery was performed on 120 patients, with an average follow-up duration of 22.3 mo. Relapses occurred in 23 individuals after an average of 18.09 mo. CEA was assayed via the Delfia® method with a limit of 5 ng/mL. Cytokeratins were assayed via the LIA-mat® TPA-M Prolifigen® method with a limit of 72 U/L.
RESULTS: In the diagnosis of patients with colorectal adenocarcinoma, CEA showed a sensitivity of 56%, a specificity of 95%, a positive predictive value of 94%, a negative predictive value of 50% and an accuracy of 76.8%. TPA-M had a sensitivity of 70%, a specificity of 96%, a positive predictive value of 97%, a negative predictive value of 66% and an accuracy of 93.6%. The elevation of one of the markers was shown to have a sensitivity of 76.9%, a specificity of 91%, a positive predictive value of 93.5%, a negative predictive value of 70% and an accuracy of 83.6%. There was no variation in the levels of the markers according to the degree of cell differentiation while there was an elevation in their concentrations in accordance with the increase in neoplastic dissemination. There was a statistically significant difference between the patients with stage IV lesions and those with stages I, II and III tumors. With regard to CEA, the average level was 14.2 ng/mL in patients with stage I lesions, 8.5 ng/mL in patients with stage II lesions, 8.0 ng/mL in patients with stage III lesions and 87.7 ng/mL in patients with stage IV lesions. In relation to TPA-M, the levels were 153.1 U/L in patients with stage I tumors, 106.5 U/L in patients with stage II tumors, 136.3 U/L in patients with stage III tumors and 464.3 U/L in patients with stage IV tumors. There was a statistical difference in patients with a high CEA level in relation to a shorter survival (P<0.05). However, there was no correlation between patients with high TPA-M levels and prognostic indices of patients undergoing radical surgery.
CONCLUSION: Cytokeratins demonstrate a greater sensitivity than CEA in the diagnosis of colorectal adenocarcinoma. There is an increase in the sensitivity of the markers with tumor dissemination. Cytokeratins cannot identify the worse prognosis in patients undergoing radical surgery. Cytokeratins constitute an advance in the direction of a perfect tumor marker in the treatment of patients with colorectal cancer.
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Affiliation(s)
- Luís C Fernandes
- Coloproctology Sector of Surgical Gastroenterology Department, UNIFESP-Escola Paulista de Medicina, Al. Santos, 211, cj.304, Paraiso Sao Paulo-SP 01419-000, Brazil.
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Carpelan-Holmström M, Louhimo J, Stenman UH, Alfthan H, Järvinen H, Haglund C. CEA, CA 242, CA 19-9, CA 72-4 and hCGbeta in the diagnosis of recurrent colorectal cancer. Tumour Biol 2005; 25:228-34. [PMID: 15627885 DOI: 10.1159/000081385] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2004] [Accepted: 07/10/2004] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The purpose of this study was to compare the utility of serum CEA, CA 19-9, CA 242, CA 72-4 and human chorionic gonadotropin (hCG)beta in the follow-up of 102 surgically treated colorectal cancer patients, out of which 40 patients developed clinical recurrence. METHODS In patients with recurrent disease, serum samples were obtained at the time of clinical recurrence, and in the disease-free group, they were obtained postoperatively. The combined use of the markers was evaluated with logistic regression analysis. The sensitivities of the different tumour markers at various specificity levels were compared by receiver operating characteristic (ROC) curve analysis. RESULTS When the five tumour markers, Dukes stage and location of the primary tumour were evaluated together in the same model, only CEA provided significant diagnostic information (p < 0.0005) in addition to the location of the primary tumour (p = 0.003). The diagnostic information provided by the other serum tumour markers was insignificant, although CA 72-4 approached borderline significance (p = 0.053). ROC curves were constructed and the difference in the values of the area under the curve (AUC) between the different serum tumour markers was determined at the time of clinical recurrence. Of the individual markers, the highest AUC was observed for CEA (AUC = 0.931). The difference in AUC values between CEA and the other tumour markers was highly significant (p < or = 0.001). CONCLUSIONS CEA had the highest diagnostic accuracy in detecting recurrent colorectal cancer. Inclusion of CA 19-9, CA 242, CA 72-4 or hCGbeta in the model did not improve the accuracy, although CA 72-4 approached borderline significance (p = 0.053). Thus, CEA seems to retain its position as the surveillance marker of choice for patients surgically treated for colorectal cancer.
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Abstract
Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.
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Affiliation(s)
- J Kievit
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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23
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Park KC, Schwimmer J, Shepherd JE, Phelps ME, Czernin JR, Schiepers C, Gambhir SS. Decision analysis for the cost-effective management of recurrent colorectal cancer. Ann Surg 2001; 233:310-9. [PMID: 11224617 PMCID: PMC1421245 DOI: 10.1097/00000658-200103000-00003] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine whether the use of [(18)F]2-fluoro-2-deoxyglucose positron emission tomography (FDG PET) in addition to computed axial tomography (CT) is helpful in managing recurrent colorectal cancer (CRC). SUMMARY BACKGROUND DATA There is no consensus on a management algorithm for CRC. However, when recurrence is suspected, CT is generally used for further evaluation and staging of disease. METHODS The authors used decision trees based on theoretical models to assess the cost-effectiveness of a CT + FDG PET strategy for the diagnosis and management of recurrent CRC compared with a CT-alone strategy. These theoretical models focus on patients with hepatic recurrence who are potentially curable through surgical hepatic resection. The population entering the decision trees consisted of patients with CRC who had undergone surgical resection of their primary CRC and who were suspected of having recurrence based on elevated levels of carcinoembryonic antigen. RESULTS The CT + FDG PET strategy was found to be cost-effective for managing patients with elevated carcinoembryonic antigen levels who were candidates for hepatic resection. The CT + FDG PET strategy was higher in mean cost by $429 per patient but resulted in an increase in the mean life expectancy of 9.527 days per patient. CONCLUSIONS These results show, through rigorous decision tree analysis, the potential cost-effectiveness of FDG PET in the management of recurrent CRC. The decision trees can be used to model various features of the management of recurrent CRC, including the cost-effectiveness of other newly emerging technologies.
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Affiliation(s)
- K C Park
- Crump Institute for Molecular Imaging, the Department of Molecular & Medical Pharmacology, the Division of Nuclear Medicine, UCLA School of Medicine, Los Angeles, California 90095, USA
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Engarås B, Kewenter J, Nilsson O, Wedel H, Hafström L. CEA, CA 50 and CA 242 in patients surviving colorectal cancer without recurrent disease. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2001; 27:43-8. [PMID: 11237491 DOI: 10.1053/ejso.2000.1027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- B Engarås
- Department of Surgery, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden
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Avital S, Haddad R, Troitsa A, Kashtan H, Brazovsky E, Gitstein G, Skornick Y, Schneebaum S. Radioimmunoguided surgery for recurrent colorectal cancer manifested by isolated CEA elevation. Cancer 2000; 89:1692-8. [PMID: 11042562 DOI: 10.1002/1097-0142(20001015)89:8<1692::aid-cncr7>3.0.co;2-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) is a sensitive marker for detecting recurrent colorectal carcinoma. An asymptomatic rise of CEA can precede by several months the detection of recurrent cancer by standard imaging modalities. Yet, surgeons are hesitant to operate solely on the basis of an observed increase in CEA. We investigated the ability of radioimmunoguided surgery to enhance the surgeon's capability of detecting intraabdominal disease in these patients. METHODS Nineteen patients who underwent radioimmunoguided surgery for suspected tumor recurrence based solely on elevated CEA were included in the study. They underwent colonoscopy and CT of the abdomen and chest, all of which were negative. They then underwent scintigraphy scan with an anti-CEA monoclonal antibody (MoAb) labeled with (99m)Tc or Indium I-111. All patients were injected with the CC49 MoAb (an anti-TAG-72 tumor-associated glycoprotein) labeled with (125)I three weeks before surgery. During surgery, traditional exploration was followed by survey with a gamma-detecting probe. RESULTS Traditional surgical exploration identified 26 recurrent tumors: 7 hepatic, 8 pelvic, 6 retroperitoneal, 3 colonic, 1 splenic, and 1 anastomotic. Radioimmunoguided surgical exploration confirmed all recurrent tumors and identified additional tumor sites in seven patients that resulted in changing the surgical plan. CEA scans correlated with intraabdominal findings in seven patients. Abdominal pathology did not correlate completely with the scans in three patients, and CEA scan results were undetermined in two patients. CONCLUSION Patients with elevated CEA and no other findings should be operated upon without delay, and radioimmunoguided surgery should be used to enhance the surgeon's knowledge of the extent of disease.
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Affiliation(s)
- S Avital
- Dept. of Surgery "A," Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel-Aviv 64239, Israel
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Kievit J. Colorectal cancer follow-up: a reassessment of empirical evidence on effectiveness. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:322-8. [PMID: 10873350 DOI: 10.1053/ejso.1999.0893] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Colorectal cancer is an important cause of death in the Western world, with a propensity of cancer recurrence even after resection with curative intent. Active follow-up has been advocated as a means to detect cancer recurrence at an earlier stage and thereby improve the survival of colorectal cancer patients. The present study assesses published evidence on the effectiveness of follow-up. Articles were obtained from a 20-year Medline search and from cross-references between articles. Articles were included, scored for quality, and extracted by explicit criteria. Regression analysis and chi-squared analysis was performed to assess (1) whether detection of recurrence at earlier asymptomatic disease stage leads to better post-treatment prognosis, and (2) whether active follow-up does improve overall (quality adjusted) survival, as compared to symptom-guided care only. The relationship between disease stage of recurrence (symptoms, number and size) and survival was analysed from 42 articles, 10 of which provided adequate data. Absence of symptoms and small number of recurrence were significantly related to better survival, smaller size insignificantly so. The potential of active follow-up seemed related to a marginally better outcome, larger gains being found in lower quality studies. Available data do suggest that survival gains vary between 0.5 and 2%, 1% seeming to be a best estimate of overall survival gain. Neither the notion that earlier detection of recurrences does significantly improve outcome, nor the hope that active follow-up provides a statistically and clinically significant gain in (quality adjusted) survival, are so far supported by adequate evidence. Colorectal cancer follow-up still fails to meet the criteria for evidence based medicine.
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Affiliation(s)
- J Kievit
- Departments of Medical Decision Making and Surgery, Leiden University, The Netherlands.
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Secco GB, Fardelli R, Rovida S, Gianquinto D, Baldi E, Bonfante P, Derchi L, Ferraris R. Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer? Ann Surg Oncol 2000; 7:32-7. [PMID: 10674446 DOI: 10.1007/s10434-000-0032-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients. METHODS Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners. RESULTS Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months. CONCLUSIONS In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.
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Affiliation(s)
- G B Secco
- Department of Surgery (DICMI), University of Genoa School of Medicine, Italy
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Ishikawa H, Fujii H, Yamamoto K, Morita T, Hata M, Koyama F, Terauchi S, Sugimori S, Kobayashi T, Enomoto H, Yoshikawa S, Nishikawa T, Nakano H. Tumor angiogenesis predicts recurrence with normal serum carcinoembryonic antigen in advanced rectal carcinoma patients. Surg Today 1999; 29:983-91. [PMID: 10554319 DOI: 10.1007/s005950050633] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Many studies have established the usefulness of serum carcinoembryonic antigen (CEA) oriented serial monitoring for predicting recurrence and prognosis; however, few studies have so far investigated serum CEA-negative recurrence. The aim of this study was to elucidate the nature of CEA-negative recurrence regarding tumor angiogenesis. Fifty-seven patients with T3/T4 rectal cancer were divided into the two groups according to the serum CEA status. Angiogenesis was defined as the intratumoral vessel count by immunohistochemical staining using CD31. The CD31 count was significantly higher in the recurrent patients in both groups and the ratio of nodal involvement was significantly higher in the recurrent patients of the CEA-negative group. Local recurrence mainly developed in the CEA-negative group; however, the CD31 count did not predict the sites of recurrence nor the relapse period in the both groups. A multivariate analysis showed a high CD31 count >26) to be a prognostic factor not only for recurrence but also for survival (P = 0.001, 0.043, respectively). These results suggest that a high degree of tumor angiogenesis in sections of T3/T4 rectal cancer may therefore be an important predictor for CEA-negative recurrence.
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Affiliation(s)
- H Ishikawa
- First Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-0813, Japan
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Leconte A, Garambois V, Ychou M, Robert B, Pourquier D, Terskikh A, Mach JP, Pèlegrin A. Involvement of circulating CEA in liver metastases from colorectal cancers re-examined in a new experimental model. Br J Cancer 1999; 80:1373-9. [PMID: 10424738 PMCID: PMC2363086 DOI: 10.1038/sj.bjc.6690531] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Both experimental and clinical data show evidence of a correlation between elevated blood levels of carcinoembryonic antigen (CEA) and the development of liver metastases from colorectal carcinomas. However, a cause-effect relationship between these two observations has not been demonstrated. For this reason, we developed a new experimental model to evaluate the possible role of circulating CEA in the facilitation of liver metastases. A CEA-negative subclone from the human colon carcinoma cell line CO115 was transfected either with CEA-cDNA truncated at its 3' end by the deletion of 78 base pairs leading to the synthesis of a secreted form of CEA or with a full-length CEA-cDNA leading to the synthesis of the entire CEA molecule linked to the cell surface by a GPI anchor. Transfectants were selected either for their high CEA secretion (clone CO115-2C2 secreting up to 13 microg CEA per 10(6) cells within 72 h) or for their high CEA membrane expression (clone CO115-5F12 expressing up to 1 x 10(6) CEA molecules per cell). When grafted subcutaneously, CO115-2C2 cells gave rise to circulating CEA levels that were directly related to the tumour volume (from 100 to 1000 ng ml(-1) for tumours ranging from 100 to 1000 mm3), whereas no circulating CEA was detectable in CO115 and CO115-5F12 tumour-bearing mice. Three series of nude mice bearing a subcutaneous xenograft from either clone CO115-2C2 or the CO115-5F12 transfectant, or an untransfected CO115 xenograft, were further challenged for induction of experimental liver metastases by intrasplenic injection of three different CEA-expressing human colorectal carcinoma cell lines (LoVo, LS174T or CO112). The number and size of the liver metastases were shown to be independent of the circulating CEA levels induced by the subcutaneous CEA secreting clone (CO115-2C2), but they were directly related to the metastatic properties of the intrasplenically injected tumour cells.
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Affiliation(s)
- A Leconte
- Centre de Recherche en Cancérologie, CRLC Val d'Aurelle--Paul Lamarque Cancer Centre, Parc Euromédecine, Montpellier, France
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Abstract
YKL-40 is a mammalian member of the chitinase protein family. Although the function of YKL-40 is unknown, the pattern of its expression suggests a function in remodelling or degradation of extracellular matrix. High serum YKL-40 has been found in patients with recurrent breast cancer and has been related to short survival. In the present study we analysed YKL-40 in preoperative sera from patients with colorectal cancer and evaluated its relation to survival. Serum YKL-40 was determined by RIA in 603 patients. Survival after operation was registered, and median follow-up time was 61 months. Three hundred and forty patients died. Sixteen per cent of the patients with Dukes' A, 26% with Dukes' B, 19% with Dukes' C and 39% with Dukes' D had high serum YKL-40 levels (adjusted for age). Analysis of serum YKL-40 as a continuous variable showed an association between increased serum YKL-40 and short survival (P < 0.0001). Patients with high preoperative serum YKL-40 concentration had significantly shorter survival than patients with normal YKL-40 (HR = 1.7; 95% CI: 1.3-2.1, P < 0.0001). Multivariate Cox analysis including serum YKL-40, serum CEA, Dukes' stage, age and gender showed that high YKL-40 was an independent prognostic variable for short survival (HR = 1.4; 95% CI: 1.1-1.8, P = 0.007). These results suggest that YKL-40 may play an important role in tumour invasion.
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Affiliation(s)
- C Cintin
- Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Denmark
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Nelson RL. The usefulness of carcinoembryonic antigen in postoperative colorectal cancer patients. Dis Colon Rectum 1997; 40:866-7. [PMID: 9221868 DOI: 10.1007/bf02055448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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