Follow-up of colorectal cancer resected for cure. An experience with CEA, TPA, Ca 19-9 analysis and second-look surgery

Carcinoembryonic Antigen (CEA), α-fetoprotein, CA 19.9 and CA 125 in Advanced Colorectal Cancer (ACC)

In 111 patients with ACC we studied CEA, FP, CA-125 and CA 19.9 during therapy and follow-up. Marker determination was performed every two months. CEA was elevated (> 5 ng/ml) in 82%, αFP(> 15 ng/ml) in 0%, CA-125 (>38 U/ml) in 37%, CA 19.9 (> 30 U/ml) in 64% of the patients. We did not find significant differences between the sensititivity of CEA alone and that of the combination of CEA + CA-125 (86%), CEA + CA 19.9 (87%), CA-125 + CA-19.9 (71%) and CEA + CA-125 + CA 19.9 (88%). We did not find any correlation between the level of positivity of the markers and the clinical parameters we examined. When serial determinations were carried out, CEA showed the best indication of response to treatment, followed by CA 19.9. In the evaluation of the response to chemotherapy we found that CA 125 presented significant percentages of false-positive (9%) (P < 0.008) and false-negative (8.1%) (P < 0.008) results, compared to CEA and CA 19.9. CA 125 did not demonstrate any utility for the follow-up of patients with colorectal cancer although increased values were found in 37%. We conclude that CEA is currently the best marker for the follow-up of patients with colorectal cancer. The combination of CEA and CA 19.9 had some utility in follow-up, without significantly improving CEA results

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).

Are high initial CEA and CA 19-9 levels associated with the presence of K-ras mutation in patients with metastatic colorectal cancer?

In certain cell culture studies, significant CEA expression was observed in K-ras mutant cells. However, the relationship between high CEA levels and K-ras status has not been sufficiently investigated. In the present study, we aimed to determine the prognostic role of initial CEA and CA 19-9 values in metastatic colorectal cancer patients according to the status of K-ras. Between 2000 and 2010, a total of 215 patients with metastatic colorectal cancer who were treated and followed up in our oncology center were analyzed. Smokers were excluded from the study. The clinicopathological findings and initial CEA and CA19-9 values were determined. K-ras mutation analysis was performed using quantitative PCR evaluation of the DNA from the tumor tissues. Eighty-two patients (38.1 %) were female and 133 (61.9 %) were male, with a median age of 59 years (range 27-83). Based on tumor localization, 127 patients (59 %) were classified as colon cancer patients and 88 patients (41 %) were classified as rectal cancer patients. The majority of patients (83.3 %) had pure adenocarcinoma histology, while 36 cases (16.7 %) had mucinous adenocarcinoma. The initial CEA levels were detected to be high (>5 ng/mL) in 108 of the patients (50.2 %), while high levels of initial CA 19-9 (>37 ng/mL) were found in 90 patients (41.8 %). K-ras mutations were detected in 99 of the patients (46 %). K-ras was found to be wild type in 116 patients (54 %). Significant differences were detected between the K-ras wild-type and mutant groups with respect to age and the initial serum CEA levels. Patients with K-ras mutations were younger (p = 0.04) and had higher initial CEA levels (p = 0.02) compared to patients with K-ras wild type. The median overall survival (OS) time and 3-year OS rate for patients with a high initial CEA level (>5 ng/mL) were significantly shorter than those of patients with a low initial CEA level (<5 ng/mL) (50.5 months and 61.8 % vs. 78.6 months and 79.1 %, p = 0.014). Furthermore, the patients with low initial CA 19-9 levels (<37 ng/mL) had a significant better median OS interval and 3-year OS rate (76.1 months and 80.1 %) compared to patients with high initial CA 19-9 levels (>37 ng/mL) (37.6 months and 55.7 %, p = 0.04). Multivariate analysis indicated that stage at the time of diagnosis (p < 0.001) and low initial serum CEA level (p = 0.037) were independent prognostic factors of OS. For K-ras mutant patients, the stage at diagnosis (p = 0.017), low initial serum CEA level (p = 0.001), and low initial serum CA 19-9 level were found to be independent prognostic indicators of OS. Our findings demonstrate for the first time that the presence of a K-ras mutation correlated with high initial CEA and CA 19-9 levels in patients with metastatic colorectal cancer. Patients with high initial CEA and CA 19-9 levels may potentially predict the presence of a K-ras mutation, and this prediction may guide targeted therapies in these patients.

Follow-up recommendations for colon cancer

Recent evidence suggests that intensive follow-up after curative resection of colorectal cancer is associated with a small but significant improvement in survival. Regimens that employ cross-sectional imaging and carcinoembryonic antigen determination appear to have the greatest benefit. A risk-adapted approach to follow-up, intensively following patients at highest risk of recurrence, increases efficacy and cost-effectiveness. Ongoing improvements in risk stratification, disease detection, and treatment will increase the benefits of postoperative surveillance. Large randomized controlled trials are needed to determine the optimal surveillance regimen and must include an analysis of survival, quality of life, and cost-effectiveness to assess efficacy properly.

First alert for recurrence during follow-up after potentially curative resection for colorectal carcinoma: CA 19-9 should be included in surveillance programs

BACKGROUND

The aim of this study was to evaluate the contribution of each examination included in the postoperative surveillance program, especially that of serum tumor markers.

PATIENTS AND METHODS

Patients who underwent curative surgery for colorectal carcinoma (CRC) from January 2000 to December 2006 were enrolled. The postoperative surveillance program in our department includes tumor marker (carcinoembryonic antigen [CEA] and carbohydrate antigen [CA] 19-9) measurement every 3 months for 5 years, chest radiograph or chest computed tomography (CT) every 3 months for 2 years and then every 6 months until 5 years, and abdominal CT every 3 months for 2 years and then every 6 months until 5 years. The first examination that revealed abnormality in patients who developed recurrence was analyzed.

RESULTS

During the study period, 105 recurrences were diagnosed. There were 45 hepatic recurrences, 23 local recurrences, 20 pulmonary recurrences, 16 lymph node recurrences, and 10 peritoneal recurrences. Computed tomography, CEA, and CA 19-9 were the first abnormal examination(s) in 77, 23, and 26 patients, respectively. Tumor markers detected the recurrence earlier than did CT in 27% of patients. CEA and CA 19-9 equally contributed to detection with respect to the number of patients, while the sites of detected recurrences differed.

CONCLUSION

For early detection of occult recurrence of CRC, CT was the most reliable modality. On the other hand, tumor markers were also relevant. Given the recent advances in multimodal approaches for advanced CRC, the combination of CT, CEA, and CA 19-9, which is currently not included in guidelines, should be routinely performed.

Colorectal carcinoma with extremely low CA19-9

Aim. The aim of this study is to determine the significance of postoperative sequential measurements of serum CA19-9 in patients with extremely low serum level. Patients and Methods. Serum level of CA19-9 of 1096 patients who underwent surgery was measured preoperatively and every three months after surgery for 5 years. Patients with CA19-9 level of less than 2 U/mL at the time of diagnosis were defined as Extremely Low CA19-9 (ELCA). Results. One hundred and seven patients (9.8%) were ELCA. Of these, 86 underwent surgery with curative intent. Serum levels of CA19-9 in patients who did not undergo curative resection (N = 12) and who developed recurrence (N = 10) were less than 2.0 U/mL in all occasions during followup. In all patients without recurrence, serum level of CA19-9 also remained less than 2.0 U/mL. Conclusion. In patients with extremely low CA19-9, who consist of 9.8% of colorectal carcinoma cases, postoperative sequential measurement of serum level of CA19-9 contributed neither to assessment of curability of surgical resection nor to detection of recurrence.

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.

Surveillance of patients following surgery with curative intent for colorectal cancer

Surveillance after resection of colorectal cancer with curative intent is an important component of post-operative care. Clinical review, imaging, colonoscopy, and cost to the community are among significant issues to consider in planning a surveillance regime. This review aims to identify the available evidence for the use of surveillance and its individual components. The literature pertaining to follow-up of patients following potentially curative surgery for colorectal cancer was reviewed in order to formulate a summary of the wide range of clinical practice. There is evidence of improved survival of patients undergoing more intense follow-up compared with those having minimal surveillance, with an estimated overall 5-year gain of up to 10%. The efficacy of individual components of follow-up regimes remains unclear, but an overall package of ‘intensive’ follow-up including clinical review, liver imaging, and colonoscopy appears to be of benefit. It is cost-effective and can be specialist or community-based.

Mutant p53 protein in the serum of patients with colorectal cancer: Correlation with the level of carcinoembryonic antigen and serum epidermal growth factor receptor

INTRODUCTION

Enzyme-linked immunosorbent assay (ELISA) was used for analysis of serum mutant p53 protein, carcinoembryonic antigen (CEA), and epidermal growth factor receptor (EGFR). Serum samples were obtained from 48 patients with colorectal cancer (CRC) and a control group of twenty healthy individuals.

RESULTS

The results demonstrated a significant increase of serum mutant p53, EGFR, and CEA levels in CRC patients compared to the control group (P<0.001 for each). Mutant p53 protein was significantly different in the different CRC grades (P=0.028). p53, CEA, and EGFR can differentiate successfully between different CRC grades and normal control (P<0.001 for each). Sensitivities of p53, CEA, and EGFR were 39.6, 31, and 71%, respectively. There was no correlation between CEA, EGFR, and p53 indicating that these variables were independent. Positive status of serum CEA and (or) p53 was found in 29 out of 48 (60%) patients. Also, positive status of serum CEA and (or) EGFR was found in 39 out of 48 (81%) patients.

CONCLUSION

Thus, the simultaneous determination of p53 or EGFR combined with the CEA may increase the sensitivity to diagnose CRC patients and may aid in disease prognosis.

Cost-effectiveness of two follow-up strategies for curative resection of colorectal cancer: comparative study using a Markov model

The follow-up of patients with curative resection of colorectal cancer is still controversial. The means mobilized for postoperative monitoring come at a high cost. However, the modalities are neither formalized nor validated with regard to an improved 5-year survival rate. To compare the cost-effectiveness of both strategies for patient follow-up during the 7 years following curative resection of colorectal cancer, we performed a costeffectiveness analysis adjusted for quality of life. Using data from the literature and a population study, a simulation of follow-up on patients who had undergone curative resection of colorectal cancer was carried out over a 7-year period using a Markov model. Two Markov processes were modeled to compare the cost-effectiveness ratio adjusted for quality of life in patients with a follow-up in accordance with the recommendations of the 1998 French Consensus Conference (standard follow-up) with the carcinoembryonic antigen (CEA) assay and a simplified follow-up. The influence of standard follow-up on the quality-adjusted life expectancy of patients who had Duke's stage A and B colorectal cancer appears to be modest, with increases of 2.5 months and 1.3 months, respectively; it is more acceptable for patients who had had Duke's stage C, with an increase of 11 months. The high variability of cost-effectiveness ratios (> 7 years) of +/- 44,830 and 180,195 Euro per quality-adjusted life-years (QALY), respectively) did not favor the standard follow-up. The cost-effectiveness ratio (> 7 years) of patients having had Duke's stage C colorectal cancer was 1,058 (sd: 2746) Euro per QALY and could favor the standard follow-up. This study showed that standard follow-up with CEA assay tended to preferentially improve the survival of Duke's stage C patients. The type of examination needed and the frequency with which it has to be carried out should take account of the stage, treatment for the initial illness, and the patient's age.

Cost and effectiveness of follow-up examinations in patients with colorectal cancer resected for cure in a French population-based study

The cost of follow-up examinations for patients having undergone potentially curative surgery for colorectal cancer is considerable. The aim of this study was to provide a thorough assessment of the cost and effectiveness of the follow-up tests used during the 5 years after surgical resection for colorectal cancer and its recurrences. We studied medical and economic data from the records of 256 patients registered in the Herault Tumor Registry who underwent potentially curative surgical resection in 1992. Recurrence, curative recurrence, survival, and the cost of follow-up tests were assessed respectively for at least 5 years. We analyzed the cost and effectiveness of follow-up tests in patients who received either follow-up with carcinoembryonic antigen (CEA) monitoring as advocated by the 1998 French consensus conference recommendations (standard follow-up) or a more minimal follow-up schedule. Nine patients died in the postoperative period. The 5-year survival rates in the standard and minimal follow-up groups were 85% and 79%, respectively (p=0.25). Cost-effectiveness ratios were 2123 in Dukes' stage A patients, 4306 in Dukes' stage B patients, and 9600 in Dukes' stage C patients. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the standard follow-up group were 1238 and 2261.5, respectively. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the minimal follow-up group were 1478 and 573, respectively. There were no survivors 5 years after a recurrence when the recurrence was detected by physical examination, chest X-ray, and colonoscopy in either follow-up group. Dukes' classification is a poor indicator of patient selection. The follow-up tests should only include CEA monitoring and abdominal ultrasonography for the diagnosis of recurrence.

Colorectal cancer follow-up: a reassessment of empirical evidence on effectiveness

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.

Is follow-up of colorectal cancer patients worthwhile?

Between 1978 and 1989, 1,045 of 1,399 patients (580 male and 474 female) underwent curative surgery for colorectal carcinoma. Of these patients, 350 (33 percent) had recurrences, another 16 (1.5 percent) developed a metachronous colorectal cancer, and 23 (2 percent) had cancers of other organs. An isolated locoregional recurrence was found in 75/350 (21 percent). The remaining 275/350 patients (79 percent) showed systemic dissemination of the carcinoma. Reoperations with curative intent were performed on 56/350 patients (16 percent). Only 21 of the 56 resected patients (38 percent), i.e., 21/350 (6 percent), were without recurrence at the end of the follow-up period on December 31, 1990. Despite a curative reoperation, 62 percent of the patients again developed recurrent growths. There is an imbalance between the efforts invested in tumor follow-up and the benefits gained. Further follow-up programs should be investigated in a controlled, prospective fashion.

Monoclonal antibody imaging in patients with colorectal cancer and increasing levels of serum carcinoembryonic antigen. Experience with ZCE-025 and IMMU-4 monoclonal antibodies and proposed directions for clinical trials

In an effort to identify the site of recurrent colorectal cancer in patients with occult metastasis and increasing serum CEA levels, we conducted two trials using monoclonal antibodies (MoAb) against CEA. The first utilized Indium-111-labeled ZCE-025; an immunoglobulin G1 (IgG1) anticarcinoembryonic antigen (anti-CEA) antibody (Hybritech, San Diego, CA). The second study used Tc-99m-labeled Fab' fragment of IMMU-4 (Immunomedics, Morris Plains, NJ). Eighteen patients were imaged with the ZCE-025 and 14 with the Tc-99m Fab' IMMU-4. True-positive scans, defined as at least one correct correlation of the MoAb scan and surgical/histologic findings, were observed in 12 of 15 patients undergoing exploration or biopsy using the ZCE-025 and 11 of 14 using the IMMU-4. There were no true-negative scans with the ZCE-025 and only 2 of 14 with the IMMU-4. There were 3 false-positive scans with the ZCE-025 and 1 of 14 with IMMU-4. There were no false-negative scans with either ZCE-025 or IMMU-4. Four (31%) of 13 patients undergoing exploration and imaged with ZCE-025 and 5 (36%) of 14 imaged with IMMU-4 had complete tumor resection. Treatment decisions were affected in 3 (16%) of 18 ZCE-025-imaged patients and 3 (21%) of 14 IMMU-4 ones. Two (14%) of 14 patients imaged with IMMU-4 had negative MoAb scans and negative laparotomies. Despite these findings, it is not known whether such early detection and resection will translate into improved survival rates. The authors suggest two randomized studies, one designed to ascertain the role of MoAb added to blind exploratory laparotomy. In that study, patients with increasing CEA levels and a negative workup will be randomized to an exploratory laparotomy preceded by MoAb anti-CEA scans or a straight exploratory laparotomy without the assistance of a MoAb anti-CEA scan. Endpoints will be differences in complete resectability and survival. A second study will examine the merits of blind exploratory laparotomies. In that study, patients with increasing CEA levels and a negative workup would be randomized to MoAb imaging, exploratory laparotomy, and radioimmunoguided surgery, and the other cohort of patients would continue to have conventional radiologic workup. Exploration in this latter group would be performed only when indicated by radiologic or endoscopic studies. The endpoint of the study would compare survival in the two cohorts of patients. These two studies may ultimately settle the debate regarding the correct approach to patients with occult metastatic colorectal cancer and a increasing levels of serum CEA.

Radioimmuno-guided endoscopy (RIGE) in the detection of primary and recurrent rectal tumor

The usefulness of radioimmunoguided endoscopy in the detection of primary and recurrent rectal cancer was investigated. Of the 15 patients included in our study, 4 with suspected primary rectal cancer were examined preoperatively, while the remaining 11 were studied after radical resection of rectal carcinoma with the aim of detecting local recurrence. Radioimmunoguided endoscopy was performed employing a hand-held gamma-detecting probe (mod. 2 Oris, France), after the administration of a 111In labeled monoclonal antibody to CEA. Radioimmuno-guided endoscopy results detected the presence of primary or recurrent periluminal cancer in seven cases. In four it modified the preoperative stage based on the findings of conventional investigation and it influenced the surgical decision in five cases. No toxicity was noted and none of the patients developed HAMAs.

Role of CEA, TPA, and Ca 19-9 in the early detection of localized and diffuse recurrent rectal cancer

Sixty-six consecutive patients who underwent curative resection for rectal cancer were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue plasminogen activator (TPA), and carcinomatous antigen 19-9 (Ca 19-9) determinations in the early diagnosis of resectable recurrences. Thirty-three recurrences were detected between 6 and 42 months. CEA, TPA, and Ca 19-9 showed a sensitivity of 72.7 percent, 78.8 percent, and 60.1 percent, respectively, and a specificity of 60.6 percent, 60.6 percent, and 87.9 percent, respectively. In 23 cases the rise in the value of CEA and/or TPA and/or Ca 19-9 was the first sign of recurrences, and the diagnosis was established later by clinical methods. In this group, the lead time was two months for liver metastases and four months for disseminated metastases. As far as the relationship between localization of recurrence and marker level increase is concerned, of 16 hepatic metastases CEA, TPA, and Ca 19-9 showed a sensitivity of 94 percent (P less than 0.05), 69 percent, and 62 percent, respectively. Of six patients with local recurrences, CEA, TPA, and Ca 19-9 showed a sensitivity of 50 percent, 100 percent (P less than 0.05), and 83.3 percent, respectively. Of three patients with peritoneal carcinomatosis, CEA, TPA (P less than 0.05), and Ca 19-9 showed a sensitivity of 0 percent, 100 percent, and 0 percent, respectively. No significant differences were reported among the three markers according to multiple metastases and metachronous polyps. Fourteen patients (42.4 percent) underwent surgical treatment for recurrent disease, and eight of them (57 percent) showed a resectable disease, for a total resectability rate of 24.2 percent. The findings of our study indicate that a follow-up program based on CEA, TPA, and Ca 19-9 assays is related to an early diagnosis and a good resectability rate for both local and metastatic recurrences from rectal cancer.

Early results of follow-up after radical resection for colorectal cancer. Preliminary results of a prospective randomized trial

One-hundred and six consecutive patients were included in a prospective study of intensive monitoring after radical resection for colorectal cancer, 54 being randomized into a conventional follow-up group (Group I) and 52 into an intensified follow-up group (Group II). After a median follow-up of 2 years the overall rate of detection recurrence in Group I was 24% (13/54) and in Group II 25% (13/52). The recurrence rates among those followed up for at least 2 years were 36% (10/28) and 30% (9/30), respectively. Of the recurrences in Group I, one was local, five regional and six distant, and the corresponding figures in Group II were three, four and five. One radical extirpation of a local perineal recurrence has been performed in Group I, whereas two intestinal reresections for local anastomotic recurrences and two hepatic resections for solitary hepatic metastases have been performed in Group II. Mortality to date is 13% (7/54) in Group I and 8% (4/52) in Group II. Two adenomatous polyps have been removed from the colon in Group I during endoscopic surveillance and seven in Group II. These preliminary results encourage us to continue the trial up to 5 years after primary surgery.

Clinical use of tumor markers in oncology

The perfect tumor marker would be one that was produced solely by a tumor and secreted in measurable amounts into body fluids, it should be present only in the presence of cancer, it should identify cancer before it has spread beyond a localized site (i.e., be useful in screening), its quantitative amount in bodily fluids should reflect the bulk of tumor, and the level of the marker should reflect responses to treatment and progressive disease. Unfortunately, no such marker currently exists, although a number of useful but imperfect markers are available. The predominant contemporary markers are discussed here by chemical class, as follows: glycoprotein markers, including carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-hCG), and prostate specific antigen (PSA); mucinous glycoproteins, including CA 15-3, CA 19-9, mucinous-like cancer antigen and associated antigens, and CA 125; enzymes, including prostatic acid phosphatase (PAP), neuron specific enolase (NSE), lactic acid dehydrogenase (LDH), and placental alkaline phosphatase (PLAP); hormones and related endocrine molecules, including calcitonin, thyroglobulin, and catecholamines; and, molecules of the immune system, including immunoglobulins and beta-2-microglobulin. The biologic properties of each group of tumor markers are discussed, along with our assessment of their role in clinical medicine today.

Gastrointestinal cancer follow-up: the effectiveness of sequential CEA, TPA and Ca 19-9 evaluation in the early diagnosis of recurrences

One-hundred and seventy-four consecutive patients who underwent curative resection for gastric and colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and Ca 19-9 determinations and independent clinical examinations, in the early diagnosis of resectable recurrences. Sixty-six recurrences (33 from gastric and 33 from colorectal cancer) were detected between 6 and 42 months after primary surgery. In gastric cancer CEA, TPA and Ca 19-9 showed a sensitivity of 64%, 73% and 60% respectively and a specificity of 67%, 65% and 54% respectively. Nine patients (27%) underwent surgical treatment for recurrent disease, and four of these (44.4%) had resectable recurrence, for a total resectability rate of 12%. Of these four patients, three are still living after 12, 36 and 44 months respectively from re-operation without evidence of neoplastic disease. In one of these patients, re-operation was performed on the basis of the elevation of the three markers, without any other clinical sign of disease. This patient had a resectable solitary hepatic recurrence. In colorectal cancer. CEA, TPA and Ca 19-9 showed a sensitivity of 73%, 73% and 49% respectively, and a specificity of 77%, 87% and 97% respectively. Fourteen patients (42.4%) underwent surgical treatment for recurrent disease and eight of these (57%) showed resectable recurrence, for a total resectability rate of 24.2%. Six patients are still living after 9, 16, 21, 31, 41 and 53 months respectively from re-operation without evidence of neoplastic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple operations for recurrent colorectal cancer

The benefit of an aggressive surgical approach in selective patients with recurrent colorectal cancer has been demonstrated by several investigators. The disease-free 5 year survival is 30%, and in carefully selected series it is as high as 46%. These procedures can be performed safely with minimal morbidity and mortality by surgeons who are experienced in the techniques of radical surgery. It is important and should be our focus to try to identify those patients who will benefit the most from an aggressive surgical approach, by better definition of the biology of the tumor through tumor differentiation and DNA and oncogene analysis.

Second-look surgery for recurrent colorectal carcinoma: is it worthwhile?

Second-look surgery for recurrent colorectal carcinoma has been advocated for over four decades. Routine follow-up procedures gave way to clinically directed or carcinoembryonic (CEA)-directed procedures in the mid-1970's. In this paper, we review the results of second-look surgery for recurrent colorectal carcinoma and ask the question, "Is it worthwhile?" Excluding surgery for symptomatic patients, we conclude that second-look surgery should only be performed for recurrent colorectal carcinoma with the intent of rendering the patient disease-free. Without effective systemic therapy, "palliative" or "debulking" procedures probably do not increase survival. The most likely candidates for such a curative approach with second-look surgery are those with isolated liver, pulmonary, and, less frequently, regional recurrences.

Utility and cost of carcinoembryonic antigen monitoring in colon cancer follow-up evaluation. A Markov analysis

The use of carcinoembryonic antigen (CEA) to monitor patients after intentionally curative colon cancer resection can have advantages (improved life expectancy as a result of early detection of recurrences) as well as disadvantages (false-positive CEA rises and early detection of incurable recurrences in asymptomatic patients). This study estimated how the favorable and unfavorable effects of CEA monitoring affect life expectancy and quality of life of colon cancer patients. These effects were simulated using a Markov analysis for which the variables had been defined on the basis of data found in literature. The influence of CEA monitoring on quality adjusted life expectancy appears to be modest and varies, according to the data used, from an average increase of +7 days (+0.3%) to an average decrease of -5 days (-0.09%). This value is dependent, among other things, on patient related variables; the adverse effects especially dominate in older patients with a favorable Dukes' stage of the primary tumor and if operative mortality exceeds 2%. The total cost of CEA monitoring, including diagnosis and therapy performed as a result of true- or false-positive CEA rise, is considerable. High cost and low return leads to a high marginal cost-effectiveness ratio, which varies from $22,963 to $4,888,208 per quality adjusted life year saved. It is concluded that CEA monitoring should not be used for routine following of colon cancer patients, as its advantages have so far been demonstrated insufficiently.

The role of CEA, TPA and CA 19-9 in the early detection of recurrent colorectal cancer

Eighty-eight consecutive patients who underwent curative resection for colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential CEA, TPA and CA 19-9 determinations and independent clinical examination in the early diagnosis of resectable recurrences. Twenty nine recurrences were detected between 8 and 38 months after primary surgery. CEA, TPA and CA 19-9 showed a sensitivity of 72%, 62% and 38%, and a specificity of 78%, 86% and 97%, respectively. Of eight recurrences in which CEA was not raised, five induced a rise in TPA and two a rise in CA 19-9. The rise in the serum concentration of one of the three markers was the first sign of relapse in 23 (79%) patients. Two second-look laparotomies based solely on a rise in serum markers were performed. In one case diffuse recurrent disease was found, and in the other a resectable solitary hepatic metastasis was found.