Screening for liver metastases from colorectal cancer with carcinoembryonic antigen and alkaline phosphatase

Korea4K: whole genome sequences of 4,157 Koreans with 107 phenotypes derived from extensive health check-ups

BACKGROUND

Phenome-wide association studies (PheWASs) have been conducted on Asian populations, including Koreans, but many were based on chip or exome genotyping data. Such studies have limitations regarding whole genome-wide association analysis, making it crucial to have genome-to-phenome association information with the largest possible whole genome and matched phenome data to conduct further population-genome studies and develop health care services based on population genomics.

RESULTS

Here, we present 4,157 whole genome sequences (Korea4K) coupled with 107 health check-up parameters as the largest genomic resource of the Korean Genome Project. It encompasses most of the variants with allele frequency >0.001 in Koreans, indicating that it sufficiently covered most of the common and rare genetic variants with commonly measured phenotypes for Koreans. Korea4K provides 45,537,252 variants, and half of them were not present in Korea1K (1,094 samples). We also identified 1,356 new genotype-phenotype associations that were not found by the Korea1K dataset. Phenomics analyses further revealed 24 significant genetic correlations, 14 pleiotropic associations, and 127 causal relationships based on Mendelian randomization among 37 traits. In addition, the Korea4K imputation reference panel, the largest Korean variants reference to date, showed a superior imputation performance to Korea1K across all allele frequency categories.

CONCLUSIONS

Collectively, Korea4K provides not only the largest Korean genome data but also corresponding health check-up parameters and novel genome-phenome associations. The large-scale pathological whole genome-wide omics data will become a powerful set for genome-phenome level association studies to discover causal markers for the prediction and diagnosis of health conditions in future studies.

AKP and GGT level can provide an early prediction of first-line treatment efficacy in colorectal cancer patients with hepatic metastases

Aim: It is important to early evaluate or predict the efficacy to avoid ineffective treatment for most colorectal cancer (CRC) patients with liver metastases. Patients & methods: The medical records of 440 patients with histologically confirmed primary CRC admitted to the Fudan University Shanghai Cancer Center were reviewed. Results: High baseline serum alkaline phosphatase (AKP) and γ-glutamyl transferase (GGT) is associated with worse overall survival. In patients with a high serum AKP and GGT a decreased percentage had high objective response rate and better progression-free survival. Conclusion: Measuring the changes of serum AKP or GGT in CRC patients with hepatic metastases before and after the first cycle of treatment is a convenient, fast and economical way to early predict antitumor treatment efficacy.

Electrochemical Detection and Capillary Electrophoresis: Comparative Studies for Alkaline Phosphatase (ALP) Release from Living Cells

Alkaline phosphatase (ALP) is one of the main biomarkers that is clinically detected in bone and liver disorders using optical assays. The electrochemical principle is important because point-of-care testing is increasing dramatically and absorbance techniques hardly compete with the medical revolution that is occurring. The detection of ALP using electrochemical detection is contributing to the integration systems field, and hence enhancing the detection of biological targets for pharmaceutical research and design systems. Moreover, in vitro electrochemical measurements use cost effective materials and simple techniques. Graphite screen-printed electrodes and linear sweep voltammetry were used to optimize the electrochemistry of the enzymatic product p-aminophenol using the enzyme kinetic assay. ALP release from embryonic and cancer cells was determined from adhesion cell culture. Additionally, capillary electrophoresis and colorimetric methods were applied for comparison assays. The resulting assays showed a dynamic range of ALP ranging from 1.5 to 1500 U/L, and limit of detection of 0.043 U/L. This was achieved by using 70 μL of the sample and an incubation time of 10 min at an optimal substrate concentration of 9.6 mM of p-aminophenol phosphate. A significant difference (p < 0.05) was measured between the absorbance assays. This paper demonstrates the advantages of the electrochemical assay for ALP release from cells, which is in line with recent trends in gene expression systems using microelectrode array technologies and devices for monitoring electrophysiological activity.

Overview of Optical and Electrochemical Alkaline Phosphatase (ALP) Biosensors: Recent Approaches in Cells Culture Techniques

Alkaline phosphatase (ALP), which catalyzes the dephosphorylation process of proteins, nucleic acids, and small molecules, can be found in a variety of tissues (intestine, liver, bone, kidney, and placenta) of almost all living organisms. This enzyme has been extensively used as a biomarker in enzyme immunoassays and molecular biology. ALP is also one of the most commonly assayed enzymes in routine clinical practice. Due to its close relation to a variety of pathological processes, ALP's abnormal level is an important diagnostic biomarker of many human diseases, such as liver dysfunction, bone diseases, kidney acute injury, and cancer. Therefore, the development of convenient and reliable assay methods for monitoring ALP activity/level is extremely important and valuable, not only for clinical diagnoses but also in the area of biomedical research. This paper comprehensively reviews the strategies of optical and electrochemical detection of ALP and discusses the electrochemical techniques that have been addressed to make them suitable for ALP analysis in cell culture.

Prognostic value of serum alkaline phosphatase in spinal metastatic disease

Background

Determination of the appropriateness of invasive management in patients with spinal metastatic disease requires accurate pre-operative estimation of survival. The purpose of this study was to examine serum alkaline phosphatase as a prognostic marker in spinal metastatic disease.

Methods

Chart reviews from two tertiary care centres were used to identify spinal metastatic disease patients. Bivariate and multivariate analyses were used to determine if serum alkaline phosphatase was an independent prognostic marker for survival.

Results

Overall, 732 patients were included with 90-day and 1-year survival of n = 539 (74.9%) and n = 324 (45.7%), respectively. The 1-year survival of patients in the first quartile of alkaline phosphatase (≤73 IU/L) was 78 (57.8%) compared to 31 (24.0%) for patients in the fourth quartile (>140 IU/L). Preoperative serum alkaline phosphatase levels were significantly elevated in patients with multiple spine metastases, non-spine bone metastasis, and visceral metastasis but not in patients with brain metastasis. On multivariate analysis, elevated serum alkaline phosphatase was identified as an independent prognostic factor for survival in spinal metastatic disease.

Conclusion

Serum alkaline phosphatase is associated with preoperative metastatic tumour burden and is a biomarker for overall survival in spinal metastatic disease.

Biological Appraisal of Liver Status in Adenocarcinomas

A prospective study of the ability of laboratory tests to detect or to exclude hepatic metastases was performed. Seventy-four patients who underwent liver biopsies were divided into 3 groups: 1) 33 patients with secondary liver involvement from adenocarcinoma; 2) 21 subjects suffering from a non-malignant hepatic disease, and 3) 20 cancerous patients free of overt hepatic metastases. They were investigated with 7 laboratory tests. No single test had a positive predictive value higher than 75%. This percentage was increased to 84% by combining the results of both CEA and rapidly migrating liver alkaline phosphatase isoenzyme ALP 1. More important was the fact that when those parameters were both normal, the negative predictive value was 93%, thus tending to exclude a liver metastatic involvement with an acceptable confidence limit.

Tumor Markers, Liver Function Tests and Symptoms in 115 Patients with Isolated Colorectal Liver Metastases

Development of the hybridoma technique has made the identification of several new tumor antigens possible. Although it was hoped that they would be more tumor-specific, none of these markers are found exclusively in tumor or in serum of tumor patients. Compared with carcinoembryionic antigen (CEA) and liver function tests, the roles of these markers (CA 19-9, CA 125, CA 15-3) were prospectively evaluated in 115 patients with colorectal liver metastases. Patients were classified according to tumor volume (T1 <25%, T2 25-75%, T3 >75%), and the extension of infiltration (solitary/multiple/diffuse; unilateral, bilateral). Patients with benign liver or biliary disease served as a control group (n=63). Overall sensitivity was 87% for *1 , 50% for *2 and 38% for *3 , with a significant correlation with tumor size. CEA serum levels were elevated in 88% of all patients. CA 19-9 was less sensitive: positive in 59%. Because of some complementary elevations, the combined use of CEA, CA 19-9 and CA 125 raised sensitivity to 94%. CA 19-9 and LDH could be useful for confirmation because of their higher specificity; however, the specificity of CEA rose to 93% on using a cut-off of 10 ng/ml instead of 3 ng/ml. The results indicate that CEA and CA 19-9 as well as liver function tests are helpful for preoperative staging in conjunction with imaging procedures before liver resection or regional chemotherapy.

Liver Cancer Detection by a Simple, Inexpensive and Effective Immunosensor with Zinc Oxide Nanoparticles

Regular monitoring of blood α-fetoprotein (AFP) and/or carcino-embryonic antigen (CEA) levels is important for the routine screening of liver cancer. However, AFP and CEA have a much lower specificity than des-γ-carboxyprothrombin (DCP) to detect liver cancer. Therefore, the study reported here was designed, to develop a screen-printed DCP immunosensor incorporating zinc oxide nanoparticles, for accurate determination of DCP. The designed immunosensor shows low detection limits for the detection of DCP: 0.440 ng/mL (based on impedance measurement), 0.081 ng/mL (based on real part of impedance measurement) and 0.078 ng/mL (based on imaginary part of impedance measurement), within the range of 3.125 ng/mL to 2000 ng/mL. In addition, there was little interference to DCP determination by molecules such as Na⁺, K⁺, Ca²⁺, Cl⁻, glucose, urea, and uric acid. It is therefore concluded that the DCP immunosensor developed and reported here is simple, inexpensive and effective, and shows promise in the rapid screening of early-stage liver cancer at home with a point-of-care approach.

Multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor successfully treated by laparoscopic surgery: Report of a case

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Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer.

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Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

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This report is the first to describe multiple hepatic sclerosing hemangiomas treated by laparoscopic surgery.

Introduction

Hepatic sclerosing hemangioma is a very rare benign tumor, characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. We report here a rare case of multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor that was successfully treated using laparoscopic surgery.

Presentation of case

A 67-year-old woman with multiple liver tumors underwent single-incision laparoscopic sigmoidectomy under a diagnosis of advanced sigmoid cancer with multiple liver metastases. Examination of surgical specimens of sigmoid colon revealed moderately differentiated adenocarcinoma invading the serosa, and no lymph node metastases. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 remained within normal limits throughout the course. Two months after sigmoidectomy, the patient underwent laparoscopic partial hepatectomy of S1 and S6 of the liver and cholecystectomy. Histopathological examination showed that the tumors mainly comprised hyalinized tissue and collagen fibers with sporadic vascular spaces on hematoxylin and eosin-stained sections, yielding a diagnosis of multiple hepatic sclerosing hemangioma. No evidence of recurrence has been seen as of 21 months postoperatively.

Discussion

Differentiating multiple sclerosing hemangiomas from metastatic liver tumors was quite difficult because the radiological findings were closely compatible with liver metastases. Laroscopic hepatectomy provided less blood loss, a shorter duration of hospitalization, and good cosmetic results.

Conclusion

Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer. Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases

BACKGROUND

The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.

METHODS

Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated.

RESULTS

Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds.

CONCLUSION

Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Serological diagnostic factors for liver metastasis in patients with colorectal cancer

AIM: To investigate the serological diagnostic factors for liver metastasis in patients with colorectal cancer.

METHODS: One hundred and six adult in-patients with colorectal cancer were studied and divided into patients with liver metastasis (n = 56) and patients without liver metastasis (n = 50). Serum levels of tumor and biochemical markers for liver were measured at the time of diagnosis.

RESULTS: The mean survival time was 55.9 mo, 36.8 mo and 68.3 mo for the overall patients, patients with liver metastasis and patients without liver metastasis, respectively. Lactate dehydrogenase (LDH) level was significantly correlated with the survival time of colorectal cancer patients. The levels of alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase (GGT), LDH and carcinoembryonic antigen (CEA) were significantly higher in patients with liver metastasis than in those without liver metastasis. Patients with lymph node metastasis had a higher risk of liver metastasis than those without lymph node metastasis. The cut points of LDH, GGT and CEA for screening liver metastasis were 180 U/L, 30 U/L and 5.0 μg/L, respectively. The sensitivity was 64.3%, 69.6% and 70.4%, and the specificity was 64.0%, 60.0% and 52.4%, respectively. The sensitivity of parallel test was 85.2% for LDH and CEA, and 92.6% for GGT and CEA, respectively. The specificity of serial test was 85.7% for LDH (or GGT) and CEA.

CONCLUSION: Early diagnosis of liver metastasis is of great significance. The sensitivity and specificity of combined tumor and biochemical markers are rather good in screening colorectal liver metastasis.

Localization of radiolabeled anti-CEA antibody in subcutaneous and intrahepatic colorectal xenografts: influence of tumor size and location within host organ on antibody uptake

INTRODUCTION

Radioimmunotherapy (RIT) has been shown to be more effective against solid tumor micrometastases, possibly due to an inverse relationship between tumor size and radiolabeled antibody uptake. In this study, the accretion of radiolabeled antibody in intrahepatic micrometastases in an experimental model was investigated using quantitative digital autoradiography, enabling the analysis of antibody uptake in microscopic tumors.

METHODS

Mice bearing subcutaneous or intrahepatic metastatic models of LS174T colorectal cancer were injected with radiolabeled anti-carcinoembryonic antigen antibody ([(125)I]A5B7). Tissues were taken to investigate distribution of radionuclide and tumor uptake. In a therapy study, mice bearing intrahepatic metastatic tumors were injected with [(131)I]A5B7.

RESULTS

Subcutaneous tumors and large metastatic deposits had similar uptake (e.g., approximately 15%ID/g at 24 h). Small metastatic deposits had higher uptake (e.g., approximately 80%ID/g at 24 h) and prolonged retention at later time points. Small deposit uptake was significantly reduced by accompanying large deposits in the same liver. RIT resulted in increased survival time (untreated mean survival of 21.6+/-12.9 vs. treated mean survival of 39.1+/-30.8 days), but there was a large range of response within groups, presumably due to variation in pattern and extent of tumor as observed in the biodistribution study. Liver function tests and body weight did not change with tumor growth or therapy response, strongly supporting the use of in vivo imaging in metastatic tumor therapy studies.

CONCLUSIONS

Radioimmunodetection and therapy might be greatly influenced by the size and distribution of intrahepatic tumor deposits.

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.

Community compliance with carcinoembryonic antigen: follow-up of patients with colorectal cancer

PURPOSE

The aim of this study was to determine whether recommendations for surveillance carcinoembryonic antigen (CEA) testing in stage II/III colorectal cancer (CRC) are adhered to upon discharge from our cancer center, patterns of care after CEA elevation, and whether differences in outcomes exist between patients who did and did not receive recommended CEA monitoring.

PATIENTS AND METHODS

A retrospective, single-institution chart review was completed at the Cross Cancer Institute (CCI) in Edmonton, Alberta. The Alberta Cancer Registry (ACR) identified patients with CRC diagnosed between January 1 and December 31, 2001. Patients with stage II/III CRC seen and/or treated at the CCI and later discharged to the community with follow-up recommendations based on American Society of Clinical Oncology guidelines were included. Carcinoembryonic antigen monitoring > or = every 4 months for > or = 2 years was deemed acceptable for study purposes.

RESULTS

The ACR identified 152 stage II/III CRC cases meeting inclusion criteria. Eleven patients (7.2%) received the minimum predefined CEA follow-up. Eighty-seven CEA follow-up tests were elevated; only 20 (23%) elevated CEAs were investigated with predefined timely intervention. Twenty-six patients (17.1%) had documentable tumor recurrence. There was no difference in overall survival or time to recurrence between the groups who received and did not receive appropriate follow-up, although small numbers limit the effectiveness of statistical analysis.

CONCLUSION

Post-therapy surveillance is important in CRC management. Our study reveals follow-up recommendations based on best available evidence for interval CEA testing are not followed in the community. These findings suggest the need for review of recommendations and change in management for monitoring discharged patients with stage II/III CRC.

Ultraschall in der Tumornachsorge

According to the guidelines, ultrasonography (US) is now established as the cross-sectional imaging technique of choice in postoperative care of colorectal carcinoma. Although conventional percutaneous US is inferior to computed tomography (CT) and magnetic resonance imaging (MRI) for detecting hepatic metastases, the application of specific contrast media has significantly increased sensitivity and specificity to 87% and 88%, respectively. The combination of US and CT/MRI achieves the highest detection rates. During follow-up of rectal carcinoma, in up to 20% of locoregional recurrences are diagnosed solely by endorectal sonography and result in repeat resection with curative intention. In noncolorectal carcinoma, US is recommended in the guidelines for following up hepatocellular carcinoma and malignant thyroid disease, but the available data are insufficient to support those recommendations.

Intensive follow-up after liver resection for colorectal liver metastases: results of combined serial tumour marker estimations and computed tomography of the chest and abdomen - a prospective study

The aim of the study was to prospectively evaluate an intensive follow-up programme using serial tumour marker estimations and contrast-enhanced computed tomography (CT) of the chest and abdomen in patients undergoing potentially curative resection of colorectal liver metastases. Seventy-six consecutive patients having undergone potentially curative resections of colorectal liver metastases in a single unit were followed up with a protocol of 3 monthly carcinoembryonic antigen and carbohydrate antigen 19-9 estimations and contrast-enhanced spiral CT of the chest, abdomen and pelvis for the first 2 years following surgery and 6 monthly thereafter. The median period of follow-up was 24 months (range 18-60). Recurrent tumour was classed as early if within 6 months of liver resection. Thirty-seven of the 76 patients (49%) developed recurrence on follow-up. Nineteen recurrences were in the liver alone (51%), 16 liver and extrahepatic (43%) and two extrahepatic alone (6%). Of the 19 patients with isolated liver recurrence, eight developed within 6 months of liver resection none of which were resectable. Of the 11 recurrences after 6 months, five (45%) were resectable. Of the 37 recurrences, CT indicated recurrence despite normal tumour markers in 19 patients. Tumour markers suggested recurrence before imaging in 12 and concurrently with imaging in 6. In the 12 patients who presented with elevated tumour markers before imaging, there was a median lag period of 3 months (range 1-21) in recurrence being detected on further serial imaging. Seventeen patients who developed recurrence had normal tumour markers before initial resection of their liver metastases. Of these 17, 10 (58%) had an elevation of tumour markers associated with recurrence. Over a median follow-up of 2 years following liver resection, the use of CT or tumour markers alone would have failed to demonstrate early recurrence in 12 and 18 patients respectively. A combination of tumour markers and CT detected significantly more (P < 0.05) recurrence than either modality alone. Tumour markers and CT should be used in combination in the follow-up of patients with resected colorectal liver metatases, including patients whose markers are normal at the time of initial liver resection.

Optimal follow-up in colorectal cancer patients: what tests and how often?

Patients' benefit from follow-up examinations after curative surgery for colorectal cancer is unproven in spite of numerous different programs' having been designed for that purpose. Unfortunately, no final results from prospective randomized studies have been published yet and no ideal marker for recurrent cancer is available to identify patients in whom new curative treatment may be possible. So far, screening for metachronous neoplasia with intervals of several years may influence survival, whereas benefit from detecting recurrent colorectal cancer may be claimed only by using historical or other inappropriate controls. The tradition of follow-up is expensive and prospective evidence for any cost benefit is needed to justify continuous use of our limited resources in this area of patient care.

Preoperative evaluation and postoperative surveillance for patients with colorectal carcinoma

As the understanding of the biology of carcinoma of the colon and rectum increases and the effectiveness of adjuvant therapy for patients with such carcinoma improves, preoperative staging of disease has assumed an increasingly important role. The rationale and specifics of preoperative evaluation and the role, rationale, and controversies regarding postoperative surveillance after curative resection of colorectal carcinoma are discussed.

Colorectal cancer. Principles of postoperative follow-up

Monitoring patients after primary large bowel surgery for malignancy is predicated on the concept that early detection of recurrence may provide salvage treatment for cure. Knowledge of the pathologic site and stage provides important information as to the probability of recurrence and the patterns of failure that are likely to occur. Available methods to detect recurrence include clinical, roentgenographic, and serum tests that are done more frequently during the first 2 years after surgery. Monitoring plasma carcinoembryonic antigen levels can lead to identification of asymptomatic recurrences, but there is controversy about the curability of recurrences outside the liver. Newer techniques (such as computed tomographic portography, intraoperative ultrasonography, and radioimmunoguided surgery) provide greater diagnostic accuracy and lead to more appropriate procedures during "second-look" operations. For example, hepatic resection in properly selected patients offers up to a 30% chance of cure and should be pursued aggressively. A search for metachronous cancers by endoscopy also should be done. Knowledge of the potential and patterns of failure can provide a useful guide during the postoperative follow-up care of the patient with large bowel cancer.

Role of carcinoembryonic antigen and liver function tests in the detection of recurrent colorectal carcinoma

The optimal laboratory evaluation for the early detection of liver metastases from colorectal cancer is controversial. This investigation was undertaken to compare the efficacy of liver function tests (LFTs) with that of carcinoembryonic antigen (CEA) levels for the early detection of liver metastases. Patients who developed liver metastases after potentially curative resections of adenocarcinoma of the colorectum between 1974 and 1988 were reviewed. The following laboratory tests were serially evaluated during the follow-up period: CEA, alkaline phosphatase (AP), serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), and lactic dehydrogenase (LDH). These values were retrospectively assessed from the time of documented liver metastases to identify which lab value(s) were elevated initially. Ninety-two patients were available for study. Average time for the occurrence of liver metastases was 20 months (range, 3-72 months). The incidence of elevation of individual tests at the time of suspicion of liver metastasis was: CEA, 94.6 percent (P less than 0.25, chi-squared); AP, 18.5 percent; SGOT, 12.0 percent; SGPT, 5.4 percent; and LDH, 29.3 percent. When comparing CEA with a battery of LFTs at the time of suspicion of liver metastasis, CEA was elevated with normal LFTs in 64.1 percent (P less than 0.05, chi-squared), the most frequent occurrence. At least one LFT was elevated with a normal CEA in only 2.2 percent; CEA and at least one LFT were increased in 30.4 percent; and both tests were normal in only 3.3 percent. These results indicate that, of the individual laboratory tests performed, CEA elevation heralds liver metastases significantly more frequently. LDH is the liver function test most frequently elevated when liver metastases are first suspected. When CEA is directly compared with a battery of LFTs, CEA is statistically significantly more frequently elevated. In fact, suspicion of liver metastases would have been delayed by the omission of LFTs in only 2.2 percent of patients. Therefore, we conclude that LFTs should be deleted from the follow-up of colorectal cancer patients, decreasing costs without significantly decreasing accuracy.

Liver function tests in patients with computed tomography demonstrated hepatic metastases

One hundred patients with computed tomographic (CT) evidence of liver metastases (and confirmation by biopsy or progression of disease) had serum levels of alkaline phosphatase, serum glutamic oxaloacetic transaminase, and serum glutamic pyruvic transaminase measured within two weeks of scanning. All three enzymes were within the normal range in 33% of patients. Even with advanced involvement (defined as three or more metastatic lesions over 3 cm in diameter), 20% of patients had normal levels of all three liver enzymes. Although liver function tests (LFTs) (enzyme levels) are inexpensive and simple to perform, they failed to detect a significant number of patients with liver metastases.

Relationship between colorectal liver metastases and CEA levels in gallbladder bile

While computerized tomographic (CT) scanning and intraoperative exploration are both considered accurate measures of liver involvement with metastatic disease, 10% to 30% of colorectal liver metastases remain undetected. Attempting to improve current methods for detecting colorectal liver metastases, CEA levels in gallbladder bile and serum from patients with known liver metastases were determined. One hundred per cent of patients with single and multiple metastases of various dimensions were observed to have gallbladder bile CEA levels strikingly higher than serum values (4.7 to 259 times greater, p = 0.0009). Linear regression analysis of estimated tumor volume and surface area versus gallbladder bile CEA levels predicted that very small tumors (less than or equal to 1 cm3 in volume) might produce detectable levels (9 to 41 ng/mL) of biliary CEA. For this reason, patients who lack clinical and radiologic evidence of distant metastases at the time of primary colorectal resection but who do have elevated gallbladder bile CEA levels (greater than or equal to 10 ng/mL) are being followed for the appearance of occult hepatic metastases.

Colorectal cancer. The bases for a comprehensive follow-up

The purpose of this article was to review the effectiveness of follow-up in patients with colorectal cancer submitted to curative treatment. A comprehensive follow-up involves rational initial management of the primary tumor, knowledge of prognostic factors, selection of the patient to be followed, determination of the time for follow-up, use of the most appropriate tests for early diagnosis of recurrence, and eventual curative treatment. The updated answers to all these questions are given through an extensive review of the world literature and confronted with the authors' experience of eight years of follow-up in a series of 170 colorectal cancer patients treated for cure. Although the future might be more promising, past world experience suggests only a few patients could be saved. It is concluded that there is no place for incomplete and disperse screening tests, and only comprehensive, intensive, and very well-coordinated follow-up programs should be undertaken if better results are hoped to be achieved.

Efficiency of composite tests in gastrointestinal cancer. Preoperative prediction of liver metastases by scintigraphy, alkaline phosphatase, and carcinoembryonic antigen

The efficiency of composite tests (liver scintigraphy, serum alkaline phosphatase, and serum carcinoembryonic antigen) in finding or excluding liver metastases preoperatively was evaluated in 185 surgical patients with high probability for gastrointestinal cancer--142 with colorectal and 43 with gastric disorders. A pathoanatomic verification procedure showed liver metastases in 21 and 7 patients, respectively. For each test two cut-off levels were defined in accordance with the operational purpose of the test: either to diagnose metastases (no false-positive test results) or to exclude metastases (no false-negative test results). Generally, composite tests increased overall efficiency; in the colorectal group 39% of the patients were correctly classified by the combined, triple test; in the gastric group 94% were correctly classified. In conclusion, we think composite tests are useful, and the operational approach described may be helpful in decision-making and test evaluation.

The limitation of liver function tests in metastatic carcinoid tumors

To evaluate the utility of liver function tests (LFT) as indicators of metastatic carcinoid tumors, a retrospective study was performed. The LFT results of 17 patients with carcinoid tumors metastatic to the liver were compared with 17 patients with other malignant tumors. In the noncarcinoid group, 82.4% of the patients had elevated alkaline phosphatase (AP) or gamma glutamyl transpeptidase (GGTP), whereas only 28.6% of carcinoid patients had abnormal enzymes. The medians of all LFT values were significantly higher in noncarcinoid patients than in the carcinoid group, except for glutamic pyruvic transaminase (SGPT). Our data indicate that LFT are helpful in screening for liver metastases in patients with noncarcinoid tumors, but are unreliable in carcinoid tumors. Imaging tests should be used to rule out liver metastases in carcinoid tumors, irrespective of LFT results.

Comparing predictive decision rules in postoperative CEA monitoring

To evaluate the usefulness of serial postoperative carcinoembryonic antigen (CEA) assays, seven previously published decision rules for predicting tumor recurrence were compared retrospectively using CEA values from 214 patients followed 36 to 120 months after surgery for colorectal carcinoma. Decision rules employing cutoff values to predict tumor recurrence were found inadequate for the asymptomatic patient. This attenuation of prognostic usefulness appeared attributable to inadequacies of CEA assays for predicting late recurrences. From these analyses, elevated CEA results without other objective evidence might be insufficient to justify second-look surgery. In addition, late recurring tumors tended not to cause elevated CEA levels.

The preoperative liver scan and surgical decision-making in patients with colorectal cancer

The influence of preoperative liver scans and liver function tests on surgical decision-making was analyzed in 196 patients who underwent surgical therapy for colorectal cancer. One hundred and thirteen patients who had preoperative liver scans were compared with 83 patients who did not. No statistically significant difference existed between the liver scan group and the nonscan group in terms of when surgical decision-making occurred. Likewise, the results of the liver scan did not influence when operative decisions were made. The majority of decision-making occurred intraoperatively when ultimate confirmation of the presence or absence of hepatic metastases was made. Presumptive surgical decisions were made preoperatively, but final decisions occurred intraoperatively when all relevant patient data could be correlated. Liver scanning has limited usefulness in the preoperative evaluation of patients with colon cancer as it does not affect decision-making and is much more costly than liver function testing.

Measurement of high molecular weight forms of enzymes in serum in the detection of hepatic metastases of colorectal cancer

Total gamma-glutamyl transferase and alkaline phosphatase, liver-specific alkaline phosphatase and high molecular weight forms of the two enzymes were measured in the sera of 42 patients with colorectal cancer, of whom 26 were apparently metastases-free and 16 had palpable liver metastases. The average levels of all enzymes were significantly higher in the group with metastases, but there was considerable overlap between the groups. The predictive values of positive results were of the order of 50-75%; predictive values of negative results were more than 70% for all tests, with high molecular weight alkaline phosphatase (87%) performing best in this respect. However, measurement of high molecular weight enzymes does not offer marked advantages over more conventional enzyme tests in the detection of hepatic metastases of colorectal cancer.

Preoperative staging with computerized axial tomography and biochemical laboratory tests in patients with hepatic metastases

Preoperative biochemical liver function tests and computerized axial tomographic (CAT) scans were performed on 100 patients as part of a prospective randomized study of treatments for liver metastases from colorectal cancer. The CAT scans reliably reflected the presence of disease in most patients but only accurately demonstrated the number and location of metastases in 43% of the patients. Extrahepatic metastases were present in 35 patients but were only seen on the CAT scans in three of these patients. The biochemical tests, which were useful for detecting hepatic metastases, were alkaline phosphatase (AP), lactic dehydrogenase (LDH), and carcinoembryonic antigen (CEA). When hepatic disease was minimal, these tests were less likely to be elevated than when there was extensive disease. Even with the combination of late generation CAT scans and biochemical tests, the accurate quantification and location of hepatic metastases and extrahepatic disease require a surgical assessment.

Carcinoembryonic antigen (CEA) and alkaline phosphatase in progressive colorectal cancer with special reference to patient survival

The prognostic value of serial CEA tests was evaluated in 175 consecutive patients with progressive colorectal cancer who subsequently died of their disease. The upper normal plasma CEA limit was determined to be 8 ng/ml from serial CEA determinations in 31 patients radically operated on for colorectal cancer and observed in median 40 months without evidence of recurrence. A CEA value of greater than 8 ng/ml was highly suggestive of residual disease or recurrence, even when no clinical evidence was present. Approximately 90% of the patients dying from colorectal cancer showed an increase in CEA to greater than 8 ng/ml during the course of the disease. In 63% of the patients CEA increase preceded clinical progression or relapse, with a median time period of 4 months. Sixty-eight per cent of the patients had rising CEA values over an extended time period of many months, 14% had a preterminal increase, 13% had constantly normal and 5% constantly elevated CEA. As 6/9 patients developed a drop in CEA in relation to initiation of chemotherapy without clinical response, it is concluded that CEA is not a reliable indicator of clinical response to chemotherapy. Patients with liver metastases had higher CEA and alkaline phosphatase levels than patients with only localized disease. However, no good statistical correlation between CEA and serum alkaline phosphatase was found in patients with liver metastases (coefficient of correlation r = 0.35). An increase in CEA from normal to above 8 ng/ml predicted a decrease in survival time of median 60% counted from the time of diagnosis. The numerical CEA value was predictive of shortening of survival only when greater than 3000 ng/ml. Such high values were observed only in a minority of the patients (12%). Greater than 1000 U/l (27% of the patients) alkaline phosphatase predicted an extremely poor prognosis, with a median survival of 1 month (range 0.5-4 months). It is concluded that a rise in CEA to greater than 8 ng/ml indicates with high degree of certainty relapse or disease progression in colorectal cancer patients. CEA is not a reliable indicator of clinical response to chemotherapy, and an increase in the CEA level is of little prognostic value concerning survival. Alkaline phosphatase seems to be a more valuable predictor of a worsening of prognosis.

In pursuit of the abnormal serum alkaline phosphatase: a clinical dilemma

The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive workup, and in that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination.

Major hepatic resection for metachronous metastases from colon cancer

Hepatic resection of metastatic colorectal cancer is being performed with increasing frequency. Reports describe wide variations in survival after resection of solitary of multiple metastases. In 23 consecutive patients having major hepatic resection for metachronous metastases from colorectal cancers, 18 patients had one, two, or three metastases and five had four or more individual metastases; the cure rate of one, two, or three metachronous metastases was comparable to reports of resected solitary simultaneous metastases. The median maximum diameter of metastases in patients both surviving and dead was 7 cm. Features separating surviving from dead patients were resection margins of at least 1 cm and fewer than four metastatic nodules. All patients with four or more hepatic metastases died of disease, 80% with further liver metastases. Only three of 18 (17%) patients with one, two, or three metastases developed further hepatic lesions. This study suggests that the biology of the hepatic metastatic disease is paramount; timing of the hepatic resection is of little importance. Delayed resection of suitable biologic situations does not impair survival opportunities, and early resection of inappropriate biologic situations with more than three hepatic metastases does not improve survival. Therefore, programs of early detection with the use of carcinoembryonic antigen (CEA) screening or "second look" operations will not increase cure rates.

Detection of recurrent cancer of the colon and rectum

Outpatient follow-up in patients operated upon due to carcinoma of the colon and rectum is usually performed, due to a high rate of recurrence and with the aim of finding a curable recurrence. Due to the enormous cost of an extended follow-up system, a careful evaluation of the benefit is needed. The aim of the present investigation was to study the efficacy of the different tools in an extended follow-up. One hundred ninety patients with carcinoma of the colon and rectum were--apart from traditional clinical follow-up--followed with an extensive laboratory battery including carcinoembryonic antigen (CEA), erythrocyte sedimentation rate (ESR), hemoglobin (Hb), electrophoresis, ALP, and GT. Forty-seven recurrences were found. Thirty-one of these recurrences were first detected by a rise in CEA. Seven cases were detected at clinical follow-up and six cases due to symptoms suggestive of recurrence. The predictive value of a positive test was 79.4% for CEA but very low for the other tests studied. A negative value for any of the tests in the battery was usually accurate. Follow-up after colorectal carcinoma should include CEA as the only laboratory parameter. Postoperative colonoscopy for removal of missed synchronous lesions, chest X-ray, and endoscopic investigations of the anastomotic region also seem to be of value.

Detection of liver metastases. A prospective study comparing liver enzymes, scintigraphy, ultrasonography and computed tomography

A prospective comparative study between liver enzymes, scintigraphy, ultrasonography and computed tomography for detection of liver metastases was performed in 113 patients who were eligible for operation for a carcinoma in the gastrointestinal tract. Twenty-three of the 113 patients (20 per cent) had liver metastases. The accuracy of scintigraphy was 79 per cent, of ultrasonography 85 per cent and of computed tomography 88 per cent. The results of these tests showed no statistical differences. Ultrasonography and computed tomography were significantly more accurate than alkaline phosphatase and gamma-glutamyl transpeptidase (respectively P less than 0.01 and P less than 0.05). Taking into account cost effectiveness, simplicity and patient tolerance, ultrasonography is the test of choice for the detection of liver metastases.

Screening for liver metastases from ovarian cancer with serum carcinoembryonic antigen and radionuclide hepatic scintiphotography

The association between pre-operative serum carcinoembryonic antigen (CEA) and liver scanning employing technetium (99mTc)-tin colloid was investigated in 30 women subsequently proven to have primary epithelial ovarian carcinoma to determine whether these two investigations improve the detection of hepatic metastases. The upper limit of normal for CEA (greater than or equal to 5 ng/ml) did not represent the optimal levels for use in predicting ovarian carcinoma nor the presence of liver metastases. But with CEA levels greater than 10 ng/ml sensitivity for liver metastases was 57%. Liver scanning alone demonstrated metastases in five out of seven patients (71%) with parenchymal liver metastases. The combination of CEA and liver scan was positive in six out of these seven patients (86%).

Alpha-fetoprotein and carcinoembryonic antigen in patients with primary liver carcinoma, metastatic liver disease, and alcoholic liver disease

Alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), alkaline phosphatase (ALP) and gamma-glutamyltranspeptidase (GT) were determined in three groups of patients: 21 with primary liver carcinoma (PLC), 106 with metastatic liver disease, and 110 with various degrees of alcoholic liver diseases. AFP was elevated in 12 out of 14 with hepatocellular carcinoma but in none of 7 with cholangiocarcinoma. CEA was elevated in 8 of 14 with hepatocellular carcinoma and in 5 of 7 with cholangiocarcinoma. In metastatic liver disease, 83% had elevated CEA greater than or equal to 5.0 micrograms/l, 50% having CEA levels greater than 20 micrograms/l. AFP was moderately elevated in 26% of the patients, the values being less than 100 micrograms/l in all but one. In patients with alcoholic liver disease, 31% had elevated CEA levels greater than or equal to 5.0 micrograms/l; one of these had an extremely high value of 245 micrograms/l. AFP was moderately elevated to less than 100 micrograms/l in only 9%. CEA is a sensitive indicator of metastases: a value above 20 micrograms/l is almost always associated with malignancy. However, the presence of alcoholic liver diseases must be considered in evaluating patients with increased CEA levels. AFP and CEA seemed to be of value in differentiation between primary and secondary liver carcinoma. ALP and GT are also relatively sensitive indicators of malignant liver disease, but they are more unspecific than AFP and CEA.