The prognostic value of serum and immunohistochemical tumour markers in advanced gastric cancer

Serum β-hCG as a Biomarker in Pancreatic Neuroendocrine Tumors: Rethinking Single-Analyte Approach

Despite recent advances, neuroendocrine tumors (NETs) remain a challenging topic, due to their diversity and the lack of suitable biomarkers. Multianalyte assays and the shift to an omics-based approach improve on the conventional single-analyte strategy, albeit with their own drawbacks. We explored the potential of serum β-hCG as a biomarker for NETs and discussed its role in disease monitoring. We recruited 40 patients with non-functioning pancreatic NETs, all with liver metastases. Serum β-hCG concentrations were measured at 3-month intervals over 48 months. We performed a comparative and a repeated measures analysis of β-hCG depending on WHO grade (G1, G2), liver tumor burden (LTB; below 10%, 10-25%), and RECIST 1.1. (stable disease, progressive disease). Patients with progressive disease (p < 0.001), 10-25% LTB (p < 0.001) and WHO Grade 2 (p < 0.001) displayed higher β-hCG concentrations. Throughout the study, β-hCG concentrations consistently increased across the entire cohort. Delta β-hCG during the study period was greater in patients with 10-25% LTB (p < 0.001), progressive disease (p < 0.001), and G2 (p = 0.003). Serum β-hCG correlates with established indicators of malignancy and disease progression in metastatic NETs, supporting further studies as a monitoring and prognostic biomarker. Despite promising results from novel biomarkers, there is still a place for single-analyte assays in NETs.

Aberrant trophoblastic differentiation in human cancer: An emerging novel therapeutic target (Review)

Various types of human cancer may develop aberrant trophoblastic differentiation, including histological changes and altered expression of β‑human chorionic gonadotropin (β‑hCG). Aberrant trophoblastic differentiation in epithelial cancer is usually associated with poor differentiation, tumor metastasis, unfavorable prognosis and treatment resistance. Since β‑hCG‑targeting vaccines have failed in an early phase II trial, it is crucial to obtain a better understanding of the molecular pathogenesis of trophoblastic differentiation in human cancer. The present review summarizes the clinical and translational research on this topic with the aim of accelerating the development of an effective targeted therapy. Ectopic expression of β‑hCG promotes proliferation, migration, invasion, vasculogenesis and epithelial‑mesenchymal transition (EMT) in vitro, and enhances metastatic and tumorigenic capabilities in vivo. Signaling cascades modulated by β‑hCG include the TGF‑β receptor pathway, EMT‑related pathways, the c‑MET receptor tyrosine kinase and mitogen‑activated protein kinase/ERK pathways, and the SMAD2/4 pathway. Taken together, these findings indicated that TGF‑β receptors, c‑MET and ERK1/2 are potential therapeutic targets. Nevertheless, further investigation on the molecular basis of aberrant trophoblastic differentiation is mandatory to improve the design of precision therapy for this aggressive type of human cancer.

DNA methylation drives a new path in gastric cancer early detection: Current impact and prospects

Gastric cancer (GC) is one of the most common and deadly cancers worldwide. Early detection offers the best chance for curative treatment and reducing its mortality. However, the optimal population-based early screening for GC remains unmet. Aberrant DNA methylation occurs in the early stage of GC, exhibiting cancer-specific genetic and epigenetic changes, and can be detected in the media such as blood, gastric juice, and feces, constituting a valuable biomarker for cancer early detection. Furthermore, DNA methylation is a stable epigenetic alteration, and many innovative methods have been developed to quantify it rapidly and accurately. Nonetheless, large-scale clinical validation of DNA methylation serving as tumor biomarkers is still lacking, precluding their implementation in clinical practice. In conclusion, after a critical analysis of the recent existing literature, we summarized the evolving roles of DNA methylation during GC occurrence, expounded the newly discovered noninvasive DNA methylation biomarkers for early detection of GC, and discussed its challenges and prospects in clinical applications.

Nomogram based on clinical characteristics for predicting overall survival in gastric cancer patients with preoperative anemia

BACKGROUND

Preoperative anemia is associated with increased postoperative morbidity and mortality and increased perioperative transfusion risk. For surgical patients, this affects physical and cognitive ability and quality of life, but it is an important and modifiable risk factor.

AIM

To determine the effect of preoperative anemia on the prognosis of gastric cancer (GC) patients and generate a prognostic nomogram to predict the postoperative overall survival (OS) of GC patients with preoperative anemia.

METHODS

Clinicopathological and follow-up data of GC patients treated at Zhejiang Provincial People's Hospital (China) from 2010 to 2015 were collected. Independent prognostic factors were screened by univariate and multivariate Cox regression analyses. Then, these factors were used to construct a nomogram to predict 1-, 3-, and 5-year postoperative OS in preoperative anemic GC patients. The nomogram was assessed by calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA).

RESULTS

Nine hundred and sixty GC patients were divided into two groups (preoperatively anemic and nonanemic), and postoperative survival analysis was performed on both groups, yielding a shorter postoperative survival for preoperatively anemic patients than for nonanemic patients. A total of 347 GC patients with preoperative anemia were included. Age, preoperative alpha-fetoprotein level, monocyte count, lymphocyte count, clinicopathological stage, liver metastasis, and GC type were identified as independent prognostic factors for OS. The area under the ROC curve (AUC) of the nomogram for predicting 1-, 3-, and 5-year OS was 0.831, 0.845, and 0.840, respectively, for the training cohort, and the corresponding AUC values in the validation cohort were 0.827, 0.829, and 0.812, respectively. Calibration curves and DCA indicated good performance of the nomogram.

CONCLUSION

In all, we have successfully produced and verified a useful nomogram for predicting OS in GC patients with preoperative anemia. This nomogram based on a variety of clinicopathological indices can provide an effective prognostic assessment and help clinicians choose an appropriate treatment strategy for GC patients with preoperative anemia.

An Immaculate Deception: Persistently Elevated Serum β-Hcg in Metastatic Signet Ring Cell Gastric Adenocarcinoma

BACKGROUND

Persistent elevations in beta-human chorionic gonadotropin (β-hCG) can be an ominous sign of both trophoblastic and non-trophoblastic malignancies. The absence of a clearly identified etiology of β-hCG elevation warrants pursuit of further diagnostic testing to determine the source of ectopic β-hCG.

CASE REPORT

A virginal 26-year-old woman with past medical history significant for persistently elevated β-hCG presented to our Emergency Department with shortness of breath, pleuritic chest pain, nausea, and vomiting, and was found to have widely metastatic gastric signet ring cell adenocarcinoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although elevated serum β-hCG is a generally a marker of pregnancy, β-hCG elevation without clear etiology necessitates ruling out other insidious processes. Failure to maintain and pursue a broad differential in the context of unexplained elevations of β-hCG can result in catastrophic missed or delayed diagnosis.

A novel robust nomogram based on preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) for predicting lymph node metastasis of gastric cancer

BACKGROUND

Accurate assessment of lymph node status in gastric cancer (GC) patients can help to select appropriate treatment strategies for GC, but the diagnostic accuracy of conventional methods needs to be improved. The aim of this study was to investigate the predictive value of preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) on lymph node status in GC patients and to construct a risk prediction model.

METHODS

This study retrospectively analyzed the clinicopathological characteristics of 349 patients with GC who underwent radical gastrectomy, among which 250 patients were recruited in the training cohort and 99 patients in the independent validation cohort. Significant risk factors in univariate analysis were further identified as independent variables in multivariate logistic regression analysis, which were then incorporated and presented in a nomogram. Receiver operating characteristic (ROC) curves, Calibration curve and decision curve analysis (DCA) curves were used to evaluate the discrimination, prediction accuracy and clinical effectiveness of the model.

RESULTS

Multifactorial logistic regression analysis showed that alcohol use (OR =2.203, P=0.036), Depth of invasion (OR =7.756, P<0.001), differentiation (OR =2.252, P=0.018), carcinoembryonic antigen (CEA) (OR =2.443, P=0.017), carbohydrate antigen 19-9 (CA199) (OR =2.715, P=0.008) and HALP (OR =2.276, P=0.032) were independent risk factors for lymph node metastasis (LNM) in GC. We used these factors to construct a nomogram for predicting LNM in GC patients, and the ROC curves showed good discrimination of the model with AUC values of 0.854 (training cohort) and 0.868 (validation cohort), respectively, and the calibration curves showed good predictive ability of the nomogram, in addition to the DCA curves results showed the clinical usefulness of the model.

CONCLUSIONS

In conclusion, we established a nomogram for predicting LNM in patients with GC.

A presumed extragonadal germ cell tumor that turned out to be a gastric cancer-a case report

A solely retroperitoneal mass in males in combination with elevated serum Alpha-Fetoprotein (AFP) and beta-human choriogonadotropin (β-HCG) levels is highly indicative of a metastatic testicular cancer. Although testicular cancers are rare, they represent the most common diagnosed cancer in males between 14 and 40 years. However, in cases without evidence of a primary testicular tumor, the rare diagnosis of a retroperitoneal extragonadal germ cell tumor (EGCT) must be assumed. Here, we describe the first published case of a 66-year-old man presenting with this typical clinical picture and the diagnosis of an AFP and β-HCG producing advanced gastric cancer with retroperitoneal lymph node metastases mimicking a primary retroperitoneal EGCT. The final diagnosis was only made by gastroscopy performed after a CT-guided retroperitoneal lymph node biopsy revealed an adenocarcinoma, suggesting an upper gastrointestinal tract primary origin. However, a specific initial anamnesis and also in the primary staging, including a full-body CT-scan there was no hint for another primary tumor. Only the slightly unusual extension of the retroperitoneal mass up to the ligamentum hepatoduodenale and the pylorus, as well as the atypical age made us question our initial diagnosis. This extraordinary case is of special clinical interest to all practising physicians and once again highlights the importance of keeping rare differential diagnosis such as AFP-producing gastrointestinal tumors in mind.

Clinical Evaluation of Serum Tumor Markers in the Diagnosis of Gastric Adenocarcinoma Staging and Grading

ᅟ: Detection and quantitative measurements of diffused tumor markers in blood samples of patients with cancer is a facile and convenient method to determine prognosis and the appropriateness of the treatment. This study was done to evaluate the level of CA125, CEA, AFP, Beta HCG, and CA19-9 tumor markers and their relation to the stage and grade of the disease in patients with gastric adenocarcinoma.

MATERIALS AND METHODS

In a descriptive cross-sectional study, of 81 patients referred to the oncology department of Tohid Hospital, Sanandaj, Iran, in 1 year, with recently detected gastric adenocarcinoma, serum level of CEA, CA19-9, CA125, AFP, and Beta HCG tumor markers was measured by ELISA method before chemotherapy and surgery. Patients were divided into four groups based on stage of disease (I, II, III, IV), and in terms of tumor differentiation, degrees were classified in to three groups: low, high, and intermediate. To determine the correlation of tumor markers level with the stage and grade of the disease, the Kruskal-Wallis and Mann-Whitney U tests were used.

RESULTS

By progression, the stages of the disease, the serum level of CA19-9, CA125, and AFP tumor markers demonstrated a significant increase. But this difference between level of HCG and CEA was not significant with the staging. There was no significant difference between the serum level of tumor markers and the grading of disease in the patients.

CONCLUSION

Preoperative CA19-9, CA125, and AFP tumor markers measurements could be beneficial in detecting the progressed stages of the disease.

Prognostic Significance of Sodium Iodide Symporter and Deiodinase Enzymes mRNA Expression in Gastric Cancer

Context

Thyroid hormones (THs) are critically important for development, homeostasis, and metabolic regulation in mammals. Iodine, one of the constituents of TH, is actively supplied by sodium iodide symporter (NIS) into the thyroid gland. TH is subsequently transported to distant organs where its activation and deactivation is catalyzed by isoforms of deiodinases (DIOs). NIS protein has been known to overexpress in cancer cases of the breast and gastrointestinal organs. Recent studies show a possible role of DIOs in various cancers.

Aims

In the present investigation, the prognostic significance of NIS and DIO-1, 2 and 3 was studied in gastric cancer using a data mining bioinformatic approach.

Methods

"The Kaplan-Meier plotter" database was used for direct in silico validation in clinically relevant 876 gastric cancer patients with >15 years of follow-up information. After obtaining KM survival plots, hazard ratio and log-rank P value were calculated.

Results

Increased expression of NIS and DIO 1-3 is significantly associated with worsen overall survival of gastric cancer patients followed for 20 years. Prognostic roles of NIS and individual DIOs were assessed in different types of gastric cancer classified based on morphologies, human epidermal growth factor receptor-2 receptor status, treatment choices, and different clinicopathological features.

Conclusions

Based on these analyses, the present study found the indication of prognostic values of these genes. This information will contribute to better understanding of managing complex and heterogeneous gastric cancer. Further, these findings may be beneficial as a companion diagnostic tool predicting more accurate gastric cancer prognosis.

Offsetting Expression Profiles of Prognostic Markers in Prostate Tumor vs. Its Microenvironment

Diagnosis of the presence of tumors and subsequent prognosis based on tumor microenvironment becomes more clinically practical because tumor-adjacent tissues are easy to collect and they are more genetically homogeneous. The purpose of this study was to identify new prognostic markers in prostate stroma that are near the tumor. We have demonstrated the prognostic features of FGFR1, FRS2, S6K1, LDHB, MYPT1, and P-LDHA in prostate tumors using tissue microarrays (TMAs) which consist of 241 patient samples from Massachusetts General Hospital (MGH). In this study, we investigated these six markers in the tumor microenvironment using an Aperio Imagescope system in the same TMAs. The joint prognostic power of markers was further evaluated and classified using a new algorithm named Weighted Dichotomizing. The classifier was verified via rigorous 10-fold cross validation. Statistical analysis of the protein expression indicated that in tumor-adjacent stroma FGFR1 and MYPT1 were significantly correlated with patient outcomes and LDHB showed the outcome-association tendency. More interestingly, these correlations were completely opposite regarding tumor tissue as previously reported. The results suggest that prognostic testing should utilize either tumor-enriched tissue or stroma with distinct signature profiles rather than using mixture of both tissue types. The new classifier based on stroma tissue has potential value in the clinical management of prostate cancer patients.

Cross-validation of survival associated biomarkers in gastric cancer using transcriptomic data of 1,065 patients

Introduction

Multiple gene expression based prognostic biomarkers have been repeatedly identified in gastric carcinoma. However, without confirmation in an independent validation study, their clinical utility is limited. Our goal was to establish a robust database enabling the swift validation of previous and future gastric cancer survival biomarker candidates.

Results

The entire database incorporates 1,065 gastric carcinoma samples, gene expression data. Out of 29 established markers, higher expression of BECN1 (HR = 0.68, p = 1.5E-05), CASP3 (HR = 0.5, p = 6E-14), COX2 (HR = 0.72, p = 0.0013), CTGF (HR = 0.72, p = 0.00051), CTNNB1 (HR = 0.47, p = 4.3E-15), MET (HR = 0.63, p = 1.3E-05), and SIRT1 (HR = 0.64, p = 2.2E-07) correlated to longer OS. Higher expression of BIRC5 (HR = 1.45, p = 1E-04), CNTN1 (HR = 1.44, p = 3.5E- 05), EGFR (HR = 1.86, p = 8.5E-11), ERCC1 (HR = 1.36, p = 0.0012), HER2 (HR = 1.41, p = 0.00011), MMP2 (HR = 1.78, p = 2.6E-09), PFKB4 (HR = 1.56, p = 3.2E-07), SPHK1 (HR = 1.61, p = 3.1E-06), SP1 (HR = 1.45, p = 1.6E-05), TIMP1 (HR = 1.92, p = 2.2E- 10) and VEGF (HR = 1.53, p = 5.7E-06) were predictive for poor OS.

MATERIALS AND METHODS

We integrated samples of three major cancer research centers (Berlin, Bethesda and Melbourne datasets) and publicly available datasets with available follow-up data to form a single integrated database. Subsequently, we performed a literature search for prognostic markers in gastric carcinomas (PubMed, 2012–2015) and re-validated their findings predicting first progression (FP) and overall survival (OS) using uni- and multivariate Cox proportional hazards regression analysis.

Conclusions

The major advantage of our analysis is that we evaluated all genes in the same set of patients thereby making direct comparison of the markers feasible. The best performing genes include BIRC5, CASP3, CTNNB1, TIMP-1, MMP-2, SIRT, and VEGF.

Clinical significance of primary tumor score determined by tumor depth and size in patients with resectable gastric cancer

Although postoperative management of gastric cancer is determined by pathological stage based on the tumor-node-metastasis classification, predicting disease recurrence and prognosis in patients undergoing gastrectomy is clinically difficult. We investigated the depth of tumor invasion and tumor size in resected specimens from patients with gastric cancer and assessed the clinical utility of primary tumor score (PTS) calculated by tumor depth and size as a prognostic marker. We classified 247 patients with gastric cancer into three groups based on cut-off values for deeper tumor invasion (pT2–T4) and larger tumor size (≥ 45 mm) as a PTS of 2 (both abnormalities), 1 (one abnormality), or 0 (neither abnormality). PTS correlated significantly with lymph node metastasis, lymphovascular invasion, and stage (P < 0.0001 each). Survival differences among groups based on PTS were significant (P < 0.0001). Multivariate analysis identified PTS alone as an independent prognostic factor (P = 0.0363). PTS derived from primary tumor information alone is a potentially useful marker for predicting tumor progression and prognosis in postoperative patients with gastric cancer.

A new score for screening of malnutrition in patients with inoperable gastric adenocarcinoma

Background

Malnutrition is common in patients with gastric cancer. Early identification of malnourished patients results in improving quality of life. We aimed to assess the nutritional status of patients with inoperable gastric adenocarcinoma (IGA) and finding a precise malnutrition screening score for these patients before the onset of chemotherapy.

Methods

Nutritional status was assessed using patient generated subjective global assessment (PG-SGA), visceral proteins, and high-sensitivity C reactive protein. Tumor markers of carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA-125) and CA 19-9 and their association with nutritional status were assessed. Then a new score for malnutrition screening was defined.

Results

Seventy-one patients with IGA completed the study. Malnourished and well-nourished patients (based on PG-SGA) were statistically different regarding albumin, prealbumin and CA-125. The best cut-off value for prealbumin for prediction of malnutrition was determined at 0.20 mg/dl and using known cut-off values for albumin (3.5 g/dl) and CA-125 (35 U/ml), a new score was defined for malnutrition screening named MS-score. According to MS-score, 92% of the patients had malnutrition and it could predict malnutrition with 96.8% sensitivity, 50% specificity and accuracy of 91.4%.

Conclusion

MS-score has been suggested as an available and easy-to-use tool for malnutrition screening in patients with IGA.

Clinical significance of circulating tumor cells in blood from patients with gastric cancer

Circulating tumor cells (CTC) have been focused on as a target for detecting occult tumors, predicting therapeutic responses and prognoses, and monitoring postoperative recurrence in the clinical management of patients with various malignancies, including gastric cancer. Recent advances in molecular diagnostic tools have contributed to high sensitivity and specificity for the detection of CTC. A conspicuous disparity exists in the incidence of CTC among studies. However, a close relationship has been reported between positivity for CTC and well‐known prognostic clinicopathological factors including depth of tumor invasion, lymph node metastasis, stage, and lymphatic and venous invasion in patients with gastric cancer. According to most studies published on the clinical impact of CTC, the presence of CTC negatively affects the prognosis of patients with gastric cancer. Moreover, the study of CTC based on a meta‐analysis demonstrated their importance as a poor prognostic indicator. In clinical management, pre‐ and post‐therapeutic monitoring of CTC using liquid biopsy may be useful for early detection of subclinical patients or disease recurrence, prediction of tumor progression, and administrative control of adjuvant chemotherapy. Although their functional properties remain unclear, molecular profiling of CTC may contribute to the development of personalized treatment that effectively inhibits tumor progression in patients with advanced gastric cancer. We herein review the clinical significance of CTC as a promising blood marker and therapeutic target in patients with gastric cancer.

Gastric cancer: somatic genetics as a guide to therapy

Gastric cancer is the leading cause of cancer-related mortality across the world, with poor prognosis and a median overall survival of ≤12 months for advanced stage gastric cancer. Environmental, genetic and other predisposing factors contribute to the development of gastric cancer and a predominant factor was found to be infection of Helicobacter pylori Advances in understanding the deranged signalling pathways that are critical for normal cellular homeostasis helped in the development of novel drugs that target specific proteins and pathways to curtail the growth of gastric cancer. Genetic studies revealed several single nucleotide polymorphisms, chromosomal aberrations and epigenetic alterations that likely play a major role in elevating the susceptibility to develop gastric cancer. Methylation pattern of specific genes may likely prove to be a valid biomarker for early detection of gastric cancer, but much progress is needed to establish specific markers. Important developments have been made in targeting human epidermal growth factor receptor-2 and vascular endothelial growth factor receptor 2 for treating advanced gastro-oesophageal junction cancer, using specific monoclonal antibodies. Lack of efficacy with regard to targeting other signalling pathways including mesenchymal-epithelial transition/hepatocyte growth factor and mammalian target of rapamycin is probably due to suboptimal patient selection for these clinical trials, which is probably due to the lack of appropriate biomarkers, to decide on responsive patient population. Besides the development of antagonists for the cell growth-related signalling pathways, advances are also being made to tackle gastric cancer by immunotherapies, targeting immune check-points, which may hold promise for better treatment options in future.

Identification of prognostic factors and surgical indications for metastatic gastric cancer

BACKGROUND

The treatment of metastatic gastric cancer is not uniform, and the prognostic factors and indications for surgery are currently unclear. This retrospective study aimed to identify the prognostic factors and clinical indications for surgery in patients with metastatic gastric cancer.

METHODS

A total of 123 consecutive patients with gastric cancer and synchronous distant metastasis treated between January 1999 and December 2011 were reviewed. Patient, tumor, laboratory, surgical, and chemotherapy factors were analyzed, with overall survival as the endpoint. Univariate analyses were performed using the log-rank test, multivariate analyses were performed using the Cox proportional hazards model, and Kaplan-Meier curves were used to estimate survival. Significance was set at p<0.05.

RESULTS

The median overall survival time was 13.1 months. Ninety-eight patients received chemotherapy. Twenty-eight patients underwent gastrectomy with metastasectomy and 55 underwent gastrectomy without metastasectomy. The median overall survival time for patients who underwent gastrectomy with metastasectomy, gastrectomy without metastasectomy, and no surgical intervention was 21.9 months, 12.5 months, and 7.2 months, respectively (p<0.001). Multivariate analysis identified gastrectomy with or without metastasectomy, performance status (PS) ≥ 3, neutrophil-to-lymphocyte ratio (NLR) >3.1, and carbohydrate antigen 19-9 (CA19-9) level >37 U/mL as predictors of poor survival. NLR and CA19-9 level were also independent prognostic factors in the group of patients who underwent surgery.

CONCLUSIONS

High pretreatment NLR, CA19-9 level, and PS are predictors of poor prognosis in patients with metastatic gastric cancer. In selected patients, gastrectomy can be performed safely, and may be associated with longer survival.

Preoperative serum tumor marker levels in gastric cancer

OBJECTIVE

Tumor markers have shown little benefit as a method for screening. However, they can be used clinically for the monitoring of tumor recurrence and used as prognostic factors because higher levels have been observed in advanced disease. This study aimed to investigate the relationship between the preoperative tumor marker levels and different clinical aspects of gastric cancer.

METHODS

One hundred and six consecutive patients with confirmed diagnosis of gastric cancer and 106 subjects (age and sex matched) with no malignancy as control group were included prospectively in this study in 3 years. The relationships between tumor markers CEA, CA 19-9 and stage of disease, tumor differentiation, presence of ringlet cell type, presence of peritoneal carcinomatozis were investigated.

RESULTS

The serum CEA and CA 125 levels were found to be significantly elevated in gastric cancer patients than in controls. The serum level of CEA had showed a significant elevation with the presence of distant metastasis. The CA 19-9 and CA 125 levels had showed significant elevations with the presence of peritoneal carcinomatozis. Conclusions : This study showed that there is a limited clinical benefit of preoperative tumor marker measurements in gastric cancer such as estimation of peritoneal dissemination.

Prognostic significance of tumor-associated trypsin inhibitor (TATI) and human chorionic gonadotropin-β (hCGβ) in patients with hepatocellular carcinoma

AIM

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third most frequent cause of cancer death worldwide. The aim of this study was to evaluate the prognostic value of serum tumor-associated trypsin inhibitor (TATI) and the free β subunit of human chorionic gonadotropin (hCGβ) in patients with HCC.

METHODS

The serum concentrations of TATI and hCGβ were determined by time-resolved immunofluorometric assays (IFMA) in pretreatment serum samples from 144 patients with HCC. Clinical data were retrieved from patient records and survival data obtained from Statistics Finland.

RESULTS

The overall cumulative disease-specific survival was 69% at 1 year, 50% at 2 years and 33% at 5 years. Disease-specific median survival time was 26 months. The overall survival in patients with low serum concentrations of TATI or hCGβ was statistically significantly better than in patients with elevated concentrations (p = 0.003 and 0.003, respectively). In multivariate analysis, both serum TATI and serum hCGβ were independent prognostic markers.

CONCLUSION

The results imply that elevated serum concentrations of TATI and hCGβ are predictors of adverse prognosis in patients with HCC and appear to be useful adjuncts in predicting prognosis in patients with HCC.

HER2 in gastric cancer: a digital image analysis in pre-neoplastic, primary and metastatic lesions

The assessment of human epidermal growth factor receptor 2 (HER2) status in gastric cancer is crucial in selecting patients who may benefit from targeted therapy, yet heterogeneous expression could represent an important drawback for HER2 testing. We aimed to analyze (i) HER2 heterogeneity in primary gastric cancers, pre-neoplastic and metastatic lesions and (ii) HER2 prognostic role. We studied 292 surgically resected primary gastric carcinomas and constructed 21 tissue microarrays including tumor tissue cores, invasive front, paired lymph node metastasis, low- and high-grade dysplasia. Microarrays were immunohistochemically stained with HER2 antibody and digitally scanned. Novel digital analysis algorithms were developed to score HER2 expression. Fluorescence in situ hybridization was performed on equivocal cases. HER2-positive cases were 13% and heterogeneous HER2 expression was observed in 71% of positive samples. Analysis of HER2 status in tumor and tumor invasive front demonstrate concordance in 177 cases (88%). Comparison of HER2 expression in primary cancer and synchronous lymph node metastasis exhibited discordant status in 14% of cases. Dysplastic epithelium surrounding the tumor showed immunohistochemical score 2 or 3 in 19% of high-grade and in 9% of low-grade dysplastic samples. HER2 status was significantly associated with intestinal-type carcinomas (P=0.018) and prognosis since patients with primary HER2-positive tumor showed decreased overall survival (P=0.006). Intratumoral HER2 expression heterogeneity and variable lymph node metastases status strongly suggest evaluating more than one sample and, if available, metastatic foci for routinely HER2 testing.

Serum CA 19-9 as a prognostic factor in patients with metastatic gastric cancer

AIM

To evaluate tumor markers as prognostic factors in patients with metastatic or recurrent gastric cancer receiving first-line chemotherapy.

METHODS

Between January 2000 and December 2008, 1178 patients with metastatic or recurrent gastric cancer were assayed for expression of three serum tumor markers, CA 19-9, CA 72-4 and carcinoembryonic antigen (CEA), prior to the initiation of first-line chemotherapy.

RESULTS

Elevated serum concentrations of carbohydrate antigen (CA) 19-9 (>37 U/mL), CA 72-4 (>4 U/mL) and carcinoembryonic antigen (CEA) (>6 ng/mL) were observed in 38, 56 and 33% of patients, respectively. Univariate analysis showed that elevated serum concentration of each of the three markers, CA 19-9 (P = 0.001), CA 72-4 (P = 0.001) and CEA (P = 0.030), was significantly associated with poor patient prognosis. However, multivariate analysis showed that an elevated CA 19-9 concentration only was significantly associated with shorter survival (hazard ratio [HR] 1.22; 95% CI, 1.08-1.37, P = 0.002). In the good risk and moderate risk groups, previously defined by clinical factors alone, survival was significantly lower in patients with elevated CA 19-9 (P < 0.001 and P = 0.021, respectively), but this difference was not observed in the poor-risk group.

CONCLUSION

Elevated serum CA 19-9 concentration in patients with metastatic or recurrent gastric cancer, especially in good or moderate risk groups, is an independent negative predictor of prognosis.

Prognostic significance of tumour markers in Chinese patients with gastric cancer

BACKGROUND AND OBJECTIVES

The clinical value of preoperative tumour markers remains elusive in gastric cancer. The aim of this study was to investigate the prognostic value of alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen (CA)19-9, CA50 and CA72-4 in gastric cancer.

METHODS

About 391 gastric cancer patients who underwent curative D2 gastrectomy between 2001 and 2006 were evaluated. The correlation between tumour markers and clinicopathologic characteristics and prognostic value of preoperative tumour markers was investigated.

RESULTS

Correlation analysis showed that AFP was associated with tumour size (P = 0.040); CEA with lymphatic invasion (P = 0.023) and pathological stage (P = 0.018); CA19-9 with tumour size (P = 0.000), Borrmann type (P = 0.027), lymphatic invasion (P = 0.020) and pathological stage (P = 0.001); CA50 with lymphatic invasion (P = 0.004) and pathological stage (P = 0.004); CA72-4 with tumour size (P = 0.000), tumour size (P = 0.000) and Borrmann type (P = 0.008); lymphatic invasion (P = 0.000), nervous invasion (P = 0.028) and pathological stage (P = 0.000). Multivariate analysis showed that CEA, tumour site, Borrmann type and pathological stage were independent prognostic factors.

CONCLUSIONS

Preoperative CEA might be a candidate for the staging system in addition to conventional factors.

Prognostic significance of tumor markers in T4a gastric cancer

BACKGROUND

The clinical importance of preoperative tumor markers remain elusive in gastric cancer. The aim of this study was to evaluate the prognostic value of AFP, CEA, CA19-9, and CA50 in T4a stage gastric cancer.

METHODS

Two hundred and seventy-three T4a gastric cancer patients who underwent curative D2 gastrectomy between 1996 and 2005 were evaluated. The correlation between tumor markers and clinicopathologic characteristics and prognostic value of preoperative tumor markers were investigated.

RESULTS

Correlation analysis showed that AFP was associated with Borrmann type (P = 0.010); CEA with sex (P = 0.029), tumors site (P = 0.014), and N stage (P = 0.001); CA19-9 with age (P = 0.047), tumor site (P = 0.011), lymphovascular invasion (P = 0.004), and N stage (P = 0.000); CA50 with age (P = 0.017), tumor site (P = 0.004), tumor size (P = 0.014), and N stage (P = 0.000). Multivariate analysis showed that the positivity of preoperative CEA, CA19-9, and CA50 were major independent poor prognostic factors of patients with T4a stage gastric cancer.

CONCLUSIONS

Preoperative serum tumor marker might be a candidate for the staging system in addition to conventional factors.

Mucin 16 (cancer antigen 125) expression in human tissues and cell lines and correlation with clinical outcome in adenocarcinomas of the pancreas, esophagus, stomach, and colon

Mucin 16 (cancer antigen 125) is a cell surface glycoprotein that plays a role in promoting cancer cell growth in ovarian cancer. The aims of this study were to examine mucin 16 expression in a large number of digestive tract adenocarcinomas and precursors and to determine whether mucin 16 up-regulation is correlated with patient outcome. Tissue microarrays were constructed using surgical resection tissues and included pancreatic (115 normal, 29 precursors, 200 pancreatic ductal adenocarcinomas), esophageal (86 normal, 104 precursors, 95 esophageal adenocarcinomas, 35 lymph node metastases), gastric (211 normal, 8 precursors, 119 gastric adenocarcinomas, 62 lymph node metastases), and colorectal (34 normal, 17 precursors, 39 colorectal adenocarcinomas) tissues. Mucin 16 was detected in 81.5%, 69.9%, 41.2%, and 64.1% of the pancreatic ductal adenocarcinomas, esophageal adenocarcinomas, gastric adenocarcinomas, and colorectal adenocarcinomas, respectively. Mucin 16 was seen in a subset of the precursors. On multivariate analysis, moderate/diffuse mucin 16 in pancreatic ductal adenocarcinomas was strongly associated with poor survival (P < .001), independent of other prognosis predictors. A similar trend was observed for esophageal adenocarcinomas (P = .160) and gastric adenocarcinomas (P = .080). Focal mucin 16 in colorectal adenocarcinomas was significantly correlated (P = .044) with a better patient outcome, when compared with mucin 16-negative cases. Using Western blot analysis, we found mucin 16 expression in 3 of 6 pancreatic ductal adenocarcinoma and 1 of 2 esophageal adenocarcinoma cell lines. We conclude that most of the digestive tract adenocarcinomas and a subset of their precursors express mucin 16. Mucin 16 expression is an independent predictor of poor outcome in pancreatic ductal adenocarcinomas and potentially in esophageal adenocarcinomas and gastric adenocarcinomas. We propose that mucin 16 may function as a prognostic marker and therapeutic target in the future.

HER2 as a Prognostic Marker in Gastric Cancer - A Systematic Analysis of Data from the Literature

Through the recent conduct of the ToGA trial, HER2 has shown to be predictive for the treatment with trastuzumab in advanced gastric and gastro-oesophageal cancer. When it comes to the prognostic properties the situation is different. Despite the fact that it is more than 20 years ago since the first studies demonstrating an association between a positive HER2 status and poor prognosis were published the issue is still controversial. In this current systematic review a large number of studies on HER2 and gastric cancer have been reviewed. The studies included in this review should fulfill the following two criteria. First criterion: The number of patients in each study should be ≥ 100, and the HER2 status should have been determined either by immunohistochemistry (IHC) or in situ hybridization (ISH). Second criterion: The selected articles should include an analysis of the association between the HER2 status and survival or relevant clinicopathological characteristics. Forty-two publications with a total of 12,749 patients fulfilled the two criteria and were reviewed in detail. The majority of the publications (71%) showed that a HER2-postive status measured either by IHC or ISH was associated with poor survival and/or clinicopathological characteristics, such as serosal invasion, lymph node metastases, disease stage, or distant metastases. Based on the current analysis a clear trend towards a potential role for HER2 as a negative prognostics factor in gastric cancer was shown, suggesting that HER2 overexpression and/or amplification is a molecular abnormality that might be linked to the development of gastric cancer.

Gastric cancer: tumor markers as predictive factors for preoperative staging

INTRODUCTION

CEA, CA 19-9, and CA 72-4 are tumor markers commonly used for gastric neoplasms. The clinical importance of the preoperative serum levels of these tumor markers in gastric cancer (GC) is not well known. Even less is known about the predictive value of the preoperative serum levels of the β-subunit of human chorionic gonadotropin (hCGβ).

AIMS AND METHODS

We designed a prospective study to evaluate the significance of the preoperative values of these tumor markers in GC. The serum levels that we considered as positive are as follows: CA 72-4, >4 U/ml; CEA, >5 ng/ml; CA 19-9, >37 U/ml; hCGβ-free subunit, <5 mUI/ml. These levels were correlated by pathological stage, lymph node status, and histology.

RESULTS

We studied 66 (42 male and 24 female) patients prospectively. Twenty-seven patients had stage I and stage II GCs, while 39 patients had stage III and stage IV GCs. Two patients tested positive for hCGβ. The preoperative positivity rates of CA 72-4 in patients at the early stages (stages I and II) and in patients with advanced disease (stages III and IV) were 0 and 28 patients, respectively. The preoperative positivity rates of CEA/CA 19.9 were 0/5 and 7/12 patients in early stages and advanced disease, respectively. The serum levels of these markers were not correlated with the histological type or tumoral grade of GC.

CONCLUSION

The preoperative serum level of CA 72-4 has the best predictive value in indicating advanced disease in patients diagnosed with GC. A combination of these four markers is better in predicting this situation.

Expression of human chorionic gonadotropin beta in gastric carcinoma: A retrospective immunohistochemical study

CONTEXT

Beta Human Chorionic Gonadotropin (βHCG), a marker of the trophoblastic neoplasm, is also secreted by non-trophoblastic neoplasms including gastric carcinomas. Its role in disease progression remains unclear.

AIM

To investigate the incidence of βHCG positivity in gastric carcinomas and correlate its presence with the biological behavior of the tumor.

SETTING AND DESIGN

A hospital-based, immunohistochemical study.

MATERIALS AND METHODS

One hundred and fifty formalin-fixed, paraffin-embedded tissue specimens from histopathologically confirmed cases of gastric carcinoma were immunostained using an indigenously developed antibody against βHCG. Tumors with diffuse reactivity to βHCG were considered as positive. Those with occasional, focal or no reactivity to βHCG were considered as negative.

STATISTICAL ANALYSIS

Differences in βHCG staining were compared according to the histological grade and surgical stage using the χ(2) test. Using the Cox proportional hazards model, the time till the onset of development of an adverse outcome after surgery (defined as death, local or distant metastasis) was compared between the bHCG positive and negative tumors.

RESULTS

Twenty-eight (18.7%) of the 150 specimens were βHCG positive. No association was found between the histological grade (P=0.49) and the surgical stage (P=0.19) with βHCG positivity. The median disease-free survival after surgery was not different among βHCG positive and negative tumors. Risk of an adverse outcome after surgery was significantly associated with the stage of the tumor (Hazard ratio=2.9, 95% confidence interval: 1.1-7.4). No association was observed with grade or βHCG positivity.

CONCLUSION

βHCG immunoreactivity was observed in about one-fifth of the gastric cancers. βHCG reactivity, however, played no role in the biological behavior.

Prognostic significance of HER2/neu expression in gastric cancer

BACKGROUND

Gastric cancer is still the most prevalent neoplasia in many countries. Therefore, besides the clinicopathological factors known to be prognostic markers, new independent parameters are being investigated. There is mounting evidence of the role of HER2/neu expression in patients with this type of cancer, and it has been solidly correlated to poor outcomes and a more aggressive disease.

PATIENTS AND METHODS

Fifty gastric cancer tissue specimens were examined for the presence of HER2/neu by immunohistochemistry. The correlation between HER2/neu expression and patient clinicopathological parameters was evaluated and the prognostic significance of HER2/neu expression was assessed.

RESULTS

HER2/neu membrane staining was detectable in 7 (14.0%) cases. The patients with HER2/neu overexpression had worse prognosis after surgical therapy compared with those without expression of HER2/neu (p = 0.001, Log-rank test). No relationship was found between HER2/neu expression and other clinicopathological parameters.

CONCLUSIONS

Using immunohistochemistry, our data showed that the association between HER2/neu overexpression and patient survival provides a good indirect validation for quality of this investigation and it may act as a prognostic parameter in gastric cancer.

B7-H3 expression in gastric cancer: a novel molecular blood marker for detecting circulating tumor cells

The clinical significance of B7-H3 expression in gastric cancer remains unclear, although the B7 ligand family plays a critical role in the T cell-mediated immune response. We therefore investigated B7-H3 expression as a blood marker of circulating tumor cells and determined correlations with tumor progression in patients with gastric cancer. B7-H3 expression in gastric cell lines was initially evaluated by immunocytochemistry. Furthermore, we used quantitative RT-PCR to assess B7-H3 mRNA expression in four cell lines and in 95 blood specimens from patients with gastric cancer, as well as in 21 samples of peripheral blood lymphocytes from healthy volunteers. B7-H3 expression in cell lines was identified by immunocytochemistry and quantitative RT-PCR. Blood specimens from patients with gastric cancer contained significantly more copies of B7-H3 mRNA than those from healthy volunteers without cancer (P < 0.0001). Levels of B7-H3 expression significantly correlated with overall stage (P = 0.013). The 5-year survival rate was significantly lower in patients with high B7-H3 expression than with low expression (P = 0.02). Multivariate analysis demonstrated that B7-H3 expression was an independent prognostic factor (P = 0.046). Our results indicate that B7-H3 appears to be a useful blood marker for predicting tumor progression in gastric cancer.

Prognostic value of preoperative CEA, CA 19-9, CA 72-4, and AFP levels in gastric cancer

INTRODUCTION

Recent research has suggested that serum tumor markers can give valuable prognostic information in gastric cancer. In this study, we examined the relationship between preoperative serum carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, CA 72-4, and alfa fetoprotein (AFP) levels on clinicopathologic significance in gastric cancer patients.

METHODS

Preoperative plasma levels of CEA, CA 19-9, CA 72-4, and AFP were retrospectively examined in 95 patients who underwent surgical resection for gastric cancer, and the prognostic value of the tumour markers were estimated.

RESULTS

The percentage of CA 19-9, CA 72-4, CEA, and AFP-positive cases were 41%, 32.6%, 24.2%, and 8.4%, respectively. CEA was more frequently positive in the patients with liver metastases (P=0.02). CA 19-9 was more frequently positive in patients with lymph node (P=0.005), peritoneal (P=0.01), and serosal (P=0.03) involvement. CA 72-4 was more frequently positive in patients with lymph node (P=0.01), peritoneal (P=0.03), and liver (P=0.01) involvement. Low 3-year cumulative survival was associated significantly with elevated serum levels of CEA (P=0.001), CA 19-9 (P=0.001), CA 72-4 (P=0.001), and AFP (P=0.01). In multivariate analysis, age, tumor stage, and CA 72-4 were the only independent prognostic factors. Being positive for CA 72-4 was associated with a 3.8-fold higher risk of death (95% confidence intervals: 1.3, 10.9).

CONCLUSION

Our results suggest that high preoperative serum levels of CA 72-4 in gastric cancer patients are associated with a higher risk of death due to gastric cancer.

Aberrant expression of beta-HCG in anaplastic large cell lymphoma

We report a case of anaplastic large cell lymphoma (ALCL) showing aberrant expression of beta subunit of human chorionic gonadotrophin (beta-HCG). The patient was a 14-year-old boy who presented with a right inguinal mass and a raised serum beta-HCG level. Biopsy of the mass revealed a malignant neoplasm composed of large, pleomorphic cells with prominent nucleoli. These malignant cells showed positive staining with CD30, ALK, epithelial membrane antigen, and beta-HCG. Chromosomal analysis showed t(2;5)(p23;q35) translocation, and polymerase chain reaction demonstrated T-cell receptor gene rearrangement. The patient did not respond well to chemotherapy, and he died 8 months after the diagnosis. To the best of our knowledge, this is the 1st case of ALCL showing aberrant expression of beta-HCG and associated with a raised serum level of beta-HCG. We report this case to bring awareness of this presumably rare occurrence to avoid the risk of misdiagnosis.

[Gastrointestinal adenocarcinomas with a choriocarcinomatous component: 2 cases and a review of 120 cases in the literature]

Gastrointestinal adenocarcinoma with a choriocarcinomatous component (GACC) is an extremely rare and highly malignant human chorionic gonadotrophin-producing neoplasm. The development of this tumour from dedifferentiation or trans-differentiation of adenocarcinomatous cells is the most likely mechanism. 102 of the 120 cases reviewed in the literature presented enough clinicopathological information to be analysed. This tumour can be purely choriocarcinomatous or associated with an adenocarcinoma as in half of the observations. It is usually found in the stomach although it may be found throughout the digestive tract. The diagnosis of GACC should only be retained after having clearly eliminated a metastasis from a choriocarcinoma in particular in the gonads. The prognosis is very poor in particular in the gastric forms of this disease, with death observed within 12 months following diagnosis in 2/3 of the patients. There is no treatment consensus, and it is decided on a case-by-case basis.

HER-2/neu amplification is an independent prognostic factor in gastric cancer

The HER-2/neu protein is intimately involved with normal cell proliferation and tissue growth and is extensively homologous and related to the epidermal growth factor receptor. HER-2/neu protein expression has been most intensively studied in the context of breast carcinoma, in which its amplification and overexpression correlate with the overall course of disease, and with a poor prognosis, and constitute a predictive factor of poor response to chemotherapy and endocrine therapy. In this study, we investigated the relationship between the expression of HER-2/neu and the clinicopathological characteristics of tumors, including survival. This study was performed with a view toward the future introduction of Herceptin therapy for gastric cancer patients. HER-2/neu overexpression and gene amplification was examined with semiquantitative standardized immunohistochemical staining, chromogenic in situ hybridization (CISH), and fluorescence in situ hybridization (FISH) in 182 gastric cancer patients who underwent curative surgery at the Kangbuk Samsung Hospital. Twenty-nine (15.9%) of 182 patients expressed the HER-2/neu protein by immunohistochemistry. HER-2/neu gene amplification was detected in seven patients by CISH and FISH. Intestinal-type cancers exhibited higher rates of HER-2/neu amplification than did diffuse-type cancers (P < 0.05). Tumors with HER-2/neu amplification were associated with poor mean survival rates (922 vs 3243 days) and 5-year survival rates (21.4% vs 63.0%; P < 0.05). Age, TNM stage, and amplification of HER-2/neu were found to be independently related to survival by multivariate analysis. HER-2/neu amplification may constitute an independent prognostic factor in gastric cancer patients, and patients exhibiting HER-2/neu amplification might constitute potential candidates for new adjuvant therapies which involve the use of humanized monoclonal antibodies.

Preoperative hCGbeta and CA 72-4 are prognostic factors in gastric cancer

In gastric cancer, the role of tumour markers in assessment of prognosis is unconfirmed. In our study, we evaluated the prognostic significance of serum tumour markers carcinoembryonic antigen (CEA), CA 19-9, CA 72-4, CA 242 and free beta subunit of human chorionic gonadotropin (hCGbeta) in gastric cancer. Preoperative serum samples were obtained from 146 patients with gastric cancer, including 29 with stage I, 11 with stage II, 42 with stage III and 64 patients with stage IV cancer. Quantitation of CEA, CA 19-9, CA 72-4 and CA 242 in serum was performed with commercial assays. HCGbeta was measured with an in-house immunofluorometric assay based on monoclonal antibodies specific for the free beta-subunit of hCG. Survival analysis was performed with Kaplan-Meier life-tables and log-rank test, and with multivariate Cox regression analysis. Disease-specific cumulative 2-year survival rate was 40%. Serum levels of CEA, CA 72-4, CA 242 and hCGbeta showed significant correlation with stage (p<0.027); for CA 19-9 the association was of borderline significance (p=0.056). Of the studied markers, CA 19-9, CA 72-4, CA 242 and hCGbeta were found to be prognostic factors in univariate analysis (p< 0.022). In multivariate analysis, stage had the statistically most significant association with prognosis followed by hCGbeta, tumour histology according to the Laurén classification and by CA 72-4. In gastric cancer, tumour markers hCGbeta and CA 72-4 are independent prognostic factors in addition to stage and histological type of the tumour.

Clinical significance of circulating tumor cells in blood by molecular detection and tumor markers in esophageal cancer

BACKGROUND

The clinical significance of circulating tumor cells in the blood during surgery has not been elucidated in esophageal squamous cell carcinoma (ESCC). We evaluated the relationship between circulating tumor cells and clinicopathologic findings, compared with that of serum squamous cell carcinoma (SCC) antigen and carcinoembryonic antigen (CEA), in ESCC.

METHODS

Blood samples from 54 consecutive patients were obtained from the peripheral artery and the superior vena cava at three points in time: immediately before surgery, and before and after tumor resection. CEA-specific reverse transcriptase-polymerase chain reaction (RT-PCR), which can quantify circulating tumor cells in blood, was performed. The preoperative values of serum SCC antigen and CEA were also obtained for all patients.

RESULTS

CEA messenger RNA (CEA mRNA) was detected in the blood of 31 out of 54 patients (57.4%). CEA mRNA positivity was detected most frequently after tumor resection and correlated with nodal status and stage grouping. The incidence of total recurrence and blood-borne recurrence was significantly greater in patients with CEA mRNA positivity than in those with CEA mRNA negativity (P =.036 and.0026, respectively). Preoperative serum levels of SCC antigen and CEA did not correlate with clinicopathologic findings and tumor recurrence.

CONCLUSIONS

CEA mRNA detected by RT-PCR was more predictive of tumor recurrence than serum tumor markers. Effective adjuvant therapy is recommended for patients with CEA mRNA positive expression.

Docetaxel in advanced gastric cancer

Standard chemotherapy for advanced gastric cancer remains undefined. Two of the most popular regimens-ECF [epirubicin-cisplatin-5-fluorouracil (5-FU)] and PELF (cisplatin-epirubicin-5-FU-leucovorin)-have been shown to be active, but each has limitations. Phase II trials show that single-agent docetaxel is an active agent in advanced gastric cancer, producing overall response rates (ORRs) of 17.5-24%. Docetaxel has also been shown to lack cross-resistance with other drugs in gastric cancer, and is likely to be at least additive to cisplatin and 5-FU. Phase II results of docetaxel combinations in advanced gastric cancer are encouraging. Docetaxel-cisplatin has yielded response rates similar to those achieved by ECF and PELF. Adding 5-FU to docetaxel-cisplatin has achieved an ORR of 52 versus 45% for docetaxel-cisplatin in a randomized phase II trial. Docetaxel-based regimens demonstrate acceptable tolerability despite predictable hematotoxicity. Neutropenia, the major toxicity, is manageable by dose modification or by using prophylactic granulocyte colony stimulating factor. Several phase III trials are now ongoing, including a large-scale trial of docetaxel-cisplatin-5-FU versus cisplatin-5-FU. Results will show whether docetaxel improves overall response and survival, as suggested in the phase II setting.

Preoperative serum levels of CA 72-4, CEA, CA 19-9, and alpha-fetoprotein in patients with gastric cancer

INTRODUCTION

The clinical importance of preoperative serum levels of CA 72-4, carcinoembryonic antigen (CEA), CA 19-9, and alpha-fetoprotein (AFP) was prospectively evaluated in 44 patients with gastric cancer.

METHOD

The serum tumor marker levels were determined by commercial radioimmunoassay kits. Positivity for CA 72-4 (>4 U/mL), CEA (>5 ng/mL), CA 19-9 (>37 U/mL), and AFP (>10 ng/mL) were correlated according to the stage, histology, and lymph node metastasis.

RESULTS AND DISCUSSION

CA 72-4 showed a higher positivity rate for gastric cancer (47.7%) than CEA (25%), CA 19-9 (25%), and AFP (0%). The combination of CA 72-4 with CEA and CA 19-9 increased the sensitivity to 61.4%. The positivity rates of CA 72-4 in patients at stages I and II (initial disease) and in patients at stages III and IV (advanced disease) were 9% and 60.6%, respectively (P < 0.005). No correlation was found between CEA and CA 19-9 levels and the stage of gastric cancer. There was a tendency of positivity for CA 72-4 to suggest lymph node involvement, but it was not significant (P = 0.075). Serum levels of tumor markers did not show a correlation with the histological types of gastric cancer.

CONCLUSION

Preoperative serum levels of CA 72-4 provided a predictive value in indicating advanced gastric cancer.

Status of c-erbB-2 in gastric adenocarcinoma: a comparative study of immunohistochemistry, fluorescence in situ hybridization and enzyme-linked immuno-sorbent assay

c-erb-2 amplification and overexpression are currently attracting a great deal of attention because a new adjuvant therapy using an antibody against the c-erbB-2 gene product, trastuzumab (Herceptin; Genentech, Inc., South San Francisco, CA), has proved effective in treating breast cancer with amplification and/or overexpression of c-erbB-2. Aberrations of c-erbB-2 have also been detected in ovarian, endometrial and gastric carcinomas at varied frequencies. Amplification of the c-erbB-2 locus (17q12-q21.32), overexpression of c-erbB-2 protein (p185) and serum levels of soluble c-erbB-2 protein fragments (p105) were examined in gastric cancer patients using fluorescence in situ hybridization (FISH), immunohistochemistry and enzyme-linked immunosorbent assay (ELISA), respectively. Overexpression of c-erbB-2 protein was found in 29 (8.2%) of the 352 gastric carcinomas analyzed. In FISH analysis, all tumors with 3+ immunostaining and 1 of 5 tumors with 2+ staining showed high-level amplification of c-erbB-2. Pre-operative serum p105 was quantified in serum specimens from 129 patients with gastric cancer and 28 patients with benign diseases. There were no significant differences in the serum p105 levels among 11 patients with c-erbB-2-overexpressing carcinomas, 118 patients with c-erbB-2 non-overexpressing carcinomas and 28 controls, although a single case of gastric carcinoma overexpressing c-erbB-2 with extensive liver metastasis had a higher level than the cut-off value. The mechanisms of overexpression of p185 and high-level amplification of c-erbB-2 in gastric adenocarcinomas seem similar to those well-established in breast cancers. Patients having gastric adenocarcinoma with c-erbB-2 amplification are potential candidates for a new adjuvant therapy using humanized monoclonal antibody.

The chemotherapy of metastatic gastric adenocarcinomas with hypersecretion of alpha-fetoprotein or beta-human chorionic gonadotrophin: report of two cases

The chemotherapy of advanced gastric adenocarcinomas (GAs) is based on agents such as cisplatin, 5-fluorouracil and anthracyclins. Reproducible objective response rates are reported as approximately 40%. However, the median survival remains short, not exceeding 10 months. Amongst GA, a subset of tumours with increased plasma alpha-fetoprotein (alphaFP) and/or beta human chorionic gonadotrophin (betaHCG) levels form a well-defined histopathological entity. This subgroup has been associated with poor prognosis, due to the presence of poorly differentiated and rapidly proliferating cells. No specific chemotherapy has been proposed for this particular form of GA. We report two cases of patients with GA and hypersecretion of alphaFP and/or betaHCG. Despite bulky liver metastases and resistance to two standard chemotherapy regimens, both patients exhibited sensitivity to chemotherapy combining bleomycin, oxaliplatin and etoposide. These results suggest that patients with this particular subset of GA may benefit from chemotherapy regimens similar to those given to germ-cell tumour patients.

The HER-2/neu oncogene in tumors of the gastrointestinal tract

The HER-2/neu oncogene is localized to chromosome 17q and shares significant homology with the epidermal growth factor receptor. As a result of its potential role in the selection of therapy, HER-2/neu testing has reached near-standard-of-practice status in breast cancer. There is considerable interest in HER-2/neu as a prognostic factor and target of therapy in tumors of the gastrointestinal tract. In this review of HER-2/neu expression in esophageal squamous cell carcinoma and adenocarcinomas of the esophagus, stomach, and colon, a wide range of expression of HER-2/neu from 0 to 83% likely reflects both differences in methods and reagents, as well as study bias associated with patient selection (i.e., early versus advanced disease). For esophageal squamous cell carcinoma, little information exists as to the prognostic significance of HER-2/neu expression. In adenocarcinoma associated with Barrett's esophagus there is contradictory data. However, most of the information available indicates that this marker has significant prognostic value. In gastric adenocarcinoma, the wide expression range may truly reflect patient selection because HER-2/neu positivity appears linked to advanced rather than early disease with limited invasion. The majority of studies favor a significant prognostic value of HER-2/neu status for this tumor. Finally, in colorectal cancer HER-2/neu overexpression also appears to be a significant adverse outcome indicator as judged by the current published literature. In conclusion, given that either HER-2/neu protein overexpression or gene amplification is associated with approximately one-fourth of all gastrointestinal tract malignancies, strategies designed to employ the marker in therapy selection appear warranted. During the next several years it will not be surprising to see these tumors treated with antiHER-2/neu modalities such as Herceptin, likely in combination with other agents initially for patients with advanced disease, and possibly for individuals with high-risk lesions in an adjuvant setting.

Specific staining of human chorionic gonadotropin beta in benign and malignant gastrointestinal tissues with monoclonal antibodies

AIMS

Human chorionic gonadotropin (hCG) beta in serum is a promising tumour marker for gastrointestinal malignancies. Our aim was to investigate the expression of hCGbeta by immunohistochemistry in various gastrointestinal cancers and benign tissues.

METHODS AND RESULTS

A monoclonal antibody (MAb) specific for free hCGbeta was used to stain 107 tissue samples from various gastrointestinal malignancies and 36 benign or normal tissue samples. The specificity of the staining was verified and the results compared with those obtained with a widely used commercial polyclonal antibody (PAb) which reacts with both free hCGbeta and intact hCG, as well as with luteinizing hormone beta. With the MAb, we observed positive immunohistochemical staining in 24% of the malignant gastrointestinal tumours. Gastric (60%) and pancreatic (56%) carcinomas, as well as extrahepatic cholangiocarcinomas (36%), were positive most frequently. We also discovered immunoreactivity in half of the non-malignant samples from pancreatic and biliary tissues. With the PAb, hCG immunoreactivity was evident more frequently in some cancers, but the staining was diffuse and occasionally polymorphonuclear leucocytes were strongly stained.

CONCLUSIONS

This study shows that our MAbs specific for hCGbeta are well suited for immunohistochemistry. Our results confirm previous findings on gastrointestinal cancers and, furthermore, we demonstrate hCGbeta tissue expression in pancreatic adenocarcinoma. The results support reports on hCGbeta as a serum tumour marker for digestive tract diseases.

The prognostic significance of preoperative serum CA 19-9 in patients with resectable gastric carcinoma: comparison with CEA

BACKGROUND AND OBJECTIVES

In this study, the prognostic value of pre-operative serum levels of tumor markers CA 19-9 and carcinoembryonic antigen (CEA) in gastric carcinoma which has been a controversial matter was investigated.

METHODS

Preoperative serum CA 19-9 (cut-off value 37 U/ml) and CEA (cut-off value 5 ng/ml) levels were measured in 168 patients with resectable gastric carcinoma. The correlation between tumor marker levels and clinicopathological features and overall survival was studied.

RESULTS

CA 19-9 and CEA positivity rates were 31.5 and 17.8% respectively. In CA 19-9 positive patients, the ratio of males, tumors exceeding subserosa and advanced stage tumors (stages III and IV) was significantly higher (P = 0.052, P = 0.0005 and P= 0.029, respectively). A weak correlation was found with CA 19-9 positivity and tumor location; however, no correlation existed between CA 19-9 positivity and age, tumor size, histologic type, lymph node, hepatic and peritoneal metastasis. The proportion of tumors extending beyond subserosa and with lymph node metastasis was significantly higher in CEA positive patients (P = 0.011 and P = 0.045, respectively). No correlation was found between CEA positivity and gender, age, tumor location, tumor size, and hepatic and peritoneal metastasis; however, a weak correlation existed between CEA positivity and histologic type and tumor stage. Overall survival was significantly poorer in CA 19-9 and CEA positive patients (log-rank test, P = 0.014, P = 0.003, respectively). However, the Cox proportional hazards regression analysis did not show independent prognostic value for both tumor markers.

CONCLUSIONS

In resectable gastric carcinoma, preoperative serum CA 19-9 and CEA levels may indicate stage of the disease, but neither has an independent prognostic value.

Clinical importance of preoperative carcinoembryonic antigen and carbohydrate antigen 19-9 levels in gastric cancer

Although serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 are commonly measured before surgery for gastric carcinoma, this clinical significance is not fully understood. We evaluated a total of 549 patients with gastric cancer who underwent gastrectomy. Levels of CEA and CA19-9 were measured preoperatively in all patients. We retrospectively analyzed correlations between CEA or CA19-9 and clinicopathologic features, and estimated the prognostic utility of the tumor markers by analyzing clinicopathologic characteristics of the carcinoma as a function of seropositivity or negativity of the antigens in combination or by raising the levels. The positivity rates of CEA (> or =5 ng/mL) and CA19-9 (> or =37 U/mL) were 19.5% and 18%, respectively. Serum CEA and CA19-9 positivity significantly correlated with depth of invasion, hepatic metastasis, and curativity. Forty-nine patients positive for both CEA and CA19-9 had significantly higher frequencies of lymph node metastasis, deeper invasion by the tumor, lower rates of curative resection (p < 0.01), and higher rates of hepatic metastasis (p < 0.05) than 377 patients with normal levels of CEA and CA19-9. Surgical outcomes of patients who were CEA- and CA19-9-positive were poorer than those of patients with normal CEA and CA19-9 levels (p < 0.01). Significant correlation was found between serum CEA and CA19-9 level (p < 0.001, r = 0.24). Doubling the threshold level of serum positivity to 10 ng/mL (CEA) and 74 U/mL (CA19-9) improved the prognostic value of these factors. However, multivariate analysis using Cox's hazards model revealed that only CEA positivity using the doubled threshold value (10 ng/mL) (p = 0.04, hazard ratio = 1.7), nodal involvement (p = 0.01, hazard ratio = 1.9), and depth of invasion (p = 0.02 hazard ratio = 1.5) significantly predicted prognosis. Carcinoembryonic antigen positivity using the doubled threshold level (10 ng/mL) was an important prognostic factor in patients with gastric cancer.

The roles of chemotherapy and surgery in gastric carcinoma and the influence of prognostic factors on survival

In this study, we present the results of surgery and chemotherapy and the impact of various prognostic factors on survival in patients with gastric carcinoma with a follow-up of 6 years. All of the 328 cases were adenocarcinoma histologically and had a median age of 55 years. Median survival was 11 months, and the 5-year survival rate was 18%. Nonmetastatic cases were associated with improved survival as compared with the cases with metastatic disease (p<0.001). Patients with gastrectomy had improved survival (p<0.001). Subtotal gastrectomized patients had better survival rates in comparison to the total gastrectomized patients (p = 0.03). Addition of splenectomy to total gastrectomy and adjuvant chemotherapy did not influence survival rates (p>0.05). In metastatic patients, we determined beneficial effects of gastrectomy and chemotherapy on survival. The benefit was most predominant in chemoresponsive patients (p<0.001). Higher serum CA 19.9 levels in patients without metastases, higher serum lactate dehydrogenase and carcinoembryonic antigen levels in patients with metastases, and lower serum albumin levels in both stages were determined as significant predictors of poor survival. On multivariate analysis, only higher serum CA 19.9 level was the independent unfavorable prognostic factor of survival time in nonmetastatic patients (p = 0.008). In metastatic disease, older age (p = 0.03) and male gender (p = 0.05) were associated with poorer survival. In conclusion, gastric cancer is a great health problem, especially in developing countries, and we need more optimal approaches and treatment modalities for gastric cancer.

Beta-HCG aberrant expression in primary mediastinal large B-cell lymphoma

We report on a primary mediastinal large B-cell lymphoma with aberrant expression of beta-human chorionic gonadotropin (beta-hCG). The patient, a 33-year-old man, had cough, dyspnea, fever, superior vena cava syndrome, and a mediastinal bulky tumor. A biopsy showed that the latter was characterized by large cells, sclerosis, and compartmentalization. The neoplastic elements expressed CD45, CD20, CD79a and, partially, CD30, whereas they were negative for CD3, epithelial membrane antigen and cytokeratins. Surprisingly, they displayed a clear-cut positivity for beta-hCG. The remaining oncofetal markers applied (PLAP and alpha1-fetoprotein) were negative. Electron microscopy demonstrated the presence of numerous nuclear pockets and the lack of intercellular junctions. DNA analysis by polymerase chain reaction showed clonal rearrangement of Ig heavy-chain genes. The patient responded promptly to the administration of MACOP-B. To the best of our knowledge, this is the first example of B-cell lymphoma showing positivity for beta-hCG; a similar aberrant expression was previously observed only in three Japanese patients with human T-cell lymphotropic virus type I+ adult T-cell lymphoma/leukemia. Because primary mediastinal large B-cell lymphoma has in the past been frequently confused with germ cell tumors, pathologists should be aware of possible beta-hCG expression by lymphomatous cells to avoid the risk of misdiagnosis.

Increased mortality in postmenopausal women with serum CA125 elevation

OBJECTIVES

Serum CA125 is used in monitoring treatment and detecting recurrence in ovarian cancer (OC). We have also shown that CA125 can be used with ultrasound for the early detection of OC. However, physiological, benign, and malignant conditions are also associated with CA125 elevation. The aim of the study was to determine the prognostic implications of CA125 elevation in asymptomatic postmenopausal women.

METHODS

The study involved 771 volunteers in an OC screening trial of 22,000 women who had elevated serum CA125 levels (>/=30 U/ml). The control group consisted of an equal number of volunteers with normal levels. Survival was analyzed from the first point of CA125 elevation. Univariate analyses utilized the log-rank chi2 test. A logistic model was constructed for the multivariate analyses.

RESULTS

The mean duration of follow-up was 1614 days (SD 897 days). Eighty-four women died (elevated CA125 group-62, control group-22). Univariate analyses showed that mortality in the elevated CA125 group was significantly greater (log-rank chi2 = 23.556, P < 0.0001, RR = 2.76), even when preexisting morbid conditions were excluded (log-rank chi2 = 14.644, P = 0.0001, RR = 2.4). Multivariate analysis showed that CA125 elevation, age (>60 years), and a prior history of cancer were associated with a poor prognosis.

CONCLUSIONS

Serum CA125 elevation is associated with a significantly increased risk of death from all causes in the next 5 years. These findings may have implications for asymptomatic postmenopausal women with CA125 elevation.

Serum CA 125 level as a predictor of peritoneal dissemination in patients with gastric carcinoma

BACKGROUND

Prediction of peritoneal dissemination is very difficult using current diagnostic tools such as computed tomography, ultrasonography, or various tumor markers. The predictive value of serum CA 125 levels for peritoneal metastasis from gastric carcinoma was studied.

METHODS

The sera from 384 patients with gastric carcinoma were measured for CA 125 titer using an immunoradiometric assay. Carcinoembryonic antigen, carbohydrate antigen 19-9, and sialyl-Tn antigen were measured in the same samples.

RESULTS

The serum CA 125 level was elevated according to the degree of peritoneal dissemination. The reference value for peritoneal dissemination was determined to be 35 U/mL, resulting in a sensitivity of 39.4%, specificity of 95.7%, and diagnostic accuracy of 90.8%. The diagnostic ability was more reliable than the other imaging modalities including computed tomography and ultrasonography and the other useful tumor markers for gastric carcinoma. The serum CA 125 level was elevated after gastrectomy for approximately 2 months, most likely due to the continuous inflammation of the peritoneum and lost predictive significance for peritoneal dissemination during this period.

CONCLUSIONS

Measurement of the serum CA 125 titer may be a powerful predictor of peritoneal metastases in patients with gastric carcinoma.

Prognostic factors and rational approach in the treatment of submucosal cancer of the stomach

In early gastric cancer, lymph node metastasis is known to be a prognostic factor. A retrospective study of 134 patients with submucosal gastric cancer (SMGC) who had undergone gastrectomy with lymph node dissection was performed to evaluate the prognostic factors and indication of postoperative chemotherapy. Five-year disease-free survival rate for 121 patients without nodal metastasis was 100% with (n = 62) or without postoperative chemotherapy (n = 59). On the other hand, it was 72.9% for 13 patients with nodal metastases, although all patients had undergone D2 or D3 resection and received postoperative chemotherapy. Tumor recurrence occurred only in three patients (n = 3) with alpha-fetoprotein (AFP) producing cancer and lymph node metastasis. Multivariate analysis with the Cox's proportional hazard model revealed AFP positivity to be a new independent prognostic factor in addition to lymph node metastasis in the patients with SMGC. Our findings suggest that routine use of postoperative chemotherapy does not appear rational for the patients without nodal metastasis and that new modalities of operation and chemotherapy may be necessary for the patients with AFP producing SMGC with nodal metastasis. The necessity of chemotherapy in conventional-type SMGCs with nodal involvement remains to be studied in future.