Should carcinoembryonic antigen be used in the management of patients with colorectal cancer?

The optimal minimum lymph node count for carcinoembryonic antigen elevated colon cancer: a population-based study in the SEER set and External set

PURPOSE

The aim of this paper was to clarify the optimal minimum number of lymph node for CEA-elevated (≥ 5 ng/ml) colon cancer patients.

METHODS

Thirteen thousand two hundred thirty-nine patients from the SEER database and 238 patients from the Second Affiliated Hospital of Harbin Medical University (External set) were identified. For cancer-specific survival (CSS), Kaplan-Meier curves were drawn and data were analyzed using log-rank test. Using X-tile software, the optimal cut-off lymph node count was calculated by the maximal Chi-square value method. Cox regression model was applied to perform survival analysis.

RESULTS

In CEA-elevated colon cancer, 18 nodes were defined as the optimal minimum node. The number of lymph node examined (< 12, 12-17 and ≥ 18) was an independent prognosticator in both SEER set (HR_{12-17 nodes} = 1.329, P <  0.001; HR_{< 12 nodes} = 1.985, P <  0.001) and External set (HR_{12-17 nodes} = 1.774, P <  0.032; HR_{< 12 nodes} = 2.741, P <  0.006). Moreover, the revised 18-node standard could identify more positive lymph nodes compared with the 12-node standard in this population.

CONCLUSIONS

With the purpose of favorable long-term survival and accurate nodal stage for CEA-elevated colon cancer patients, the 18-node standard could be regarded as an alternative to the 12-node standard advocated by the ASCO and NCCN guidelines.

Preoperative carcinoembryonic antigen to body mass index ratio contributes to prognosis prediction in colorectal cancer

Both carcinoembryonic antigen (CEA) level and body mass index (BMI) are traditional prognostic markers in colorectal cancer (CRC); however, to the best of our knowledge, the value of the CEA to BMI ratio (CBR) has never been addressed. In the present study, 191 patients with CRC treated using radical resection were retrospectively included, and the significance of the CBR in predicting disease-free survival (DFS) or overall survival (OS) rates was calculated. The prognostic efficacy of the CBR in predicting OS was compared with individual CEA and BMI values. The survival differences of the subgroups were calculated by Kaplan-Meier analysis, and corresponding risk factors were then estimated by a Cox proportional hazards model. As a result, 29.84% (57/191) of the patients were assigned to the high CBR group (cut-off, ≥0.28); the CBR had a sensitivity of 56.50 and 68.90%, and a specificity of 80.60 and 80.10% for DFS and OS, respectively. Patients with a high CBR more commonly underwent laparotomy and exhibited advanced T stages, the presence of tumor deposits and advanced Tumor-Node-Metastasis stages (stage II or III). The CBR was more efficient than the CEA or BMI alone in predicting OS. In addition, patients with a high CBR presented with a significantly worse outcome than patients with a low CBR. Finally, the CBR was an independent risk factor for both DFS and OS. In conclusion, the CBR was a more robust prognostic factor in CRC, and patients with a relatively high CBR exhibited poorer survival.

Preoperative low absolute lymphocyte count to fibrinogen ratio correlated with poor survival in nonmetastatic colorectal cancer

BACKGROUND

Preoperative absolute lymphocyte count (LC) and fibrinogen (FIB) are useful prognostic indicators in colorectal cancer (CRC). However, the prognostic value of the LC to FIB ratio (LFR) has never been addressed.

METHODS

A total of 189 nonmetastatic CRC patients after resection were enrolled retrospectively. The significance of the LFR in predicting disease-free survival (DFS) and overall survival (OS) was estimated by receiver operating characteristic curve analysis, and the prognostic efficacy was compared with individual LC and FIB. Patients were assigned to LFR low or high subgroups. Differences in clinicopathological features among these subgroups were calculated, and the survival differences of these subgroups were determined by the Kaplan-Meier analysis. A Cox proportional hazards model was applied to test the risk factors for survival.

RESULTS

Taking 0.54 as the optimal cutoff point, the LFR had sensitivities of 79.70% and 86.40% and specificities of 52.30% and 51.00% in predicting the DFS and OS, respectively. A total of 109/189 (57.67%) patients were assigned to the LFR low group, and these patients were more likely to be characterized by criteria such as T3 + T4 (P < 0.01), stage 3 (P < 0.01), tumor deposits (P = 0.01), high CEA (P < 0.01), or CA19-9 levels (P = 0.04). And they also displayed worse DFS (log rank = 18.57, P < 0.01) and OS (log rank = 20.40, P < 0.01) than the high LFR group. Finally, the LFR was independently associated with inferior DFS (HR = 0.32, 95% CI: 0.16-0.61, P < 0.01) and OS (HR = 0.23, 95% CI: 0.09-0.55, P < 0.01).

CONCLUSIONS

The LFR is a useful prognostic indicator in nonmetastatic CRC, and patients with a relatively low LFR had poor survival.

Prognostic value of carcinoembryonic antigen levels before and after curative surgery in colon cancer patients

Purpose

CEA is a useful tumor marker for colon cancer. The aim of this study was to investigate the prognostic value of changes in CEA levels before and after surgery in colon cancer patients who underwent radical surgery.

Methods

A total of 601 colon cancer patients who underwent radical surgery from January 2007 to December 2017 at a single institution were evaluated. Patients were categorized according to preoperative and postoperative CEA levels. We adjusted patient characteristics using propensity score matched analysis between groups and compared survival outcomes according to changes in CEA levels before and after surgery.

Results

According to the preoperative and postoperative CEA levels, patients were classified into 3 groups: group 1, ≤5 and ≤5 ng/mL, respectively (n = 407); group 2, >5 and ≤5 ng/mL, respectively (n = 127); and group 3 (>5 and >5 ng/mL, respectively (n = 67). Postoperative CEA elevation was associated with adverse clinical features. Before and after matching, the patients in group 3 showed significantly lower disease-free survival and overall survival rates compared to the patients in group 1 and group 2. In multivariate analysis, changes in CEA levels were an independent prognostic factor of overall survival (P = 0.041).

Conclusion

The changes in CEA levels before and after surgery can be a useful prognostic factor for disease-free survival and overall survival in colon cancer patients.

Prognostic value of postoperative serum carcinoembryonic antigen levels in colorectal cancer patients who smoke

Serum carcinoembryonic antigen (CEA) levels can help predict the prognosis of colorectal cancer patients. Accordingly, high preoperative CEA levels that is not restored after surgery are indicative of a worse outcome. On the other hand, smoking can increase serum CEA levels independently of the disease status. Thus, we aimed to evaluate the impact of smoking on the prognostic value of serum CEA levels. This retrospective cohort study included 273 patients who underwent curative resection for stage I–III colorectal adenocarcinoma at a single institution, between January 2010 and December 2017. Patients were grouped as follows: group A, normal preoperative and postoperative CEA levels (n = 152); group B, elevated preoperative CEA levels that returned to reference values after surgery (n = 69); and group C, elevated postoperative serum CEA levels (n = 52). Patients were also grouped according to their smoking history: group S (current smokers, n = 79) and group NS (never and former smokers, n = 194). Group A showed a higher 3-year disease-free survival (DFS) rate (84.9%) than groups B (75.4%) and C (62.0%) (p < 0.001). Postoperative serum CEA levels were significantly higher in the S group than in the NS group (2.6 vs. 3.1 ng/mL, p = 0.009), whereas preoperative levels were similar (3.8 vs. 4.1, p = 0.182). Further, smokers showed higher 3 year-DFS rates than nonsmokers in group C (83.3% vs. 43.9%, p = 0.029). This suggests that while elevated postoperative CEA levels are associated with lower DFS rates in never and former smokers, they are not associated with lower DFS rates in current smokers. We conclude that persistent smoking alters the prognostic value of postoperative serum CEA levels in colorectal cancer patients and that, consequently, alternative surveillance strategies need to be developed for colon cancer patients with smoking habits.

Nomograms predicting survival and recurrence in colonic cancer in the era of complete mesocolic excision

Background

More extensive lymphadenectomy may improve survival after resection of colonic cancer. Nomograms were created predicting overall survival and recurrence for patients who undergo D2-D3 lymph node dissection, and their validity determined.

Methods

This was a multicentre study of patients with colonic cancer who underwent resection with D2-D3 lymph node dissection in Japan. Inclusion criteria included R0 resection. A training cohort of patients operated on from 2007 to 2008 was analysed to construct prognostic models predicting survival and recurrence. Discrimination and calibration were performed using an external validation cohort from the Japanese colorectal cancer registry (procedures in 2005-2006).

Results

The training cohort consisted of 2746 patients. Predictors of survival were: age (hazard ratio (HR) 1·04), female sex (HR 0·71), depth of tumour invasion (HR 1·15, 1·22, 2·96 and 3·14 for T2, T3, T4a and T4b respectively versus T1), lymphatic invasion (HR 1·11, 1·15 and 2·95 for ly1, ly2 and ly3 versus ly0), preoperative carcinoembryonic antigen (CEA) level (HR 1·21, 1·59 and 1·99 for 5·1-10·0, 10·1-20·0 and 20·1 and over versus 0-5·0 ng/ml), number of metastatic lymph nodes (HR 1·07), number of lymph nodes examined (HR 0·98) and extent of lymphadenectomy (HR 0·23, 0·13 and 0·11 for D1, D2 and D3 versus D0). Predictors of recurrence were: female sex (HR 0·82), macroscopic type (HR 3·82, 4·56, 6·66, 7·74 and 3·22 for types I, II, III, IV and V versus type 0), depth of invasion (HR 1·25, 2·66, 5·32 and 6·43 for T2, T3, T4a and T4b versus T1), venous invasion (HR 1·43, 3·05 and 4·79 for v1, v2 and v3 versus v0), preoperative CEA level (HR 1·39, 1·43, 1·56 and 1·85 for 5·1-10·0, 10·1-20·0, 20·1-40·0 and 40·1 or more versus 0-5 ng/ml), number of metastatic lymph nodes (HR 1·07) and number of lymph nodes examined (HR 0·98). The validation cohort comprised 4446 patients. The internal and external validated Harrell's C-index values for the nomogram predicting survival were 0·75 and 0·74 respectively. Corresponding values for recurrence were 0·78 and 0·75.

Conclusion

These nomograms could predict survival and recurrence after curative resection of colonic cancer.

Serum carcinoembryonic antigen to predict recurrence in the follow-up of patients with colorectal cancer

Introduction:

Serum carcinoembryonic (CEA) antigen is used as a diagnostic screening tool during follow-up in colorectal cancer patients. However, it remains unclear whether preoperative serum CEA is a reliable marker in the follow-up to predict recurrence. The aim of the study is to determine the value of elevated pre- and postoperative serum carcinoembryonic antigen levels (CEA > 5 µg/L) as an independent prognostic factor for locoregional and distant recurrence in patients who underwent curative surgery for colorectal cancer.

Methods:

This single center retrospective observational cohort study includes patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and had pre- and postoperative serum CEA measurements. Five-year disease-free survival and multivariate Cox regression analyses were performed to adjust for confounding factors.

Results:

Preoperative serum CEA level was measured in 2093 patients with colorectal cancer. No significant association was found between an elevated preoperative serum CEA and locoregional recurrence (adjusted hazard ratio (HR) 1.29 (95% confidence interval (CI) 0.91, 1.84; P=0.26)). However, a significant association was found between an elevated preoperative serum CEA and systemic recurrence (adjusted HR 1.58 (95% CI 1.25, 2.00; P<0.01)]. The five-year disease-free survival was lower in patients with elevated preoperative serum CEA levels ( P<0.01). Postoperative serum CEA level was the most sensitive for hepatic metastases during follow-up (73.3%).

Conclusions:

The preoperative serum CEA level is an independent prognostic factor for systemic metastasis after curative surgery for colorectal cancer in patients with stage I–III disease. The level is the most sensitive for hepatic metastasis compared to metastasis to other anatomic sites.

Next Generation Proteomics for Clinical Biomarker Detection Using SWATH-MS

The technology of "sequential windowed acquisition of all theoretical fragment ion spectra," known as SWATH-MS, is rapidly gaining popularity as a next generation proteomics technology for comprehensive proteome quantitation. In this chapter, we describe the use of SWATH-MS as a label-free quantitative technique in a proteomics study to identify novel serological biomarker for colorectal cancer. We compared the secreted glycoprotein profiles (glyco-secretomes) enriched from the colon adenocarcinoma cell line HCT-116 and its metastatic derivative, E1, and observed that laminin β-1 (LAMB1) was oversecreted in E1 cells. This novel oversecretion of LAMB1 was validated in colorectal cancer patient serum samples, and ROC analyses showed that LAMB1 performed better than carcinoembryonic antigen (CEA) as a clinical diagnostic biomarker for colorectal cancer. We focus here on the sample preparation methodology and data processing workflow for SWATH-MS studies.

Perioperative Serum Carcinoembryonic Antigen Ratio Is a Prognostic Indicator in Patients With Stage II Colorectal Cancer

Purpose

The aim of this study was to evaluate whether the perioperative carcinoembryonic antigen (CEA) ratio could be used as a determinant for adjuvant therapy after curative surgery in stage II colorectal cancer.

Methods

Data for 119 patients with stage II colorectal cancer who underwent radical surgery between 2010 and 2013 were collected. The perioperative CEA ratio was defined as the postoperative/preoperative serum CEA level, and the patients were grouped according to their perioperative CEA ratios: high ratio (≥0.5) and low ratio (<0.5). Overall survival rates were calculated, and their prognostic significances were analyzed.

Results

The overall survival rates of the high and the low perioperative CEA groups were 68.2% and 86.8%, respectively (P = 0.033). In patients with normal preoperative CEA levels (<5 ng/mL), the high perioperative CEA ratio group showed a worse survival rate than the low perioperative CEA ratio group (71.7% vs. 100.0%, P = 0.007). In patients with high preoperative CEA levels (≥5 ng/mL), the high perioperative CEA ratio group showed a worse survival rate than the low perioperative CEA ratio group (33.3% vs. 75.0%, P = 0.036). In the multivariate analysis, perioperative CEA ratio (P = 0.046), age (P = 0.034), and venous invasion (P = 0.015) were independent prognostic factors for survival.

Conclusion

The perioperative CEA ratio is a prognostic indicator for stage II colorectal cancer. Patients with normal preoperative serum CEA levels might also be considered for adjuvant therapy if their perioperative CEA ratios are higher than 0.5.

CEA Response and Depth of Response (DpR) to Predict Clinical Outcomes of First-Line Cetuximab Treatment for Metastatic Colorectal Cancer

BACKGROUND

The decrease in carcinoembryonic antigen (CEA) level is faster and greater during cetuximab treatment than bevacizumab treatment and correlates with prolonged survival in patients with metastatic colorectal cancer (mCRC) who receive cetuximab.

OBJECTIVE

We investigated if the degree of change in the CEA value can serve as a diagnostic tool for predicting survival, as well as tumor regression in mCRC patients treated with cetuximab combined regimen as first-line treatment.

PATIENTS AND METHODS

Associations among the CEA decrease, depth of response (DpR), and clinical outcomes were evaluated in 113 patients with mCRC from two phase II trials of first-line therapy: the JACCRO CC-05 trial of cetuximab plus FOLFOX and the CC-06 trial of cetuximab plus SOX. Analysis was performed using Spearman's rank correlation coefficient. A 75% decrease in the CEA was used as the cut-off value to define the CEA response and discriminate CEA responders on the basis of the results of a previous study.

RESULTS

Ninety-two patients were eligible for analyses of both CEA and DpR. The median CEA decrease was 67.4%, and the median time to CEA nadir was 2.8 months, which was similar to the median time to DpR of 3.0 months. The DpR was associated with PFS and OS (rs = 0.56, P < 0.0001; rs = 0.39, P = 0.0090, respectively); moreover, the CEA decrease correlated with PFS (rs = 0.56, P < 0.0001), as well as OS (rs = 0.35, P = 0.019). CEA responders had significantly longer PFS (11.8 vs. 5.5 months, hazard ratio [HR] 0.46, P = 0.0009) and slightly, but not significantly longer OS (36.2 vs. 23.5 months; HR 0.57; P = 0.072) than CEA non-responders. The CEA decrease was statistically significantly associated with the DpR (rs = 0.44, P < 0.0001).

CONCLUSIONS

Our study demonstrates that both DpR and CEA response correlate with clinical outcomes of first-line treatment with cetuximab. The CEA decrease may serve as a surrogate for DpR in patients who receive first-line cetuximab treatment (UMIN000004197, UMIN000007022).

Methylated free-circulating HPP1 DNA is an early response marker in patients with metastatic colorectal cancer

Detection of methylated free-circulating DNA (mfcDNA) for hyperplastic polyposis 1 (HPP1) in blood is correlated with a poor prognosis for patients with metastatic colorectal cancers (mCRC). Here, we analyzed the plasma levels of HPP1 mfcDNA in mCRC patients treated with a combination therapy containing a fluoropyrimidine, oxaliplatin and bevacizumab to test whether HPP1 mfcDNA is a suitable prognostic and response biomarker. From 467 patients of the prospective clinical study AIO-KRK-0207, mfcDNA was isolated from plasma samples at different time points and bisulfite-treated mfcDNA was quantified using methylation specific PCR. About 337 of 467 patients had detectable levels for HPP1 mfcDNA before start of treatment. The detection was significantly correlated with poorer overall survival (OS) (HR = 1.86; 95%CI 1.37-2.53). About 2-3 weeks after the first administration of combination chemotherapy, HPP1 mfcDNA was reduced to non-detectable levels in 167 of 337 patients. These patients showed a better OS compared with patients with continued detection of HPP1 mfcDNA (HR HPP1(sample 1: pos/ sample 2: neg) vs. HPP1(neg/neg) = 1.41; 95%CI 1.00-2.01, HPP1(neg,pos/pos) vs. HPP1(neg/neg) = 2.60; 95%CI 1.86-3.64). Receiver operating characteristic analysis demonstrated that HPP1 mfcDNA discriminates well between patients who do (not) respond to therapy according to the radiological staging after 12 or 24 weeks (AUC = 0.77 or 0.71, respectively). Detection of HPP1 mfcDNA can be used as a prognostic marker and an early marker for response (as early as 3-4 weeks after start of treatment compared with radiological staging after 12 or 24 weeks) to identify patients who will likely benefit from a combination chemotherapy with bevacizumab.

The prognostic significance and treatment modality for elevated pre- and postoperative serum CEA in colorectal cancer patients

Purpose

The purpose of this study was to evaluate the prognostic significance of serum CEA (s-CEA) changes in colorectal cancer (CRC) patients with sustained elevated postoperative s-CEA levels.

Methods

Between January 1999 and December 2008, 9,380 CRC patients underwent surgery. Curative resection was performed in 1,242 CRC patients with high preoperative s-CEA levels (>6 ng/mL). High s-CEA levels were normalized in 924 patients (74.4%) within 2 weeks from surgery, whereas high s-CEA levels were persistent in 318 patients (25.6%). Patients were divided into 2 groups according to their postoperative s-CEA levels: group 1 (37 patients with a 1-year postoperative s-CEA>6 ng/mL) and group 2 (281 patients with a 1-year postoperative s-CEA≤6 ng/mL).

Results

A postoperative recurrence was identified in 24 patients (64.9%) in group 1 and 65 patients (23.1%) in group 2 (P < 0.001). A curative resection after recurrence was performed in 22 patients (33.8%) from group 2, but no patients from group 1 (P = 0.001). The 5-year overall survival and time to recurrence were significantly lower in patients with recurrent cancer in group 1 (P < 0.001).

Conclusion

Patients with persistent elevated postoperative s-CEA levels are at high risk for recurrence and a low survival rate. More intensive surveillance of patients with high postoperative s-CEA levels should be mandatory.

[Analysis of histoprognostic factors for the non metastatic rectal cancer in a west Algerian series of 58 cases]

Introduction

L'objectif de notre travail est d'analyser les facteurs histo-pronostiques des cancers du rectum non métastatique opérés au service de chirurgie «A» de Tlemcen à ouest Algérien durant une période de six ans.

Méthodes

Etude rétrospective de 58 patients qui avait un adénocarcinome rectal. Le critère de jugement était la survie. Les paramètres étudiés, le sexe, l’âge, stade tumoral, et les récidives tumorales.

Résultats

L’âge moyen était de 58 ans. Avec 52% d'hommes contre 48% femmes avec sex-ratio (1,08). Le siège tumoral était: moyen rectum avec 41,37%, 34,48% au bas rectum et dans 24,13% au haut rectum. La classification TNM avec 17,65% au stade I, 18,61% au stade II, 53, 44% au stade III et 7,84% au stade IV. La survie médiane globale était de 40 mois ±2,937 mois. La survie en fonction du stade tumoral, le stade III et IV avait un faible taux de survie (19%) a 3 ans contre le stade I, II avait un taux de survie de (75%) (P = 0,000) (IC 95%). Les patients avec récidives tumorales avaient un taux de survie faible à 3 ans par rapport à ceux n'ayant pas eu de récidive (30,85% Vs 64,30% P = 0,043).

Conclusion

Dans cette série, l’étude uni varié des différents facteurs pronostiques conditionnant la survie n'a permis de retenir que trois facteurs influençant la survie, à savoir la taille tumorale, le stade, et les récidives tumorales. En analyse multi variée en utilisant le modèle Cox un seul facteur été retenu la récidive tumorale.

Evaluating the Prognostic Role of Elevated Preoperative Carcinoembryonic Antigen Levels in Colon Cancer Patients: Results from the National Cancer Database

OBJECTIVES

Carcinoembryonic antigen (CEA) is a reliable tumor marker for the management and surveillance of colon cancer. However, limitations in previous studies have made it difficult to elucidate whether CEA should be established as a prognostic indicator. This study examines the association between elevated preoperative CEA levels and overall survival in colon cancer patients using a national population-based registry.

METHODS

Stage I-III colon cancer patients were identified from the 2004-2006 National Cancer Database. A multivariable Cox proportional hazards model was used to estimate the association between elevated CEA levels and overall survival after controlling for important patient, hospital, and tumor characteristics. A Monte Carlo Markov Chain was used to impute the large degree of missing CEA data. All models controlled for the propensity score in order to account for selection bias.

RESULTS

A total of 137,381 patients met the inclusion criteria. Overall, 34 % of patients had an elevated CEA level and 66 % had a normal CEA level, with a median survival of 70 and 100 months, respectively. Patients with an elevated CEA level had a 62 % increase in the hazard of death (HR 1.62, 95 % CI 1.53-1.74) compared with patients with a normal CEA level.

CONCLUSIONS

Preoperative CEA was an independent predictor of overall survival across all stages. The results support recommendations to include CEA levels as another high-risk feature that clinicians can use to counsel patients on adjuvant chemotherapy, especially for stage II patients.

Watch and Wait?--Elevated Pretreatment CEA Is Associated with Decreased Pathological Complete Response in Rectal Cancer

INTRODUCTION

Between 10 and 30% of rectal cancer patients experience pathological complete response after neoadjuvant treatment. However, physiological factors predicting which patients will experience tumor response are largely unknown. Previous single-institution studies have suggested an association between elevated pretreatment carcinoembryonic antigen and decreased pathological complete response.

METHODS

Clinical stage II-III rectal cancer patients undergoing neoadjuvant chemoradiotherapy and surgical resection were selected from the 2006-2011 National Cancer Data Base. Multivariable analysis was used to examine the association between elevated pretreatment carcinoembryonic antigen and pathological complete response, pathological tumor regression, tumor downstaging, and overall survival.

RESULTS

Of the 18,113 patients meeting the inclusion criteria, 47% had elevated pretreatment carcinoembryonic antigen and 13% experienced pathological compete response. Elevated pretreatment carcinoembryonic antigen was independently associated with decreased pathological complete response (OR = 0.65, 95% CI = 0.52-0.77, p < 0.001), pathological tumor regression (OR = 0.74, 95% CI = 0.67-0.70, p < 0.001), tumor downstaging (OR = 0.77, 95% CI = 0.63-0.92, p < 0.001), and overall survival (HR = 1.45, 95% CI = 1.34-1.58, p < 0.001).

CONCLUSION

Rectal cancer patients with elevated pretreatment carcinoembryonic antigen are less likely to experience pathological complete response, pathological tumor regression, and tumor downstaging after neoadjuvant treatment and experience decreased survival. These patients may not be suitable candidates for an observational "watch-and-wait" strategy. Future prospective studies should investigate the relationships between CEA levels, neoadjuvant treatment response, recurrence, and survival.

The diagnostic accuracy of carcinoembryonic antigen to detect colorectal cancer recurrence - A systematic review

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.

Blood CEA levels for detecting recurrent colorectal cancer

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).

Analysis of colorectal cancer glyco-secretome identifies laminin β-1 (LAMB1) as a potential serological biomarker for colorectal cancer

The high mortality rate in colorectal cancer is mostly ascribed to metastasis, but the only clinical biomarker available for disease monitoring and prognosis is the carcinoembryonic antigen (CEA). However, the prognostic utility of CEA remains controversial. In an effort to identify novel biomarkers that could be potentially translated for clinical use, we collected the secretomes from the colon adenocarcinoma cell line HCT-116 and its metastatic derivative, E1, using the hollow fiber culture system, and utilized the multilectin affinity chromatography approach to enrich for the secreted glycoproteins (glyco-secretome). The HCT-116 and E1 glyco-secretomes were compared using the label-free quantitative SWATH-MS technology, and a total of 149 glycoproteins were differentially secreted in E1 cells. Among these glycoproteins, laminin β-1 (LAMB1), a glycoprotein not previously known to be secreted in colorectal cancer cells, was observed to be oversecreted in E1 cells. In addition, we showed that LAMB1 levels were significantly higher in colorectal cancer patient serum samples as compared to healthy controls when measured using ELISA. ROC analyses indicated that LAMB1 performed better than CEA at discriminating between colorectal cancer patients from controls. Moreover, the diagnostic performance was further improved when LAMB1 was used in combination with CEA.

[Prognostic value of preoperative carcinoembryogenic antigen: Is it useful in all stages of colorectal cancer?]

INTRODUCTION

Recent reports have reopened discussion of the prognostic value of elevated pre-treatment carcinoembryonic antigen (CEA) levels in colorectal cancer. Due to the discrepancies in the published results, we aimed to analyze the possible predictive value of CEA, both overall and in different tumoral stages in our environment.

PATIENTS AND METHODS

We retrospectively studied 303 consecutive patients with colorectal cancer resected with curative intent by analysing tumor-related mortality. The frequency of patients with increased CEA levels (> 5mg/l) was registered. Univariate and multivariate analyses of survival curves were performed, comparing patients with increased CEA levels and those with CEA levels within normal limits, both in the overall series and in the different pTNM tumoral stages.

RESULTS

Frequency of patients with CEA>5mg/l was 31%. The median clinical follow-up was 83 months. A poor survival rate was registered in the multivariate analysis of the whole series in patients with high CEA levels: hazard ratio (HR)=1.81; 95% confidence interval (95% CI)=(1.15-3.10); P=.012. This predictive value was only maintained in stage II in the survival analysis of the distinct tumoral stages (n=104): HR=3.02; 95% CI=(1.22-7.45); P=.017.

CONCLUSIONS

Before treatment, 31% of our patients with colorectal cancer resected with curative intent had pathological CEA values. In the overall series, a high pretreatment CEA level showed an independent prognostic value for poor survival. When pTNM tumoral stages were analyzed separately, CEA level had predictive value only in pTNM II tumors.

Utility of postoperative CEA for surveillance of recurrence after resection of primary colorectal cancer

INTRODUCTION

To evaluate the usefulness of postoperative CEA levels in the surveillance of colorectal cancer patients.

METHODS

Over a 56 month period a total of 569 patients with measured CEA levels underwent curative resection for colorectal cancer. The median follow up was 40 months, during which period recurrence occurred in 149. Serum CEA levels were measured at 6 monthly intervals starting from 3 months post resection. ROC was used to calculate the optimum cut-off of CEA (5 ng/ml).

RESULTS

Postoperative elevation of CEA levels were more frequent in patients with an aggressive primary colorectal cancer (grade, T stage and nodal disease; p < 0.05). In patients found to have colorectal recurrence, a significantly higher proportion of patients were resectable in the group with a non-elevated CEA (diagnosed by CT with PET imaging p < 0.05). The median interval between CEA elevation and diagnosis of recurrence (diagnostic interval) was 4 weeks. CEA elevation led to a change in the routine surveillance program by bringing imaging forward by 2 months. CEA levels were a significant predictor of survival following resection of colorectal primary (CEA ≤5-38 months, CEA >5-27 months; p < 0.05). CEA (p < 0.05) retained its significance on multivariate analysis along with the T stage (p < 0.05).

CONCLUSION

CEA is a predictor of recurrence, resectability and survival following resection of colorectal cancer. Furthermore, an elevated CEA has a short diagnostic interval (4 weeks) for detecting recurrent disease and therefore should mandate adjustment of the routine surveillance program with the next planned imaging being brought forward (2 months).

Proper exercise decreases plasma carcinoembryonic antigen levels with the improvement of body condition in elderly women

Aging increases the risk of chronic diseases including cancers. Physical exercise has the beneficial effects for the elderly susceptible to the development of cancers, through maintaining a healthy body condition and improving the immune system. However, excessive or insufficient exercise might increase the risk for cancer. In the present study, we investigated what exercise frequency improves cancer-related biomarkers, such as carcinoembryonic antigen (CEA), alpha fetoprotein (AFP), red blood cell (RBC), and white blood cell (WBC), and the body composition of elderly women. Fifty-four females, aged 70 to 77 years, were divided into 4 groups: control, 1-day exercise (1E), 2-3-day exercise (2-3E), and 5-day exercise (5E) groups. The control group did not participate in any physical activity, while the subjects in the exercise groups underwent the exercise program for 12 weeks. As results, CEA was significantly decreased in the exercise groups, with the lowest values in 2-3E group. In contrast, AFP, RBC and WBC were not significantly changed. CEA is an oncofetal glycoprotein that is overexpressed in adenocarcinomas. Although the function of CEA has not been fully understood, CEA has been suggested to be involved in the release of pro-inflammatory cytokines via stimulating monocytes and macrophages. Moreover, body weight and body mass index were improved in the exercise groups, with the lowest levels in 5E group. Thus, we suggest that exercise for 2-3 days per week decreases the expression of CEA and improves body condition, without loading fatigue or stress, which may contribute to preventing cancer in the elderly women.

Use of FDG-PET or PET/CT to detect recurrent colorectal cancer in patients with elevated CEA: a systematic review and meta-analysis

AIM

The purpose of the present study was to conduct a systematic review and meta-analysis of the published literature to assess the diagnostic performance of FDG-PET or PET/CT in the detection of recurrent colorectal cancer (CRC) rising in patients with elevated CEA.

MATERIALS AND METHODS

The authors conducted a systematic MEDLINE search of published articles. Two reviewers independently assessed the methodological quality of each study. We estimated pooled sensitivity and specificity and positive and negative likelihood ratios, and summary receiver-operating characteristic curves in the detection of recurrent CRC in patients with elevated CEA.

RESULTS

Eleven studies with a total of 510 patients met the inclusion criteria. One hundred and six patients (106/510 = 20.8%) had true-negative FDG-PET (PET/CT) results in detection of recurrent CRC when rising CEA. The pooled estimates of sensitivity and specificity and positive and negative likelihood ratios of FDG-PET in the detection of tumor recurrence in CRC patients with elevated CEA were 90.3% (95% CI, 85.5-94.0%), 80.0% (95% CI, 67.0-89.6%), 2.88 (95% CI, 1.37-6.07), and 0.12 (95% CI, 0.07-0.20), respectively. The pooled estimates of sensitivity and specificity and positive and negative likelihood ratios of FDG-PET/CT in the detection of tumor recurrence in CRC patients with elevated CEA were 94.1% (95% CI, 89.4-97.1%), 77.2% (95% CI, 66.4-85.9%), 4.70 (95% CI, 0.82-12.13), and 0.06 (95% CI, 0.03-0.13), respectively.

CONCLUSIONS

Whole-body FDG-PET and PET/CT are valuable imaging tools for the assessment of patients with suspected CRC tumor recurrence based on the increase of CEA.

Measuring quality of care in the treatment of colorectal cancer: the moffitt quality practice initiative

PURPOSE

The Moffitt Quality Practice Initiative (MQPI) is a practice-based system of quality self-assessment, the ultimate goal of which is to improve the quality of cancer care at a statewide level. The initial phase of this project focused on developing procedures, determining feasibility, and evaluating utility for assessing quality of care for colorectal cancer within an existing affiliate network.

PATIENTS AND METHODS

Representatives from four oncology groups selected quality measures consistent with evidence-, consensus-, and safety-based guidelines that could be abstracted from medical records. Trained abstractors then reviewed records of all eligible colorectal patients seen by each practice in 2004. Frequencies of responses for each indicator were tabulated for overall and practice-specific level of adherence and were compared among practices.

RESULTS

Adherence was uniformly high for several indicators, including confirmatory pathology report, staging information, and chemotherapy discussion or recommendation. Lower adherence was evident across practices for performance of carcinoembryonic tests and complete colonoscopic evaluations. Significant variation among practices was evident only for consent for chemotherapy.

CONCLUSION

The initial phase of MQPI demonstrated the feasibility and utility of assessing quality indicators for colorectal cancer among members of an existing affiliate network. Findings identified areas where adherence to care was uniformly high, but also identified areas where both overall and practice-specific adherence were less than optimal. These efforts lay the groundwork for expanding MQPI in several directions that have in common the potential to improve the quality of cancer care on a statewide basis.

Comparison of recurrence patterns between ≤5 years and >5 years after curative operations in colorectal cancer patients

BACKGROUND AND OBJECTIVES

To identify characteristics of recurrent colorectal cancer in terms of follow-up periods, that is, ≤5 years and >5 years after curative operations

METHODS

This study enrolled 4,023 patients. Of them, 835 patients showed recurrence after primary curative resection for colorectal cancer. Recurrence occurred ≤5 years (n = 799) or >5 years (n = 36) after curative surgery. Variables and recurrence patterns were compared between the groups.

RESULTS

Among the 835 patients who experienced recurrence, only 4.3% recurred >5 years after surgery. This group showed lower preoperative serum carcinoembryonic antigen levels, more tumors with expanding growth, well-differentiated histology, and no lymph node metastasis (all P < 0.05). In terms of haematogenous metastasis, lung or liver was the most prevalent site in patients who recurred after >5 years or ≤5 years, respectively (P = 0.005). In rectal cancer patients, recurrence patterns revealed the same results. In colon cancer patients, the liver was the most prevalent site in both groups.

CONCLUSIONS

After 5 years of follow-up, routine surveillance for detecting other malignancies seems to be sufficient. However, the possibility of late (particularly late pulmonary) recurrence should be considered. Radiologic examination to detect pulmonary metastasis should be considered in the follow-up program.

Serum CA 19-9 and CEA levels as a prognostic factor in pancreatic adenocarcinoma

PURPOSE

To investigate the use of pretreatment carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) as prognostic factors to determine survival in pancreatic adenocarcinoma.

MATERIALS AND METHODS

A retrospective review of the medical records of patients who were diagnosed with pancreatic adenocarcinoma and received surgery, chemoradiotherapy or chemotherapy was performed. Factors, including CA 19-9 and CEA, associated with the survival of pancreatic cancer patients were analyzed.

RESULTS

Patients with the median age of 65 years were included (n=187). Elevated serum CA 19-9 levels and CEA levels were observed in 75.4% and 39% of patients at diagnosis, respectively. CEA was correlated with tumor stages (p=0.005), but CA 19-9 was not. CA 19-9 and CEA were elevated in 69.0% and 33.3% of patients with resectable pancreatic cancer, and elevated in 72.9% and 47.2% of patients with advanced pancreatic cancer, respectively. The median overall survival of the normal serum CEA group was longer than that of the elevated serum CEA group (16.3 months vs. 10.2 months, p=0.004). However, the median overall survival of the normal serum CA 19-9 group was not different from that of the elevated serum CA 19-9 group (12.4 months vs. 13.5 months, p=0.969). The independent factors associated with overall survival were advanced pancreatic cancer [harzard ratio (HR) 4.33, p=0.001] and elevated serum CEA level (HR 1.52, p=0.032).

CONCLUSION

Patients with elevated serum CEA level at diagnosis demonstrated poor overall survival. Pretreatment CEA level may predict the prognosis of patients with pancreatic adenocarcinoma.

Neoadjuvant oral vs. infusional chemoradiotherapy on locally advanced rectal cancer: Prognostic factors

AIM

To evaluate the prognostic factors and impact on survival of neoadjuvant oral and infusional chemoradiotherapy in patients with locally advanced rectal cancer.

BACKGROUND

There is still no definitive consensus about the prognostic factors and the impact of neoadjuvant chemoradiotherapy on survival. Some studies have pointed to an improvement in overall survival (OS) and progression-free survival (PFS) in patients with tumor downstaging (TD) and nodal downstaging (ND).

MATERIALS AND METHODS

A set of 159 patients with LARC were treated preoperatively. Group A - 112 patients underwent concomitant oral chemoradiotherapy: capecitabine or UFT + folinic acid. Group B - 47 patients submitted to concomitant chemoradiation with 5-FU in continuous infusion. 63.6% of patients were submitted to adjuvant chemotherapy.

RESULTS

GROUP A

pathologic complete response (pCR) - 18.7%; TD - 55.1%; ND - 76%; loco-regional response - 74.8%. Group B: pCR - 11.4%; TD - 50%; ND - 55.8%; LRR - 54.5%. The loco-regional control was 95.6%. There was no difference in survival between both groups. Those with loco-regional response had better PFS.

CONCLUSIONS

Tumor and nodal downstaging, loco-regional response and a normal CEA level turned out to be important prognostic factors in locally advanced rectal cancer. Nodal downstaging and loco-regional response were higher in Group A. Those with tumor downstaging and loco-regional response from Group A had better OS. Adjuvant chemotherapy had no impact on survival except in those patients with loco-regional response who achieved a higher PFS.

Circulating antibodies to carcinoembryonic antigen related to improved recurrence-free survival of patients with colorectal carcinoma

This prospective study evaluated the prognostic value of antibodies to carcinoembryonic antigen (anti-CEA), detected by indirect immunosorbent assay, in the serum of colorectal carcinoma patients. Serum carcinoembryonic antigen (CEA) concentrations, measured by electrochemiluminescence immunoassay, were elevated in 26 (37.7%) of 69 patients with colorectal cancer and could not be detected among the 28 patients with benign intestinal conditions or 37 healthy individuals who comprised the control groups. Anti-CEA immuno globulin (Ig)G or IgM was detected by immunonephelometry in 44 (63.8%) patients with colorectal cancer, three (10.7%) with benign intestinal conditions and four (10.8%) healthy blood donors. Differences in antibody detection frequencies between the cancer patient group and the control groups were statistically significant. Titres of anti-CEA correlated significantly with CEA levels and Dukes' cancer stage. Antibody titre was an independent, significant, favourable predictor for 5-year recurrence-free survival. It is concluded that measurement of serum anti-CEA combined with CEA might be useful as a tumour marker and to assess prognosis. These results need to be confirmed in large, well-controlled, randomized clinical trials.

Factors that influence survival in unresectable metastatic or locally advanced colorectal cancer

PURPOSE

Half of patients with colorectal cancer (CRC) have metastasis during the whole course of the disease. Fewer than 10% of those are still alive at 5 years. Locally advanced CRC accounts for 7% to 33% of CRC relapses. Of these, only a small number of patients are resectable with a curative intent. Management of unresectable metastatic or locally advanced CRC is a significant challenge. In this study, we focus on patients with unresectable locally advanced or metastatic CRC and analyze survival rate and prognostic factors influencing the survival.

METHODS

There were 277 patients identified. Several clinicopathologic parameters were evaluated. To determine the prognostic impact of the factors in survival, all parameters were tested from their relationship in Cox-regression model and Cox proportional hazards model. Survival curves were generated according to Kaplan-Meier method and the differences in survival were determined by employing the log-rank test.

RESULTS

Three factors that influence the survival were identified: one or more than two organs involved (p = 0.041), higher carcinoembryonic antigen (CEA) level (p = 0.001), and different salvage treatment (p < 0.001). In Kaplan-Meier survival analysis, there were significant differences between patients with one and more than two organs involved (p = 0.027), different ranges of CEA level (p = 0.004), and different salvage treatment (p < 0.001).

CONCLUSIONS

We clearly demonstrated three factors that influence the survival, including more than two organs involved, higher CEA level, and different salvage treatment. The higher the CEA level and the more organs (≥2) involved, the worse the survival. Even in patients with unresectable metastatic or locally advanced, aggressive treatment with target therapy seems to have survival benefit.

The Role of High Frequency Dynamic Threshold (HiDT) Serum Carcinoembryonic Antigen (CEA) Measurements in Colorectal Cancer Surveillance: A (Revisited) Hypothesis Paper

Following curative treatment for colorectal cancer (CRC), 30% to 50% of patients will develop recurrent disease. For CRC there are several lines of evidence supporting the hypothesis that early detection of metachronous disease offers a second opportunity for cure. This paper revisits the potential role of serum carcinoembryonic antigen (CEA) in follow-up. A comprehensive review of the literature (1978–2008) demonstrates that the initial promise of serum CEA as an effective surveillance tool has been tarnished through perpetuation of poorly designed studies. Specific limitations included: testing CEA as only an ‘add-on’ diagnostic tool; lack of standardization of threshold values; use of static thresholds; too low measurement frequency. Major changes in localizing imaging techniques and treatment of metastatic CRC further cause a decrease of clinical applicability of past trial outcomes. In 1982, Staab hypothesized that the optimal benefit of serum CEA as a surveillance tool is through high-frequency triage using a dynamic threshold (HiDT). Evidence supporting this hypothesis was found in the biochemical characteristics of serum CEA and retrospective studies showing the superior predictive value of a dynamic threshold. A multi-centred randomized phase III study optimizing the usage of HiDT against resectability of recurrent disease is commencing recruitment in the Netherlands.

Analysis of factors associated with prognosis after colorectal cancer resection in 174 Chinese elderly patients

PURPOSE

The purpose of the present study was to investigate risk factors associated with prognosis in elderly patients with colorectal cancer (CRC) and to determine treatment and follow-up strategies.

MATERIALS AND METHODS

CRC patients (age ≥70) who were treated with curative operation were studied. We compared 57 patients whose survival time was less than 2 years with 117 patients with survival time exceeding 5 years, based on the clinical, pathologic, and preoperative clinical laboratory analysis findings. A risk scoring system on basis of factors determined by multiple logistic regression analysis was explored and validated by both receiver operating characteristic and survival analysis.

RESULTS

Neuroticism, rural residence, deep layer invasion, lymphovascular invasion, and high serum CEA levels were found to be associated with adverse prognosis in the multivariate logistic regression model. Risk scoring system based on these factors showed that the patients with total score exceeding 2.5 had a significantly poorer prognosis (P < 0.05), which was validated by survival analysis.

CONCLUSIONS

Patients with neuroticism, rural residence, deep layer invasion, lymphovascular invasion, and high serum CEA level should be regarded as a high-risk group; a simple scoring system based on these factors could be used to evaluate the risk and facilitate treatment of CRC for elderly patients.

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.

An intelligent decision support algorithm for diagnosis of colorectal cancer through serum tumor markers

Nowadays, a wide range of serum tumor markers can be applied in the diagnosis of colorectal cancer. There exists a wide variability in the type and number of routinely used markers so that, sometimes, patients may receive redundant or insufficient checks. Furthermore, the traditional single cutoff point also hinders the efficient utilization of the continuous check value of a tumor marker. In order to improve the diagnostic accuracy (DA) and decrease the cost, it is necessary to optimize the check combinations and exploit the check values fully. To this end, focusing on colorectal cancer (CRC), an artificial intelligent algorithm entitled DS-STM (diagnosis strategy of serum tumor makers) is developed in this paper. DS-STM can provide decision support for physicians on the usage of different tumor markers and diagnosis of colorectal cancer (CRC). The study demonstrates that, instead of five or more tumor markers, two markers are already enough for diagnosis for most CRC patients. The experimental study shows, compared to the traditional serial test, DS-STM can improve DA from 67.53% to 73.87% for the same validation dataset. In addition, a significant cost reduction can be achieved with the new developed diagnosis strategy.

Surveillance with Serial Serum Carcinoembryonic Levels Detect Colorectal Cancer Recurrences in Patients who are Initial Nonsecretors

Serum carcinoembryonic antigen (CEA) levels, elevated in a subgroup of patients with colorectal cancer (CRC) at presentation, are serially followed as part of recommended surveillance after initial resection. The value of following serial CEA levels in patients who initially present with less than or normal levels of CEA (nonsecretors) is controversial. This study sought to determine the use of follow-up CEA levels in nonsecretors. A retrospective review was performed of patients with resected Stage I, II, and III CRC. We excluded patients who did not have a pretreatment CEA level, at least two follow-up CEA levels, or in whom CEA levels did not normalize after resection. The patients were grouped by initial CEA values: CEA 5 ng/mL or less (nonsecretors) and CEA 5 + ng/mL: (secretors). We identified 186 patients with CRC; 146 were initial nonsecretors. We identified 22 patients with recurrent colorectal cancer; 6 were secretors and 16 patients were nonsecretors. In the secretors group, CEA was elevated with recurrence in four (66%) of the patients. In the nonsecretors, CEA was elevated with recurrence in eight (50%) of the patients. In summary, many recurrences of CRC are marked by an elevation of CEA regardless of whether the patients initially presented as secretors or nonsecretors.

Preoperative carcinoembryonic antigen level as an independent prognostic factor in potentially curative colon cancer

OBJECTIVE

We evaluated the prognostic value of the preoperative serum carcinoembryonic antigen (CEA) level in patients with colon cancer.

METHODS

We reviewed 474 patients who underwent potentially curative resection for nonmetastatic colon cancer. Patients were categorized into two groups according to the preoperative serum CEA level: low CEA (<5 ng/ml) and high CEA (>or=5 ng/ml) groups.

RESULTS

During the median 45-month follow-up period, the 5-year overall and disease-free survival rates for patients with a low CEA level were 81.7% and 82.4%, respectively, which were significantly higher than the rates for those with a high CEA level (69.9%; P = 0.011 and 70.6%; P = 0.002, respectively). A multivariate analysis revealed that a preoperative serum CEA level was a significant independent prognostic factor for both overall survival (P = 0.021) and disease-free survival (P = 0.026). Both the overall and disease-free survival rates in patients with stage II tumors differed significantly between the low and high CEA groups, whereas the rates did not different between those with stage I and III tumors.

CONCLUSIONS

Preoperative serum CEA is a reliable predictor of recurrence and survival after curative surgery in patients with colon cancer, particularly in those classified as having stage II disease.

A comparative study of protein expression in primary colorectal cancer and synchronous hepatic metastases: the significance of matrix metalloproteinase-1 expression as a predictor of liver metastasis

OBJECTIVE

This study was undertaken to determine the ability of protein expression in primary colorectal cancer and metastatic liver tumour tissues to predict hepatic metastasis and intrahepatic recurrence.

MATERIAL AND METHODS

Sixty patients with colorectal cancer were enrolled in this study. The expression of the following five proteins was assessed by immunohistochemical (IHC) staining: carcinoembryonic antigen (CEA); vascular endothelial growth factor (VEGF); matrix metalloproteinase (MMP)-1; MMP-7; and tissue inhibitor of metalloproteinases (TIMP)-1. Protein expression was measured in patients with primary colorectal cancer without liver metastasis (Group A), in patients with primary colorectal cancer with liver metastasis (primary tumour; Group B), and in patients with resected metastatic liver tumour tissues (liver metastasis; Group C).

RESULTS

IHC staining revealed more protease activity (MMP-1 and -7) in Group B than in Group A. Angiogenic activity (positive VEGF expression) was significantly greater in Group C than in Group B. Multivariate analysis showed that positive MMP-1 expression, the presence of lymphovascular invasion, and an elevated pre-operative serum CEA level (> 5 ng/ml) were significantly related to synchronous liver metastasis. However, intrahepatic recurrence was not related to protein expression, the presence of lymphovascular invasion, or the pre-operative CEA level.

CONCLUSIONS

Our findings suggest that protease activity is important for metastasis, and that angiogenic activity is essential for metastatic tumour growth. Furthermore, positive MMP-1 expression in primary colorectal tumour tissues was a significant predictor of liver metastasis. However, the prognostic impact of protein marker expression in terms of intrahepatic recurrence appears to be minimal.

Differential secreted proteome approach in murine model for candidate biomarker discovery in colon cancer

The complexity and heterogeneity of the plasma proteome have presented significant challenges in the identification of protein changes associated with tumor development. We used cell culture as a model system and identified differentially expressed, secreted proteins which may constitute serological biomarkers. A stable isotope labeling by amino acids in cell culture (SILAC) approach was used to label the entire secreted proteomes of the CT26 murine colon cancer cell line and normal young adult mouse colon (YAMC) cell line, thereby creating a stable isotope labeled proteome (SILAP) standard. This SILAP standard was added to unlabeled murine CT26 colon cancer cell or normal murine YAMC colon epithelial cell secreted proteome samples. A multidimensional approach combining isoelectric focusing (IEF), strong cation exchange (SCX) followed by reversed phase liquid chromatography was used for extensive protein and peptide separation. A total of 614 and 929 proteins were identified from the YAMC and CT26 cell lines, with 418 proteins common to both cell lines. Twenty highly abundant differentially expressed proteins from these groups were selected for liquid chromatography-multiple reaction monitoring/mass spectrometry (LC-MRM/MS) analysis in sera. Differential secretion into the serum was observed for several proteins when Apc(min) mice were compared with control mice. These findings were then confirmed by Western blot analysis.

Preoperative serum carcinoembryonic antigen, albumin and age are supplementary to UICC staging systems in predicting survival for colorectal cancer patients undergoing surgical treatment

BACKGROUND

The aim of this study was to determine influence of prognostic factors in addition to UICC staging systems, on cancer-specific and overall survival rates for patients with colorectal cancer (CRC) undergoing surgical treatment.

METHODS

Between January 1996 and December 2006, a total of 1367 CRC patients who underwent surgical treatment in Kaohsiung Medical University Hospital were analyzed. We retrospectively investigated clinicopathologic features of these patients. All patients were followed up intensively, and their outcomes were investigated completely.

RESULTS

Of 1367 CRC patients, there were seven hundred and fifty-seven males (55.4%) and 610 (44.6%) females. The median follow-up period was 60 months (range, 3-132 months). A multivariate analysis identified that low serum albumin level (P = 0.011), advanced UICC stage (P < 0.001), and high carcinoembryonic antigen (CEA) level (P < 0.001) were independent prognostic factors of cancer-specific survival. Meanwhile, a multivariate analysis showed age over 65 years (P < 0.001), advanced UICC stage (P < 0.001), and high CEA level (P < 0.001) were independent prognostic factors of overall survival. Furthermore, combination of UICC stage, serum CEA and albumin levels as predictors of cancer-specific survival showed that the poorer the prognostic factors involved, the poorer the cancer-specific survival rate. Likewise, combination of UICC stage, age and serum CEA level as predictors of overall survival showed that the poorer the prognostic factors involved, the poorer the overall survival rate. Of these prognostic factors, preoperative serum CEA level was the only significant prognostic factor for patients with stage II and III CRCs in both cancer-specific and overall survival categories.

CONCLUSION

Preoperative serum albumin level, CEA level and age could prominently affect postoperative outcome of CRC patients undergoing surgical treatment. In addition to conventional UICC staging system, it might be imperative to take these additional characteristics of factors into account in CRC patients prior to surgical treatment.

Circulating vascular endothelial growth factor six months after primary surgery as a prognostic marker in patients with colorectal cancer

High preoperative circulating vascular endothelial growth factor (VEGF) is predictive of poor prognosis in patients with colorectal cancer (CRC). However, postoperative circulating VEGF has not yet been evaluated as a prognostic marker in CRC patients. In 318 consecutive patients who had undergone curative resection of primary CRC, the prognostic value of VEGF concentrations in plasma and serum obtained 6 months postoperatively was analysed and the results compared with the prognostic value of postoperative carcinoembryonic antigen (CEA) concentrations in matched serum samples. In univariate analyses, high serum and plasma VEGF ( > 533 pg/ml and > 112 pg/ml, respectively) had no significant (p = 0.17 and p = 0.13, respectively) impact on overall survival. On the contrary, high serum CEA ( > 5 ng/ ml) was significantly (p < 0.0001) correlated to a poor prognosis. Finally, in multivariate analyses, the combination of high serum CEA and high serum VEGF was significantly (hazard ratio 3.0, p = 0.02) associated with poor survival compared to high serum CEA and low serum VEGF. It is concluded that 6 months postoperatively serum CEA is a better prognostic marker than corresponding serum and plasma VEGF. However, high serum VEGF within high serum CEA was an even better predictor of overall survival than high serum CEA alone.

Prognostic value of carcinoembryonic antigen level in rectal cancer treated with neoadjuvant chemoradiotherapy

BACKGROUND

The purpose of this study was to identify clinical and pathological parameters to improve prediction of disease-free survival (DFS) and overall survival (OS) in patients treated with neoadjuvant chemoradiotherapy for rectal cancer.

METHODS

Between July 1995 and May 2007, 148 patients with primary rectal adenocarcinoma received neoadjuvant chemoradiotherapy followed by mesorectal excision. Preoperative treatment included various protocols, UFT and leucovorin (28%) and oxaliplatin-based chemotherapy (72%). Clinical and pathological variables were evaluated in relation to patient outcomes.

RESULTS

Thirteen percent of patients achieved a complete pathologic response. No response or minimal response as defined by Dworak (Tumor Regression Grade 0/1) was observed in 30 patients (20%). At a median follow-up of 37 months, the 3-year DFS and OS were 64% and 83%, respectively. Pre-treatment serum carcinoembryonic antigen (CEA) level </= 2.5 ng/ml was associated with higher DFS (74 vs. 53%; p = 0.018), higher complete pathologic responses (21 vs. 9%; p = 0.05), and less recurrences (24 vs. 44%; p = 0.014).

CONCLUSION

The data suggest that a CEA level </= 2.5 ng/ml might be a predictor not only of tumor response, as has been suggested before, but also of DFS. This finding could be useful in the future to predict individual risk and to develop more aggressive or alternative strategies.

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.

Persistent high postoperative carcinoembryonic antigen in colorectal cancer patients--is it important?

INTRODUCTION

Evaluation of pre- and postoperative serum CEA levels together has seldom been assessed for the prognosis of colorectal cancer (CRC).

OBJECTIVE

To concurrently evaluate pre- and postoperative CEA as factors of relapse and survival.

METHODS

The study consisted of 114 patients who had undergone surgery from February 2002 to June 2006 for CRC. All patients were classified into four groups according to their pre- and postoperative CEA levels. Data obtained for clinicopathologic parameters, lymph node metastasis, stage, recurrence, and CEA levels were analyzed to determine their association with survival. Multivariate analysis by the Cox proportional hazard regression model was performed to identify the independent prognostic factors associated with survival.

RESULTS

Postoperative serum CEA levels remained high in Group 3 (n = 32). Nineteen patients (59.3%) demonstrated a detectable cause for persistent high CEA levels, while the reasons for those in the other thirteen patients (40.6%) remained obscure. Abnormal preoperative CEA levels significantly correlated with the depth of tumor invasion, lymph node metastasis, TNM stage, and recurrence (p < 0.05). Abnormal postoperative CEA levels were significantly related to the depth of tumor invasion, TNM stage, and postoperative relapse (p<0.05). Patients in Group 3 demonstrated the worst survival rate. Abnormal postoperative CEA levels, lymph node metastasis, and location of the tumor were independent prognostic factors for survival.

CONCLUSION

The survival of patients with high postoperative CEA levels due to unknown reasons may be extended if they are exhaustively tested with sensitive diagnostic methods and treated at an early stage.

Tumor marker utility and prognostic relevance of cathepsin B, cathepsin L, urokinase-type plasminogen activator, plasminogen activator inhibitor type-1, CEA and CA 19-9 in colorectal cancer

BACKGROUND

Cathepsin B and L (CATB, CATL), urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 play an important role in colorectal cancer invasion. The tumor marker utility and prognostic relevance of these proteases have not been evaluated in the same experimental setting and compared with that of CEA and CA-19-9.

METHODS

Protease, CEA and CA 19-9 serum or plasma levels were determined in 56 patients with colorectal cancer, 25 patients with ulcerative colitis, 26 patients with colorectal adenomas and 35 tumor-free control patients. Protease, CEA, CA 19-9 levels have been determined by ELISA and electrochemiluminescence immunoassay, respectively; their sensitivity, specificity, diagnostic accuracy have been calculated and correlated with clinicopathological staging.

RESULTS

The protease antigen levels were significantly higher in colorectal cancer compared with other groups. Sensitivity of PAI-1 (94%), CATB (82%), uPA (69%), CATL (41%) were higher than those of CEA or CA 19-9 (30% and 18%, respectively). PAI-1, CATB and uPA demonstrated a better accuracy than CEA or CA 19-9. A combination of PAI-1 with CATB or uPA exhibited the highest sensitivity value (98%). High CATB, PAI-1, CEA and CA 19-9 levels correlated with advanced Dukes stages. CATB (P = 0.0004), CATL (P = 0.02), PAI-1 (P = 0.01) and CA 19-9 (P = 0.004) had a significant prognostic impact. PAI-1 (P = 0.001), CATB (P = 0.04) and CA 19-9 (P = 0.02) proved as independent prognostic variables.

CONCLUSION

At the time of clinical detection proteases are more sensitive indicators for colorectal cancer than the commonly used tumor markers. Determinations of CATB, CATL and PAI-1 have a major prognostic impact in patients with colorectal cancer.

Clinical and pathologic evaluation of patients with recurrence of colorectal cancer five or more years after curative resection

PURPOSE

This study was designed to evaluate the characteristics of recurrences that occur five or more years after curative resection for colorectal cancer.

METHODS

This study included a total of 352 patients who were confirmed as having recurrence after curative resection for colorectal cancer during the period from January 1995 to December 2000. Of the 352 patients, 231 had early recurrence (less than 2 years after operation), 103 had intermediate recurrence (2-5 years after operation), and 18 had late recurrence (more than 5 years after operation). The clinicopathologic findings of the patients with late recurrence were compared with those of the other two recurrence groups, with special reference to the pattern of recurrence.

RESULTS

The rate of late recurrence was 1.2 percent. In the late recurrence group, males outnumbered females by a ratio of 3.5:1 and the mean level of preoperative carcinoembryonic antigen was 4.5 ng/ml, whereas that of the early recurrence group was 30.5 ng/ml. All the lesions in the cases with late recurrence except one lesion were located in the left colon or rectum, the tumors were small-sized and polypoid, and well-differentiated adenocarcinomas were more frequently observed. Distant metastasis, especially lung metastasis, was most frequently observed.

CONCLUSIONS

Late recurrent colorectal cancer has some characteristics compared with early or intermediate recurrence. Although recurrence at more than five years postoperatively is not common, its possibility should be considered whenever performing follow-up, and surveillance for lung metastasis is recommended after more than five years of surgery.

Diagnostic accuracy of serum-carcinoembryonic antigen in recurrent colorectal cancer: a receiver operating characteristic curve analysis

BACKGROUND

Serial measurements of carcinoembryonic antigen (CEA) are frequently used in the follow-up after colorectal cancer (CRC), but its usefulness remains debatable. Choosing the appropriate cut-off point is crucial to the diagnostic accuracy (DA) of continuous test variables. Receiver operating characteristic curve (ROC) analysis is the appropriate statistical method for this purpose, but has not been applied in previous studies.

METHODS

One hundred ninety-four consecutive patients surgically treated with curative intent for CRC between July 1996 and June 1999 had systematic follow-up for five years. Follow-up included imaging, coloscopy and serial CEA measurements. Complete data including CEA measurements were available from 153 patients. ROC analysis of CEA was done with regard to detection of recurrent disease.

RESULTS

Depending on the chosen cut-off value of CEA, DA varied widely within the normal range (CEA <or=10 U/ml). CEA >4 U/ml provided the highest sensitivity (0.78) and specificity (0.91), compared to a sensitivity and specificity at the upper normal range (CEA = 10 U/ml) of 0.51 and 0.99, respectively. Thirty-three patients (24%) developed recurrence. Among 11 (5%) asymptomatic patients diagnosed by elevated CEA levels, only two patients (1.5%) were amenable to secondary curative surgery. A threefold increase of CEA in an individual patient had the same DA as the best cut-off value (>4 U/ml).

CONCLUSIONS

Diagnostic accuracy of CEA in follow-up after curative surgery for CRC is influenced by the chosen cut-off value. A threefold increase of CEA may indicate recurrent disease. The value of serial measurement of CEA was limited.