Prognostic significance of pre- and postoperative serum carcinoembryonic antigen levels in patients with colorectal cancer

Postoperative serum squamous cell carcinoma antigen and carcinoembryonic antigen predict overall survival in surgical patients with esophageal squamous cell carcinoma

Background

Tumor markers are routinely used in clinical practice. However, for resectable patients with esophageal squamous cell carcinoma (ESCC), they are applied infrequently as their prognostic significance is incompletely understood.

Methods

This historical cohort study included 2769 patients with resected ESCC from 2011 to 2018 in a high-risk area in northern China. Their clinical data were extracted from the Electronic Medical Record. Survival analysis of eight common tumor markers was performed with multivariable Cox proportional hazards regressions.

Results

With a median follow-up of 39.5 months, 901 deaths occurred. Among the eight target markers, elevated postoperative serum SCC (Squamous cell carcinoma antigen) and CEA (Carcinoembryonic antigen) predicted poor overall survival (SCC HRadjusted: 2.67, 95% CI: 1.70-4.17; CEA HRadjusted: 2.36, 95% CI: 1.14-4.86). In contrast, preoperative levels were not significantly associated with survival. Stratified analysis also demonstrated poorer survival in seropositive groups of postoperative SCC and CEA within each TNM stage. The above associations were generally robust using different quantiles of concentrations above the upper limit of the clinical normal range as alternative cutoffs. Regarding temporal trends of serum levels, SCC and CEA were similar. Their concentrations fell rapidly after surgery and thereafter remained relatively stable.

Conclusion

Postoperative serum SCC and CEA levels predict the overall survival of ESCC surgical patients. More importance should be attached to the use of these markers in clinical applications.

Clinical Significance of and Predictive Risk Factors for the Postoperative Elevation of Carcinoembryonic Antigen in Patients With Non-Metastatic Colorectal Cancer

Background

Recently, a few researches focus on the correlation between postoperative carcinoembryonic antigen (post-CEA) and the outcome of colorectal cancer (CRC), but none investigates the predictive value of post-CEA in a prognostic model. Besides, current recommendations on the frequency of post-CEA surveillance are not individualized and well followed. There is an absence of identification of patients who are more likely to have abnormal post-CEA levels and need more frequent CEA measurements.

Methods

Consecutive CRC patients who underwent curative surgery were enrolled and randomly divided into the discovery (n=352) and testing cohort (n=233). Impacts of preoperative CEA (pre-CEA) and post-CEA on prognosis were assessed. Cox regression model was applied to develop prognostic nomograms, which were validated by the concordance index (C-index), calibration curve, and receiver operating characteristic curve (ROC) analysis. And prediction improvement of the nomograms was assessed with net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Logistic regression was used to identify predictive risk factors and construct the prediction model for post-CEA elevation.

Results

Post-CEA independently predicted overall survival (OS) and disease-free survival (DFS), while pre-CEA did not. Post-CEA elevation represented higher risks in patients with normal pre-CEA, compared to those with persistent elevated CEA. The nomograms for OS and DFS were established with body mass index, tumor differentiation, N stage, lymphocyte-to-monocyte ratio, and post-CEA. The nomograms showed good calibration and superior discrimination than pTNM stage, with the C-index of 0.783 and 0.759 in the discovery set and 0.712 and 0.774 in the testing set for OS and DFS, respectively. Comparisons between models using IDI and NRI implied that the nomograms performed better than pTNM stage and the predictive power could be improved with the addition of post-CEA. The prediction model for post-CEA elevation was established with age, platelet-to-lymphocyte ratio, preoperative CA19-9, and pre-CEA. The AUC of the model in the two cohorts was 0.802 and 0.764, respectively.

Conclusions

Elevated post-CEA was a strong indicator of poor prognosis. The addition of post-CEA significantly enhanced the performance of prognostic nomograms. And the prediction model for post-CEA elevation may help identify patients who ought to reasonably receive more intensive postoperative surveillance of CEA levels.

A radiomics-based nomogram for preoperative T staging prediction of rectal cancer

Purpose

To investigate the value of a radiomics-based nomogram in predicting preoperative T staging of rectal cancer.

Methods

A total of 268 eligible rectal cancer patients from August 2012 to December 2018 were enrolled and allocated into two datasets: training (n = 188) and validation datasets (n = 80). Another set of 32 patients from January 2019 to July 2019 was included in a prospective analysis. Pretreatment T2-weighted images were used to radiomics features extraction. Feature selection and radiomics score (Rad-score) construction were performed through a least absolute shrinkage and selection operator regression analysis. The nomogram, which included Rad-scores and clinical factors, was built using multivariate logistic regression. Discrimination, calibration, and clinical utility were used to evaluate the performance of the nomogram.

Results

The Rad-score containing nine selected features was significantly related to T staging. Patients who had locally advanced rectal cancer (LARC) generally had higher Rad-scores than patients with early-stage rectal cancer. The nomogram incorporated Rad-scores and carcinoembryonic antigen levels and showed good discrimination, with an area under the curve (AUC) of 0.882 (95% confidence interval [CI] 0.835–0.930) in the training dataset and 0.846 (95% CI 0.757–0.936) in the validation dataset. The calibration curves confirmed high goodness of fit, and the decision curve analysis revealed the clinical value. A prospective analysis demonstrated that the AUC of the nomogram to predict LARC was 0.859 (95% CI 0.730–0.987).

Conclusion

A radiomics-based nomogram is a novel method for predicting LARC and can provide support in clinical decision making.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03137-1.

Relationship Between Preoperative and Postoperative Serum Carcinoembryonic Antigen and Prognosis of Patients with Stage I-III Rectal Cancer: A Retrospective Study of a Multicentre Cohort of 1022 Rectal Cancer Patients

Purpose

Based on a multi-centered and a large sample size, this study aims to analyze the relationship between preoperative and postoperative serum CEA and recurrence of rectal cancer without preoperative therapy.

Methods

This retrospective cohort study enrolled stage I to III rectal cancer patients without preoperative therapy (N = 1,022) who received radical resection of rectal cancer from 2 hospitals in China. Based on the preoperative and postoperative serum carcinoembryonic antigen, the patients were subdivided into 3 groups ie, normal preoperative CEA (≤5.0 ng/mL, N = 627), elevated preoperative (>5.0 ng/mL) but normalized postoperative CEA (normalized postoperative CEA, N = 255), as well as elevated preoperative and postoperative CEA (elevated postoperative CEA, N = 67). The generalized additive model was used to assess the relationship between carcinoembryonic antigen and the risk of recurrence. Further, the Cox regression model was used to evaluate the relationship between carcinoembryonic antigen and 3-year recurrence-free survival (RFS) after adjusting for potential confounders.

Results

The 3-year RFS of patients with elevated postoperative CEA was 45.8% (95% CI, 35.2% −59.5%), which was significantly lower compared to the other two groups of patients (normalized postoperative CEA: 75.9%, 95% CI, 70.8%-81.4%; and normal preoperative CEA: 84.9%, 95% CI, 82.2%-87.8%) (P <0.001). Based on multivariable Cox model analysis, the elevated postoperative CEA was a prognostic factor for 3 years RFS (hazard ratio [HR], 3.08; 95% CI, 2.05–4.66; P<0.001). At the same time, normalized postoperative CEA was insignificantly correlated with 3-year RFS (HR, 1.38; 95% CI, 1.00–1.92; P = 0.05) and was not an independent risk factor.

Conclusion

We found that preoperative and postoperative serum CEA of rectal cancer patients were related to the 3-year recurrence-free survival rate. Moreover, the risk of recurrence in the normalized postoperative CEA group of patients was insignificantly different from that of the normalized preoperative CEA patients. Therefore, it is necessary to combine preoperative and postoperative CEA to predict the prognosis of patients with rectal cancer, rather than using it alone.

Multiplex bioassaying of cancer proteins and biomacromolecules: Nanotechnological, structural and technical perspectives

Since the specific proteins (carbohydrate antigens, ligands and interleukins) get raised up in body tissue or fluids in cancer cases, early detection of them will provide an effective treatment and survival rate. Sensitive and accurate determination of multiple cancer proteins can be engaged in chorus by simultaneous/multiplex detection in the biomedical fields. Bioassaying technology is one of the non-invasive, high-sensitive, and economical methods. Currently, extensive application of nanomaterial (biocompatible polymers, metallic and metal oxide) in bioassays resulted in ultra-high sensitive and selective diagnosis. This review article focuses on types of multiplex bioassays for delicate and specific determination of cancer proteins for diagnostic aims. It also covers two modes of multiplex bioassays as multi labeled bioassays and spatially-separated test zones (multi-electrode mode). In this review, the nanotechnological, structural, and technical perspectives in the multiplex analysis of cancer proteins were discussed. Finally, the use of different types of nanomaterials, polysaccharides, biopolymers and their advantages in signal amplification are discussed.

A Novel Prognostic Model Incorporating Carcinoembryonic Antigen in 3-Week or Longer Postoperative Period for Stage III Colon Cancer: A Multicenter Retrospective Study

Background

The prognostic stratification of colon cancer using only the tumor-node-metastasis (TNM) stage has some limitations. We sought to increase the accuracy of stratifying patients with stage III colon cancer by constructing a prognostic model combining carcinoembryonic antigen (CEA) with TNM.

Methods

We retrospectively analyzed the data generated from stage III colon cancer patients who had early postoperative CEA measurement from 21 to 100 days after surgery from 2006 to 2017. CEA value was processed using restricted cubic splines (RCS) method. The prognostic model was developed using cox proportional hazards regression.

Results

The time later than 20 days after surgery was optimal for measuring CEA, which was determined by comparing the prognostic value for preoperative and postoperative CEA (N = 2,049), and by evaluating the relationship between the hazard ratio (HR) and postoperative CEA measuring time. Postoperative CEA, T stage and N stage were selected into the final model, and the mean integrated-AUC (iAUC) was 0.78 with 1,000 × bootstrap resampling, which was higher than the model using only T and N stages (TN model; mean iAUC, 0.66). The net reclassification improvement (NRI) was 15% when compared with TN model. Patients could be divided into high and low risk groups by the model, and 3-year disease-free survival (DFS) were 53.7% and 87.0%, respectively (HR, 4.30; 95% CI, 2.65 to 6.96; P < 0.001). Similar results were found in the validation set.

Conclusions

Stage III colon cancer could be stratified more accurately using the new prognostic model combining postoperative CEA with T and N stage.

Prognostic value of changes in serum carcinoembryonic antigen levels for preoperative chemoradiotherapy response in locally advanced rectal cancer

BACKGROUND

Preoperative chemoradiotherapy (CRT) is a standard treatment modality for locally advanced rectal cancer. However, CRT alone cannot improve overall survival. Approximately 20% of patients with CRT-resistant tumors show disease progression. Therefore, predictive factors for treatment response are needed to identify patients who will benefit from CRT. We theorized that the prognosis may vary if patients are classified according to pre- to post-CRT changes in carcinoembryonic antigen (CEA) levels.

AIM

To identify patients with locally advanced rectal cancer for preoperative chemoradiotherapy based on carcinoembryonic antigen levels.

METHODS

We retrospectively included locally advanced rectal cancer patients who underwent preoperative CRT and curative resection between 2011 and 2017. Patients were assigned to groups A, B, and C based on pre- and post-CRT serum CEA levels: Both > 5; pre > 5 and post ≤ 5; and both ≤ 5 ng/mL, respectively. We compared the response to CRT based on changes in serum CEA levels. Receiver operating characteristic curve analysis was performed to determine optimal cutoff for neutrophil–lymphocyte ratio and platelet–lymphocyte ratio. Multivariate logistic regression analysis was used to evaluate the prognostic factors for pathologic complete response (pCR)/good response.

RESULTS

The cohort comprised 145 patients; of them, 27, 43, and 65 belonged to groups A, B, and C, respectively, according to changes in serum CEA levels before and after CRT. Pre- (P < 0.001) and post-CRT (P < 0.001) CEA levels and the ratio of down-staging (P = 0.013) were higher in Groups B and C than in Group A. The ratio of pathologic tumor regression grade 0/1 significantly differed among the groups (P = 0.003). Group C had the highest number of patients showing pCR (P < 0.001). Most patients with pCR showed pre- and post-CRT CEA levels < 5 ng/mL (P < 0.001, P = 0.008). Pre- and post-CRT CEA levels were important risk factors for pCR (OR = 18.71; 95%CI: 4.62–129.51, P < 0.001) and good response (OR = 5.07; 95%CI: 1.92–14.83, P = 0.002), respectively. Pre-CRT neutrophil–lymphocyte ratio and post-CRT T ≥ 3 stage were also prognostic factors for pCR or good response.

CONCLUSION

Pre- and post-CRT CEA levels, as well as change in CEA levels, were prognostic markers for treatment response to CRT and may facilitate treatment individualization for rectal cancer.

Postoperative serum carcinoembryonic antigen levels cannot predict survival in colorectal cancer patients with type II diabetes

BACKGROUND

Most clinical guidelines recommend measuring postoperative carcinoembryonic antigen (CEA) levels to predict the prognosis of colorectal cancer. However, type II diabetes can increase serum CEA levels which may bias the prognosis. Thus, we aimed to evaluate the impact of type II diabetes on CEA prognostic accuracy in colorectal cancer.

METHODS

This retrospective cohort study included 407 patients who underwent curative resection for stage I to III colorectal adenocarcinoma in a single institution between January 2010 and June 2018. The patients were categorized into two groups according to their postoperative serum CEA levels: group A <5.0 ng/mL (n = 341) and group B ≥5.0 ng/mL (n = 66). Patients were also categorized into two subgroups according to their history of type II diabetes: patients with type II diabetes mellitus (n = 112) and patients without type II diabetes (n = 295).

RESULTS

The 3-year disease-free survival (DFS) rates were significantly higher in patients with normal postoperative CEA (group A, 83.8%) than in patients with elevated preoperative and postoperative CEA (group B, 63.6%) (p < 0.001). However, although patients with type II diabetes mellitus had higher postoperative CEA levels than those without type II diabetes mellitus (3.1 vs 2.5 ng/mL, p < 0.001), group B patients with type II diabetes mellitus had a significantly higher 3-year DFS rate than those without type II diabetes mellitus (80.0% vs 55.6%, p = 0.003).

CONCLUSION

Type II diabetes was associated with higher preoperative and postoperative CEA levels in patients with colorectal cancer. Consequently, elevated postoperative CEA level was not associated with shorter 3-year DFS in patients with type II diabetes, as opposed to patients without type II diabetes. Therefore, colorectal cancer patients with type II diabetes may need alternative tumor markers to be used during the surveillance strategy after curative surgery.

The prognostic value of combined tumor markers and systemic immune-inflammation index in colorectal cancer patients

PURPOSE

This study evaluated the significance of combining tumor markers (TM) and systemic immune-inflammation index (SII) for postoperative complications and long-term outcomes in colorectal cancer (CRC) patients.

METHODS

CRC patients (662) who underwent surgery between 2012 and 2014 were retrospectively enrolled into our study. Factors affecting postoperative complications were evaluated by logistic regression analysis. Prognostic factors were assessed using Kaplan-Meier and Cox proportional hazards models. Nomograms were constructed to predict the risk of postoperative complications and survival. A consistency index and a calibration curve were used to evaluate the predictive accuracy of nomograms.

RESULTS

TM-SII score was established by combining TM and SII. Logistic regression analyses showed that TM-SII score was an important predictor of postoperative complications in CRC patients. Kaplan-Meier analyses showed that TM-SII score was favorable for prognostic risk stratification. In addition, multivariate analyses indicated that TM-SII score was an independent prognostic indicator for disease-free survival and overall survival. TM-SII based nomograms had a moderate prediction accuracy.

CONCLUSION

TM-SII score is a good prognostic indicator for CRC patients. It may be used as a useful risk stratification tool for advanced CRC patients. TM-SII-based nomograms could be used to identify CRC patients with poor outcomes.

Clinical Significance of Preoperative Serum Carcinoembryonic Antigen Within the Normal Range in Colorectal Cancer Patients Undergoing Curative Resection

BACKGROUND

Serum carcinoembryonic antigen (CEA) is a widely used tumor marker in colorectal cancer (CRC), but within normal range of preoperative CEA levels the clinical significance of CEA is unknown.

OBJECTIVE

The aim of this study was to evaluate the usefulness of CEA within the normal range as a prognosticator of non-metastatic CRC.

METHODS

This retrospective cohort study included 2021 CRC patients with normal preoperative CEA who underwent elective curative surgery (discovery group). We determined the optimal cut-off value for disease-free survival (DFS) discrimination using the Contal and O'Quigley method. We also assessed the prognostic significance of the cut-off value in a prospective cohort of 171 stage III colon cancer patients treated with oxaliplatin-based adjuvant chemotherapy (validation group).

RESULTS

The optimal cut-off CEA value was 2.1 ng/mL in the discovery group. The DFS rates were significantly poorer in patients with high-normal preoperative CEA levels (2.1-5.0 ng/mL) than in those with low-normal CEA levels (< 2.1 ng/mL) in both groups. A high-normal CEA level was an independent risk factor for DFS in both groups, and was associated with inferior DFS in patients with stage II and III disease and in never or former smokers. The correlation between DFS and CEA levels was more distinct in left-sided colon and rectal cancer.

CONCLUSIONS

A high-normal preoperative CEA level (≥ 2.1 ng/mL), even within the normal range, was an independent prognosticator for poor DFS in CRC. The usefulness of CEA was influenced by smoking status and tumor location in addition to tumor stage.

Prognostic value of postoperative serum carcinoembryonic antigen levels in colorectal cancer patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) can increase serum carcinoembryonic antigen (CEA) levels. We thus aimed to evaluate the impact of CKD on CEA prognostic accuracy in colorectal cancer.

METHODS

Altogether, 429 patients who underwent curative resection for stages I-III colorectal adenocarcinoma were grouped according to postoperative CEA levels and history of CKD.

RESULTS

Three-year disease-free survival (DFS) was higher in patients with normal postoperative CEA (group A, 83.4%) than in those with elevated postoperative CEA (group B, 64.3%) (p < 0.001). CKD patients had higher postoperative CEA levels than non-CKD patients (odds ratio 3.27, 95% confidence interval 1.78-5.99, p < 0.001). In multivariable analysis, postoperative CEA level was an independent prognostic factor for DFS in non-CKD, but not CKD, patients.

CONCLUSIONS

CKD can increase postoperative CEA levels in colorectal cancer patients. Elevated postoperative CEA levels were associated with shorter DFS in non-CKD, but not CKD, patients.

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

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

An elevated CA 19-9 is associated with invasive cancer and worse survival in IPMN

BACKGROUND

Current guidelines for IPMN include an elevated serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. Serum CEA is also currently used for preoperative management of IPMN, although its measurement is not evidence-based. Accordingly, we aimed to assess the role of these tumor markers as predictors of malignancy in IPMN.

METHODS

IPMN resected between 1998 and 2018 at Massachusetts General Hospital were analyzed. Clinical, pathological and survival data were collected and compared to preoperative levels of CA 19-9 and CEA. Receiver operating characteristic (ROC) and Cox regression analyses were performed considering cut-offs of 37 U/ml (CA 19-9) and 5 μg/l (CEA).

RESULTS

Analysis of 594 patients showed that preoperative CA 19-9 levels > 37 U/ml (n = 128) were associated with an increased likelihood of invasive carcinoma when compared to normal levels (45.3% vs. 18.0%, P < 0.001), while there was no difference with respect to high-grade dysplasia (32.9% vs 31.9%, P = 0.88). The proportion of concurrent pancreatic cancer was higher in patients with CA 19-9 > 37 U/ml (17.2% vs 4.9%, P < 0.001). An elevated CA 19-9 was also associated with worse overall and disease-free survival (HR = 1.943, P = 0.007 and HR = 2.484, P < 0.001 respectively). CEA levels did not correlate with malignancy.

CONCLUSION

In patients with IPMN, serum CA19-9 > 37 U/ml is associated with invasive IPMN and concurrent pancreatic cancer as well as worse survival, but not with high-grade dysplasia. Serum CEA appears to have minimal utility in the management of these patients.

Prognostic implications of EGFR protein expression in sporadic colorectal tumors: Correlation with copy number status, mRNA levels and miRNA regulation

Sporadic colorectal cancer (sCRC) is the third most frequent cancer worldwide and the second most common cause of cancer-related deaths (mainly due metastatic dissemination). We investigated the immunohistochemical expression of frequently altered proteins in primary tumors from 51 patients (25 liver metastatic and 26 non-metastatic cases) with a median 103 months follow-up (103 months). We evaluated EGFR copy number (using SNP arrays and FISH) and its expression and regulation (by mRNA and miRNA arrays). We found differences between metastatic and non-metastatic sCRCs for MLH1 (p = 0.05), PMS2 (p = 0.02), CEA (p < 0.001) and EGFR (p < 0.001) expression. EGFR expression was associated with lymph node metastases (p = 0.001), liver metastases at diagnosis (p < 0.001), and advanced stage (p < 0.001). There were associations between EGFR expression-, EGFR gene copy number- and EGFR mRNA levels. We found potential interactions of two miRNAs targeting EGFR expression, (miR-134 and miR-4328, in non-metastatic and metastatic tumors, respectively). EGFR expression was associated with a worse outcome (p = 0.005). Multivariate analysis of prognostic factors for overall survival identified that, the expression of EGFR expression (p = 0.047) and pTNM stage (p < 0.001) predicted an adverse outcome. EGFR expression could be regulated by amplification or polysomies (in metastatic tumors), or miRNAs (miRNA-134, in non-metastatic tumors). EGFR expression in sCRC appears to be related to metastases and poor outcome.

Association of Preoperative and Postoperative Serum Carcinoembryonic Antigen and Colon Cancer Outcome

Importance

Guidelines recommend measuring preoperative carcinoembryonic antigen (CEA) in patients with colon cancer. Although persistently elevated CEA after surgery has been associated with increased risk for metastatic disease, prognostic significance of elevated preoperative CEA that normalized after resection is unknown.

Objective

To investigate whether patients with elevated preoperative CEA that normalizes after colon cancer resection have a higher risk of recurrence than patients with normal preoperative CEA.

Design, Setting, and Participants

This retrospective cohort analysis was conducted at a comprehensive cancer center. Consecutive patients with colon cancer who underwent curative resection for stage I to III colon adenocarcinoma at the center from January 2007 to December 2014 were identified.

Exposures

Patients were grouped into 3 cohorts: normal preoperative CEA, elevated preoperative but normalized postoperative CEA, and elevated preoperative and postoperative CEA.

Main Outcomes and Measures

Three-year recurrence-free survival (RFS) and hazard function curves over time were analyzed.

Results

A total of 1027 patients (461 [50.4%] male; median [IQR] age, 64 [53-75] years) were identified. Patients with normal preoperative CEA had 7.4% higher 3-year RFS (n = 715 [89.7%]) than the combined cohorts with elevated preoperative CEA (n = 312 [82.3%]) (P = .01) but had RFS similar to that of patients with normalized postoperative CEA (n = 142 [87.9%]) (P = .86). Patients with elevated postoperative CEA had 14.9% lower RFS (n = 57 [74.5%]) than the combined cohorts with normal postoperative CEA (n = 857 [89.4%]) (P = .001). The hazard function of recurrence for elevated postoperative CEA peaked earlier than for the other cohorts. Multivariate analyses confirmed that elevated postoperative CEA (hazard ratio [HR], 2.0; 95% CI, 1.1-3.5), but not normalized postoperative CEA (HR, 0.77; 95% CI, 0.45-1.30), was independently associated with shorter RFS.

Conclusions and Relevance

Elevated preoperative CEA that normalizes after resection is not an indicator of poor prognosis. Routine measurement of postoperative, rather than preoperative, CEA is warranted. Patients with elevated postoperative CEA are at increased risk for recurrence, especially within the first 12 months after surgery.

The prognostic value of the postoperative serum CEA levels/preoperative serum CEA levels ratio in colorectal cancer patients with high preoperative serum CEA levels

Purpose

This study aimed to assess the prognostic value of the postoperative serum carcinoembryonic antigen (CEA) levels/preoperative serum CEA levels ratio (CEA ratio) in colorectal cancer (CRC) patients with high preoperative serum CEA levels and to identify the optimal prognostic cutoff value.

Patients and methods

The medical records of 187 CRC patients in a single center who underwent surgery between September 2012 and September 2014 were retrospectively reviewed. CEA ratio was defined as the ratio between the postoperative serum CEA and preoperative serum CEA. The optimal cutoff values for the CEA ratio were determined by time-dependent receiver operating characteristic (ROC) curve analyses. The Chi-square test or Fisher’s exact probability test were used to test the correlation between CEA ratio and clinicopathological characteristics. Univariate, multivariate, and subgroup Cox proportional hazards analysis were used to identify independent prognostic factors. Kaplan–Meier method was used for establishing survival curves.

Results

The median follow-up time was 62 months (range 3–88 months). The optimal CEA ratio cutoff value closely related to disease-free survival was 0.295. In the Chi-square test, the CEA ratio was associated with pN stage (p=0.003) and postoperative CEA (p<0.001). In the multivariate analysis, the CEA ratio was an independent prognostic factor for disease-free survival (p=0.003, HR 2.300 [95% CI: 1.326–3.988]) and cancer-special survival (p=0.003, HR 2.525 [95% CI: 1.381–4.614]). The CEA ratio reflected the prognosis of CRC patients more accurately than postoperative CEA levels alone, and the CEA ratio of 0.295 was more likely to reflect the prognosis than other cutoff values.

Conclusion

The CEA ratio is a simple and useful tool for further forecasting the prognosis of CRC patients with high preoperative CEA levels and may help develop strategies for the postoperative treatment of CRC patients.

Modified Folfox6 as Adjuvant Chemotherapy in Vietnamese Patients With Colorectal Cancer

Colorectal cancer is the third most common cancer and the second leading cause of death from cancer worldwide. In Vietnam, the disease is the fifth leading cancer (8.9%), with 14 733 new cases in 2018. In recent years, the mFolfox6 regimen has been indicated commonly as the adjuvant chemotherapy after curative resection for patients with colorectal cancer. However, the efficacy of the regimen in Vietnamese patients has not been assessed and reported. In this retrospective study, we reviewed medical records of 83 patients with stage II or stage III colorectal cancer who received mFOLFOX6 regimen in order to investigate simultaneously survival and safety of this chemotherapy regimen. Three-year overall and disease-free survival were 84.3% and 79.5%, respectively. Our data revealed that postoperative Carcinoma Embryonic Antigen (CEA) level was a significant prognostic factor for survival, with hazard ratio of 3.83 and 3.67, respectively (P < .05), for overall survival and disease-free survival in the elevated CEA level group when compared to the normal CEA level group. The regimen also demonstrated to be well tolerated and can be used in routine practice as an adjuvant chemotherapy.

The effect of canceroembryonic antigen on cytokine production by immunocompetent blood cells in patients with breast cancer

Aim. Investigation of the influence of canceroembryonic antigen (CEA) on the immune cells in patients with breast tumors.

Materials and methods. Peripheral blood of 67 patients with invasive ductal carcinoma (n = 44), fibroadenoma (n = 12) and breast pre-cancer (n = 11). In the supernatants of the blood cells cytokine production induced by CEA was determined by ELISA.

Results.It was found that CEA stimulated production of IL-6, IL-8, IL-10, IL-1β, IL-1Ra, TNFα, G-CSF, GM-CSF and the protein MCP-1 by blood immune cells in patients with fibroadenoma compared with groups of patients with invasive ductal carcinoma and precancerous lesions. Stimulation index of CEA on cytokine production by immunocompetent cells in patients in these groups was lower than in groups of patients with fibroadenoma due to initially high levels of spontaneous cytokine production.

Results.  In  patients  with  fibroadenoma  CEA  was  found  to  stimulate  the  production  of  IL-6,  IL-8,  IL-10,  IL-1β,  IL-1Ra,  TNFa,  G-CSF,  GM-CSF  and  MCP-1  compared  with  groups  of  patients  with  invasive ductal carcinoma and precancerous conditions. Indexes of the influence of CEA on cytokine production by immunocompetent cells in these groups was lower than in the fibroadenoma due to initially high spontaneous production of cytokines.

Conclusion.  Evident  spontaneous  cytokine-producing  function  of  immunocompetent  blood  cells  was revealed in patients with invasive ductal carcinoma and precancerous conditions compared to patients with fibroadenoma.  The  differences  between  the  indices  of  CEA  influence  on  cytokine  production  in  patients with malignant, benign and precancerous conditions can serve as a basis for the development of methods of differential diagnosis of breast tumors.

Relations of Changes in Serum Carcinoembryonic Antigen Levels before and after Neoadjuvant Chemoradiotherapy and after Surgery to Histologic Response and Outcomes in Patients with Locally Advanced Rectal Cancer

OBJECTIVES

The histologic response to neoadjuvant chemoradiotherapy (nCRT) has been intimately related to outcomes in locally advanced rectal cancer. Serum carcinoembryonic antigen (CEA) levels change after nCRT and after surgery as compared with before nCRT.

METHODS

The subjects were 149 patients with locally advanced rectal cancer who received nCRT between 2005 and 2013. The patients were divided into 4 groups according to the serum CEA levels: group 1, 55 patients with negative serum CEA levels before nCRT; group 2, 41 patients with positive serum CEA levels before nCRT that became negative after nCRT; group 3, 37 patients with positive serum CEA levels after nCRT that became negative after surgery; and group 4, 16 patients with positive serum CEA levels after nCRT as well as after surgery.

RESULTS

Pathological complete response, T downstaging, and tumor shrinkage were significantly higher in group 1 than in other groups. Disease-free survival was significantly poorer in group 4. The lack of a decrease in the serum CEA level in group 4 was most likely attributed to the persistence of micrometastases outside the resection field.

CONCLUSIONS

Changes in serum CEA levels measured before nCRT, after nCRT, and after surgery can be used to reliably predict the histologic response to nCRT and outcomes.

Serum carcinoembryonic antigen as a tumour marker in patients with endometrial cancer

BACKGROUND

No potential tumour markers have been validated for prognosis in endometrial cancer. However, carcinoembryonic antigen (cea) is one of the most widely used tumour markers in various types of cancer. Although cea expression in endometrial cancer has been investigated, its prognostic value remains controversial, and no studies have investigated serum cea levels in large case series. In the present study, we investigated diagnostic and prognostic applications of serum cea for endometrial cancer.

METHODS

This prospective study was approved by our Institutional Review Board. Between January 2006 and December 2012, serum cea was measured prospectively in 215 patients with endometrial cancer and was subsequently measured during treatment and at scheduled follow-up examinations in patients with elevated baseline serum cea.

RESULTS

During the study period, 215 patients (142 stage i, 19 stage ii, 32 stage iii, 22 stage iv) were treated for endometrial cancer. By the time of last follow-up, 52 had relapsed (24.2%), and the median follow-up duration was 45 months (range: 1-95 months). Elevated serum cea was identified in 25 patients (11.6%) and was associated with histologic type (p = 0.04), histologic grade (p = 0.03), and myometrial invasion depth (p = 0.01). Elevated serum cea was not related to clinical stage, lymph node metastasis, distant metastasis, age, menopausal status, or body mass index. Relapse of disease was related to elevated serum cea (p = 0.006).

CONCLUSIONS

Serum cea is a potential prognostic indicator for endometrial cancer.

Preoperative Serum Carcinoembryonic Antigen Level as a Prognostic Factor for Recurrence and Survival After Curative Resection Followed by Adjuvant Chemotherapy in Stage III Colon Cancer

BACKGROUND

Carcinoembryonic antigen (CEA) is the most widely used tumor marker in colon cancer; however, there has been controversy regarding the significance of preoperative serum CEA level as a prognostic factor for recurrence. In this study, we evaluated the optimal cutoff value and prognostic significance of preoperative serum CEA level in stage III colon cancer.

METHODS

Based on a retrospective cohort of 965 patients with stage III colon cancer who underwent elective curative surgery and adjuvant chemotherapy with fluoropyrimidine and oxaliplatin (training set), we determined the optimal cutoff value of CEA for recurrence using the Contal and O'Quigley method. We assessed the prognostic value of this cutoff value in terms of disease-free survival (DFS) and overall survival (OS) in a prospective cohort of 268 patients with stage III colon cancer (validation set). A Cox proportional hazards model was used to explore the association of prognostic variables with DFS and OS.

RESULTS

The statistically determined best cutoff value for CEA was 3 ng/mL in the training set. A high CEA level (≥3 ng/mL) was associated with inferior DFS (hazard ratio [HR] 4.609, 95 % confidence interval [CI] 2.028-10.474) and OS (HR 3.956, 95 % CI 1.127-13.882) in the validation set, while multivariate analysis showed that a high CEA level was an independent risk factor for DFS and OS in both study subsets.

CONCLUSION

Preoperative serum CEA level is an independent prognostic factor for DFS and OS in patients with stage III colon cancer after curative resection and adjuvant chemotherapy.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Anastomotic recurrence of colon cancer: Genetic analysis challenges the widely held theories of cancerous cells' intraluminal implantation and metachronous carcinogenesis

BACKGROUND AND OBJECTIVES

Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy.

METHODS

An analysis of clinical and histopathological parameters, including MSI and LOH of seven sites (Myc-L, BAT26, BAT40, D5S346, D18S452, D18S64, D16S402) was performed in primary CC and AR of 18 patients. They were then compared to 36 controls not developing AR.

RESULTS

A genetic instability was present in 16/18 patients, with distinct genetic patterns between primaries and ARs. LOH at 5q21 and/or 18p11.23 were found in both primary and AR in >50% of cases, but this rate was no different from control population. CEA resulted as associated with AR (P = 0.03), whereas N status presented a borderline result (P = 0.08).

CONCLUSIONS

Our findings challenge present theories about AR development. No "genetic marker" has been found. CEA and, to a lesser extent, N status, appear associated with AR. Rectal washout is seemingly meaningless. Iterative resection should be recommended since a long survival may be expected. J. Surg. Oncol. 2016;114:228-236. © 2016 Wiley Periodicals, Inc.

Factors affecting prognosis in metastatic colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is a major cause of mortality in developed countries, and it is the third most frequent malignancy in Turkey. There are many biological, genetic, molecular, and tissue-derived prognostic factors for CRCs. In this study, we evaluated prognostic factors in patients who were metastatic at diagnosis or progressed to metastatic disease during follow-up.

PATIENTS AND METHODS

This study included 116 patients with malignancies either in the colon or rectum. Of these, 65 had metastatic disease at diagnosis, and 51 progressed to metastatic disease during the course of the disease. The parameters evaluated were age, gender, comorbidity, performance status and stage of the disease at the beginning, localization, history of surgery, chemotherapy regimen, response to first-line treatment, K-RAS status, site and number of metastases, expression of tumor predictors (CEA, CA19-9), and survival times. A multivariate analysis conducted with factors that considered statistically significant in the univariate analysis.

FINDINGS

Median age was 56 (32-82) years and the male/ female ratio was 80/36. Eleven patients were at stage II, 40 at stage III, and 65 at stage IV at diagnosis. Twenty three patients had tumor in the right colon, 48 in the left colon, and 45 in the rectum. Ninety seven patients were operated, and 27 had surgical metastasectomy. Ninety three patients received targeted therapy. At the end of follow-up, 61 patients had died, and 55 survived. Metastatic period survival times were longer in the adjuvant group, but the difference did not reach the level of statistical significance (adjuvant group: median 29 months, metastatic group: median 22 months; p=0.285). In the adjuvant group before the metastatic first-line therapy, CEA and CA 19-9 levels were significiantly lower compared to the metastatic group (p<0.005). We also found that patients with elevated tumor predictor (CEA, CA 19-9) levels before the first-line therapy had significiantly poorer prognosis and shorter survival time. Survival was significiantly better with the patients who were younger than 65 years of age, had better initial performance status, a history of primary surgery and metastatectomy, and single site of metastasis. Those who benefitted from the first-line therapy were K-RAS wild type and whose tumor markers (CEA, CA 19-9) were not elevated before the first line therapy.

CONCLUSIONS

Among the patients with metastatic CRC, those who benefited from first-line therapy, had history of metastasectomy, were K-RAS wild type and had low CA 19-9 levels before the first-line therapy, showed better prognosis independent of other factors.

Blood CEA levels for detecting recurrent colorectal cancer

BACKGROUND

Testing for carcino-embryonic antigen (CEA) in the blood is a recommended part of follow-up to detect recurrence of colorectal cancer following primary curative treatment. There is substantial clinical variation in the cut-off level applied to trigger further investigation.

OBJECTIVES

To determine the diagnostic performance of different blood CEA levels in identifying people with colorectal cancer recurrence in order to inform clinical practice.

SEARCH METHODS

We conducted all searches to January 29 2014. We applied no language limits to the searches, and translated non-English manuscripts. We searched for relevant reviews in the MEDLINE, EMBASE, MEDION and DARE databases. We searched for primary studies (including conference abstracts) in the Cochrane Central Register of Controlled Trials (CENTRAL), in MEDLINE, EMBASE, and the Science Citation Index & Conference Proceedings Citation Index - Science. We identified ongoing studies by searching WHO ICTRP and the ASCO meeting library.

SELECTION CRITERIA

We included cross-sectional diagnostic test accuracy studies, cohort studies, and randomised controlled trials (RCTs) of post-resection colorectal cancer follow-up that compared CEA to a reference standard. We included studies only if we could extract 2 x 2 accuracy data. We excluded case-control studies, as the ratio of cases to controls is determined by the study design, making the data unsuitable for assessing test accuracy.

DATA COLLECTION AND ANALYSIS

Two review authors (BDN, IP) assessed the quality of all articles independently, discussing any disagreements. Where we could not reach consensus, a third author (BS) acted as moderator. We assessed methodological quality against QUADAS-2 criteria. We extracted binary diagnostic accuracy data from all included studies as 2 x 2 tables. We conducted a bivariate meta-analysis. We used the xtmelogit command in Stata to produce the pooled estimates of sensitivity and specificity and we also produced hierarchical summary ROC plots.

MAIN RESULTS

In the 52 included studies, sensitivity ranged from 41% to 97% and specificity from 52% to 100%. In the seven studies reporting the impact of applying a threshold of 2.5 µg/L, pooled sensitivity was 82% (95% confidence interval (CI) 78% to 86%) and pooled specificity 80% (95% CI 59% to 92%). In the 23 studies reporting the impact of applying a threshold of 5 µg/L, pooled sensitivity was 71% (95% CI 64% to 76%) and pooled specificity 88% (95% CI 84% to 92%). In the seven studies reporting the impact of applying a threshold of 10 µg/L, pooled sensitivity was 68% (95% CI 53% to 79%) and pooled specificity 97% (95% CI 90% to 99%).

AUTHORS' CONCLUSIONS

CEA is insufficiently sensitive to be used alone, even with a low threshold. It is therefore essential to augment CEA monitoring with another diagnostic modality in order to avoid missed cases. Trying to improve sensitivity by adopting a low threshold is a poor strategy because of the high numbers of false alarms generated. We therefore recommend monitoring for colorectal cancer recurrence with more than one diagnostic modality but applying the highest CEA cut-off assessed (10 µg/L).

Early detection of colorectal cancer: from conventional methods to novel biomarkers

PURPOSE

Colorectal cancer (CRC) is one of the major health problems worldwide and is often diagnosed at late stage. There is growing body of evidence in early detection of this disease with novel screening modalities to reduce compliance and increase specificity of available methods. The aim of current review is to give an overview on currently available screening methods (e.g., fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy), with their own merits and disadvantages, and new genetic/epigenetic/protein markers, as novel screening modalities.

RESULT

There are several serum and fecal biomarkers that can predict CRC and polyps. Overall sensitivities for detection by fecal DNA markers ranged from 53 to 87%, while a panel of serum protein markers provides a sensitivity/specificity up to 85% for CRC. In particular, DNA methylation markers (e.g., SEPT9, SFRP2, and ALX4), circulating microRNAs (e.g., microRNA21), SNPs in microRNAs binding site (e.g., rs4596 located within a target region of the predicted miR-518a-5p and miR-527), protein markers (e.g., carcinoembryonic antigen, N-methyltransferase), or microsatellites instability in tumors with deficient mismatch repair of some genes are among the most interesting and promising biomarkers.

CONCLUSION

Increasing evidence supports the use of combined fecal and serum biomarkers with sigmoidoscopy and colonoscopy screening in order to maximize the benefits and reduce the number of false-positive tests and patients undergoing invasive methods, which in turn could overcome the limitations of the current screening methods for early detection of CRC and adenomas.

Impact of the post/preoperative serum CEA ratio on the survival of patients with rectal cancer

PURPOSE

This study demonstrated the usefulness of the post/preoperative serum carcinoembryonic antigen (CEA) ratio as a predictor of survival after surgery for stage III rectal cancer patients.

METHODS

One hundred and four patients with stage III rectal cancer who underwent surgery between 1991 and 2000 were enrolled. The ratio of the postoperative serum CEA value divided by the preoperative serum CEA value was defined as post/preoperative serum CEA ratio, and the patients were separated into two groups: post/preoperative serum CEA ratio ≤ 1 (n = 86) and >1 (n = 18).

RESULTS

The multivariate analyses demonstrated that the intraoperative blood loss, lack of a sphincter-saving procedure and a post/preoperative serum CEA ratio >1 were independent factors predicting a poor prognosis for the overall and disease-free survival. The overall and disease-free survival rates among patients with a high preoperative serum CEA level (>5 ng/ml) or patients with a high postoperative serum CEA (>5 ng/ml) were longer in patients with a post/preoperative serum CEA ratio ≤ 1, in comparison to those with a post/preoperative serum CEA ratio >1. Liver metastasis was observed more frequently in patients with a post/preoperative serum CEA ratio >1.

CONCLUSIONS

The post/preoperative serum CEA ratio may be a predictor of the prognosis after surgery for stage III rectal cancer patients.

Colorectal cancer biomarkers: To be or not to be? Cautionary tales from a road well travelled

Colorectal cancer (CRC) is the second most common cause of cancer-related death worldwide and places a major economic burden on the global health care system. The time frame for development from premalignant to malignant disease typically spans 10-15 years, and this latent period provides an ideal opportunity for early detection and intervention to improve patient outcomes. Currently, early diagnosis of CRC is hampered by a lack of suitable non-invasive biomarkers that are clinically or economically acceptable for population-based screening. New blood-based protein biomarkers for early detection of CRC are therefore urgently required. The success of clinical biomarker discovery and validation studies is critically dependent on understanding and adjusting for potential experimental, analytical, and biological factors that can interfere with the robust interpretation of results. In this review we outline some important considerations for research groups undertaking biomarker research with exemplars from our studies. Implementation of experimental strategies to minimise the potential effects of these problems will facilitate the identification of panels of biomarkers with the sensitivity and specificity required for the development of successful tests for the early detection and surveillance of CRC.

Serum vascular adhesion protein-1 predicts all-cause mortality and cancer-related mortality in subjects with colorectal cancer

BACKGROUND

Vascular adhesion protein-1 (VAP-1) participates in inflammation and catalyzes the breakdown of amines to produce aldehyde, hydrogen peroxide, and ammonia. Serum VAP-1 can predict cancer mortality, including colorectal cancer (CRC) mortality, in type 2 diabetic subjects. However, it remains unknown if serum VAP-1 can predict mortality in CRC patients. This prospective cohort study investigates if serum VAP-1 is a novel biomarker for mortality prediction in CRC.

METHODS

We enrolled 300 CRC patients. Preoperative serum VAP-1 was measured by time-resolved immunofluorometric assay. They were followed until September 2009 or death, which was ascertained by the National Death Registration System.

RESULTS

The median follow-up period was 4.7 years. Compared with normal counterpart, VAP-1 immunoactivity was upregulated in CRC tissues, especially at the invasion front. Serum VAP-1 can independently predict all-cause mortality (HR: 1.0026, 95% CI: 1.0003-1.0050, P<0.05) and cancer-related mortality (HR: 1.0026, 95% CI: 1.0001-1.0050, P<0.05). A risk score composed of age, gender, carcinoembryonic antigen (CEA) >5 ng/ml, tumor grading, tumor staging, and serum VAP-1 could stratify CRC patients into low-, intermediate-, and high-risk subgroups, with a 5-year mortality rate of 10%, 34%, and 78%, respectively.

CONCLUSIONS

Serum VAP-1 predicts mortality independently and improves risk stratification in CRC subjects.

Opposite variation tendencies of serum CA724 levels in patients with colon and rectal carcinoma

The aim of this study was to investigate tumor biomarker carbohydrate antigen 724 (CA724) in the serum of patients with carcinomas of the colon and rectum at various clinical stages. Serum was collected from 51 patients with colon carcinoma (CC) and 49 patients with rectal carcinoma (RC). CA724 levels were then measured in the different groups according to site, TNM classification, gender, age and metastastic status of the patients. The statistical significance of the differences between the groups was calculated by non-parametric statistics (Mann-Whitney and Kruskall-Wallis tests). We observed a close association between the serum CA724 levels and tumor migration in colorectal carcinoma (CRC) and opposite variation tendencies of CA724 in the evolution of CC and RC. In conclusion, we identified a close association between the serum levels of CA724 and tumor migration in CRC. The opposite variation tendencies of CA724 in the different evolution groups of CC and RC may reflect the differences between these two types of cancer. The evaluation of serum CA724 may be of monitoring and and predictive value and may also assist in the development of treatment strategies for CRC patients.

18F-FDG PET/CT superior to serum CEA in detection of colorectal cancer and its recurrence

The aim of this study was to examine whether positron emission tomography (PET)/computed tomography (CT) can detect more cases of colorectal cancer (CRC) than serum carcinoembryonic antigen (CEA), both at initial staging and during surveillance for recurrence. A retrospective review of 639 CRC patients imaged with PET/CT was performed. PET/CT was superior to serum CEA in detecting CRC, identifying 2.5 times as many CRC at initial staging compared to serum CEA and 1.5 times as many CRC recurrences. The current guideline recommendations of utilizing PET/CT only in the context of a rising serum CEA will miss more than one third of all CRC recurrences.

Diagnostic Accuracy of Elevated Serum Carcinoembryonic Antigen for Recurrence in Postoperative Stage II Colorectal Cancer Patients: Comparison With Stage III

Purpose

Elevated levels of serum carcinoembryonic antigen (CEA) following a curative resection of colorectal cancer (CRC) indicate recurrence; however, the levels of CEA may be elevated above the normal limit without recurrence. The aim of this study is to analyze the diagnostic accuracy of elevated serum CEA for predicting recurrence in postoperative stage II and stage III CRC patients.

Methods

A total of 336 stage II and stage III CRC patients who underwent a curative resection between January 2005 and October 2009 were enrolled. Sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), likelihood ratios and post-test probabilities of recurrence associated with elevated CEA were analyzed and compared.

Results

The median follow-up duration was 45 months (36 to 134 months). Twenty-seven of 189 stage II patients (14.3%) and 52 of 147 stage III patients (35.4%) developed recurrence during the follow-up period. Sensitivities, specificities, PPVs, and NPVs of elevated CEA were 37.0%, 91.4%, 41.7%, and 89.7%, respectively, in stage II patients and 46.2%, 90.5%, 72.7%, and 75.4% in stage III patients. Post-test probabilities of recurrence associated with elevated CEA were 41.8% in stage II patients and 71.9% in stage III patients.

Conclusion

The predictive performance of the probability of recurrence associated with elevated serum CEA after a curative resection in stage II CRC patients is lower than that in stage III CRC patients.

Prognostic significance of the decreased rate of perioperative serum carcinoembryonic antigen level in the patients with colon cancer after a curative resection

Purpose

The serum level of carcinoembryonic antigen (CEA) is a clinical prognostic factor in the follow-up evaluation of patients with colon cancer. We aimed to evaluate the prognostic significance of the rate of decrease of the perioperative serum CEA level in patients with colon cancer after a curative resection.

Methods

A total of 605 patients who underwent a curative resection for colon cancer between January 2000 and December 2007 were enrolled retrospectively. The rate of decrease was calculated using the following equation: ([preoperative CEA - postoperative CEA]/[preoperative CEA] ×100).

Results

In the group with a preoperative serum CEA level of >5 ng/mL, the normalized group with a postoperative serum CEA level of ≤5 ng/mL showed a better overall survival (OS) rate and disease-free survival (DFS) rate than those of the non-normalized group (P ≤ 0.0001). The "cutoff values" of the rate of decrease in the perioperative serum CEA that determined the OS and the DFS were 48.9% and 50.8%, respectively. In the multivariate analysis of preoperative serum CEA levels >5 ng/mL, the prognostic factors for the OS and the DFS were the cutoff value (P < 0.0001) and the pN stage (P < 0.0001).

Conclusion

A rate of decrease of more than 50% in the perioperative serum CEA level, as well as the normalization of the postoperative serum CEA level, may be useful factors for determining a prognosis for colon cancer patients with high preoperative CEA levels.

Individualized Cutoff Value of the Preoperative Carcinoembryonic Antigen Level is Necessary for Optimal Use as a Prognostic Marker

Purpose

Carcinoembryonic antigen (CEA) is an important prognostic marker in colorectal cancer (CRC). However, in some stages, it does not work. We performed this study to find a way in which preoperative CEA could be used as a constant prognostic marker in harmony with the TNM staging system.

Methods

Preoperative CEA levels and recurrences in CRC were surveyed. The distribution of CEA levels and the recurrences in each TNM stage of CRC were analyzed. An optimal cutoff value for each TNM stage was calculated and tested for validity as a prognostic marker within the TNM staging system.

Results

The conventional cutoff value of CEA (5 ng/mL) was an independent prognostic factor on the whole. However, when evaluated in subgroups, it was not a prognostic factor in stage I or stage III of N2. A subgroup analysis according to TNM stage revealed different CEA distributions and recurrence rates corresponding to different CEA ranges. The mean CEA levels were higher in advanced stages. In addition, the recurrence rates of corresponding CEA ranges were higher in advanced stages. Optimal cutoff values from the receiver operating characteristic curves were 7.4, 5.5, and 4.5 ng/mL for TNM stage I, II, and III, respectively. Those for N0, N1, and N2 stages were 5.5, 4.8, and 3.5 ng/mL, respectively. The 5-year disease-free survivals were significantly different according to these cutoff values for each TNM and N stage. The multivariate analysis confirmed the new cutoff values to be more efficient in discriminating the prognosis in the subgroups of the TNM stages.

Conclusion

Individualized cutoff values of the preoperative CEA level are a more practical prognostic marker following and in harmony with the TNM staging system.

Characterization of the timing and prevalence of receptor tyrosine kinase expression changes in oesophageal carcinogenesis

Despite being common in epithelial malignancies, the timing of receptor tyrosine kinase (RTK) up-regulation is poorly understood and therefore hampers the identification of the receptor to target for effective treatment. We aimed to determine if RTK expression changes were early events in carcinogenesis. Oesophageal adenocarcinoma and its pre-invasive lesion, Barrett's oesophagus, were used for immunohistochemical analysis of the RTK panel, EGFR, ErbB2, ErbB3, Met, and FGFR2, by utilizing a cohort of patients with invasive disease (n = 367) and two cohorts with pre-invasive disease, one cross-sectional (n = 110) and one longitudinal in time (n = 91). The results demonstrated that 51% of oesophageal adenocarcinomas overexpressed at least one of the RTK panel, with 21% of these overexpressing multiple receptors. Up-regulation of RTK expression was an early event corresponding with low-grade dysplasia development (25% in areas without dysplasia versus 63% in low-grade dysplasia, p < 0.001). There was a trend for an increase in the prevalence of concomitant overexpression of multiple receptors as intestinal metaplasia progressed to low-grade dysplasia, 7% versus 10%; and from low-grade dysplasia to high-grade dysplasia, 10% versus 19% (p = 0.06 and 0.24, respectively). The timing of receptor up-regulation varied; FGFR, ErbB2, and Met overexpression occurred as dysplasia first developed, whilst EGFR overexpression was predominately seen in invasive disease and ErbB3 overexpression was uniformly rare. We provide evidence for a frequent and early role for multiple different RTKs in oesophageal carcinogenesis. Given the early timing of receptor deregulation, inhibiting RTKs in pre-invasive disease may also represent a novel and effective chemopreventive strategy.

Inflammation-based prognostic system predicts survival after surgery for stage IV colorectal cancer

BACKGROUND

The aim of this study was to estimate whether the Glasgow prognostic score (GPS) is useful for predicting the survival of patients after surgery for stage IV colorectal cancer (CRC).

METHODS

The GPS was calculated on the basis of admission data as follows: patients with both an increased C-reactive protein (CRP) level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL) were allocated a score of 2, and patients showing one or none of these abnormalities were allocated a score of 1 or 0, respectively.

RESULTS

A total of 108 patients with stage IV CRC were enrolled. Although multivariate analyses showed that tumor pathology, subclass of stage IV CRC, and the GPS were associated with overall survival, the GPS could divide the patients into 3 independent groups showing significant differences in postoperative survival (P = .018).

CONCLUSIONS

The GPS is not only one of the most significant clinical characteristics associated with the overall survival of patients with stage IV CRC, but also a useful indicator that is capable of dividing such patients into 3 independent groups before surgery.

Prognostic value of circulating cytokines for stage III colon cancer

BACKGROUND

This study was to determine preoperative serum levels of epidermal growth factor (EGF), interleukin-6 (IL-6), and C-reactive protein (CRP) in stage III colon cancer and correlate them with disease status and prognosis. The circulating EGF in correlation with primary site epidermal growth factor receptor (EGFR) was also evaluated.

METHODS

Seventy-seven patients with curatively resected stage III colon cancer were selected for analysis. Enzyme-linked immunosorbent assay was used to determine EGF and IL-6 serum levels, and serum CRP levels were measured via immunoturbidimetry. EGFR expression was observed with immunohistochemical studies.

RESULTS

The median levels of EGFR, IL-6, and CRP were 189.4 pg/mL, 9.09 pg/mL, and 1.4 mg/mL, respectively. The factors related to recurrence with statistical significance included positive node status (P = 0.041), lymphovascular invasion (P = 0.001), and preoperative IL-6 level ≥9 pg/mL (P = 0.020). CRP and EGF levels were not significantly associated with disease-free survival rates (P = 0.438 and P = 0.309, respectively). Multivariate analysis using Cox's proportion model revealed that lymph node status was the single independent prognostic factor for predicting time until recurrence (odds ratio, 4.99; 95% confidence interval, 1.09-22.91; P = 0.038).

CONCLUSION

IL-6 expression in stage III colon cancer patients appears to be a prognostic marker of tumor behavior. No correlations between serum EGF concentrations and tumor EGFR positivity were found in this study.

Clinical significance of serial serum carcinoembryonic antigen values for treating rectal cancer with preoperative chemoradiotherapy

Purpose

Preoperative chemoradiotherapy is now widely accepted to treat rectal cancer; however, the prognosis for rectal cancer patients during and after chemoradiotherapy must be determined. The aim of this study was to evaluate the serial serum carcinoembryonic antigen (s-CEA) samples in patients with rectal cancer who underwent radical surgery after concurrent chemoradiotherapy (CRT).

Methods

This study evaluated 236 patients with rectal cancer who received preoperative CRT followed by curative surgery between June 2005 and June 2010. We measured the patient's s-CEA levels pre-CRT, post-CRT and post-surgery. Patients were classified into four groups according to their s-CEA concentrations (group 1, high, high, high; group 2, high, high, normal; group 3, high, normal, normal; group 4, normal, normal, normal). We analyzed the clinicopathologic factors and the outcomes among these groups.

Results

Of the 236 patients, 12 were in group 1, 31 were in group 2, 67 were in group 3, and 126 were in group 4. The 3-year disease-free survival rate in group 1 was poorer than those in group 3 (P = 0.007) and group 4 (P < 0.001). In a univariate analysis, type of surgery, clinical N stage, pathologic T or N stage, lymphovascular invasion, perineural invasion, and CEA group were prognostic factors. A multivariate analysis revealed that type of surgery, pathologic T stage, and lymphovascular invasion were independent prognostic factors; however, no statistical significance was associated with the CEA group.

Conclusion

High pre-CRT, post-CRT, and post-surgery s-CEA levels in patients with rectal cancer were associated with high rates of systemic recurrence and poor survival. Therefore, patients with sustained high s-CEA levels during CRT require careful monitoring after surgery.

Ion chromatography based urine amino Acid profiling applied for diagnosis of gastric cancer

Aim. Amino acid metabolism in cancer patients differs from that in healthy people. In the study, we performed urine-free amino acid profile of gastric cancer at different stages and health subjects to explore potential biomarkers for diagnosing or screening gastric cancer. Methods. Forty three urine samples were collected from inpatients and healthy adults who were divided into 4 groups. Healthy adults were in group A (n = 15), early gastric cancer inpatients in group B (n = 7), and advanced gastric cancer inpatients in group C (n = 16); in addition, two healthy adults and three advanced gastric cancer inpatients were in group D (n = 5) to test models. We performed urine amino acids profile of each group by applying ion chromatography (IC) technique and analyzed urine amino acids according to chromatogram of amino acids standard solution. The data we obtained were processed with statistical analysis. A diagnostic model was constructed to discriminate gastric cancer from healthy individuals and another diagnostic model for clinical staging by principal component analysis. Differentiation performance was validated by the area under the curve (AUC) of receiver-operating characteristic (ROC) curves. Results. The urine-free amino acid profile of gastric cancer patients changed to a certain degree compared with that of healthy adults. Compared with healthy adult group, the levels of valine, isoleucine, and leucine increased (P < 0.05), but the levels of histidine and methionine decreased (P < 0.05), and aspartate decreased significantly (P < 0.01). The urine amino acid profile was also different between early and advanced gastric cancer groups. Compared with early gastric cancer, the levels of isoleucine and valine decreased in advanced gastric cancer (P < 0.05). A diagnosis model constructed for gastric cancer with AUC value of 0.936 tested by group D showed that 4 samples could coincide with it. Another diagnosis model for clinical staging with an AUC value of 0.902 tested by 3 advanced gastric cancer inpatients of group D showed that all could coincide with the model. Conclusions. The noticeable differences of urine-free amino acid profiles between gastric cancer patients and healthy adults indicate that such amino acids as valine, isoleucine, leucine, methionine, histidine and aspartate are important metabolites in cell multiplication and gene expression during tumor growth and metastatic process. The study suggests that urine-free amino acid profiling is of potential value for screening or diagnosing gastric cancer.

Investigation of nonspecific cross-reacting antigen 2 as a prognostic biomarker in bone marrow plasma from colorectal cancer patients

Carcinoembryonic antigen (CEA) is still the only routinely used biomarker in colorectal cancer (CRC), but its utility is hampered by poor specificity and sensitivity, and the search for novel biomarkers is highly warranted. The nonspecific cross-reacting antigen 2 (NCA-2), a truncated CEA species molecule which is transcribed from the same gene, has been suggested as an alternative biomarker to CEA. In the present work, specific immunofluorometric assays were used for detection of NCA-2 and full-length CEA in bone marrow plasma from 277 CRC patients to assess their value as prognostic biomarkers, and detection was also performed in tumor tissue and a CRC cell line. Elevated plasma CEA was associated with advanced tumor stage at diagnosis and adverse patient outcome, while for NCA-2, although the same trends were observed, no additional prognostic information was gained. While specific detection of NCA-2 was clearly achieved in plasma samples, cross-reactivity with full-length CEA was observed when the antigen was exposed to common fixation chemicals. The results from this study indicate that NCA-2 is probably not a prognostic biomarker in CRC and, furthermore, underline the issue of antibody specificity when investigating CEA species molecules.

Early postoperative CEA level is a better prognostic indicator than is preoperative CEA level in predicting prognosis of patients with curable colorectal cancer

PURPOSE

Carcinoembryonic antigen (CEA) measurements performed preoperatively and during the early postoperative period were examined prospectively to assess their prognostic value for colorectal cancer (CRC) patients receiving curative surgery.

METHODS

Between 2000 and 2004, 1,361 patients with CRC who underwent curative surgery at the Taipei Veterans General Hospital were enrolled prospectively. CEA was measured prior to surgery and during the third or fourth postoperative week. The endpoint was length of postoperative disease-free survival, and prognostic importance was determined using the log-rank test and Cox regression hazard model.

RESULTS

Six hundred (44.1%) CRC patients had high CEA concentrations preoperatively, and 188 (13.8%) patients retained high values postoperatively. Within the median follow-up period of 61 (6-108) months, CRC recurred in 313 patients. By univariate analysis TNM staging, tumor differentiation, lymphovascular invasion, preoperative CEA concentration, and postoperative CEA concentration affected the outcome. By multivariate analysis, the prognostic importance of postoperative CEA was retained (95% CI, 1.73-3.01; HR = 2.28) but that of preoperative CEA was lost (95% CI, 0.82-1.33; HR = 1.05). CRC recurred earlier in patients with high postoperative CEA concentrations; metastasis to the liver was common (72.3%) among patients in this group.

CONCLUSIONS

Early postoperative CEA concentration is an independent prognostic factor for CRC. Patients with high postoperative CEA values should receive aggressive follow-up examinations for early relapse of CRC, with special attention paid to recurrence at the liver.

Increased plasma proteasome chymotrypsin-like activity in patients with advanced solid tumors

The chymotrypsin-like (ChT-L) activity is one of the key regulators of intracellular protein degradation. Elevated proteasome ChT-L activity has recently been reported in plasma of patients with leukemia and myelodysplastic syndrome and suggested to have a prognostic significance. The aim of the present study was to evaluate plasma proteasome ChT-L activity in patients with newly diagnosed solid tumors at early and advanced stages of the disease. The activity was assayed using the fluorogenic peptide substrate, Suc-Leu-Leu-Val-Tyr-AMC, in a cohort of 155 patients with early/advanced rectal (n=43/29), gastric (n=6/13), and breast (n=37/27) cancer and compared with that in normal individuals (n=55). The median plasma proteasome ChT-L activity was elevated by 20-32% in patients with advanced stage of rectal, gastric, and breast cancer compared with healthy donors. The difference turned out to be statistically significant (P<0.001). By contrast, values in patients with early stage of malignancies were not significantly different from those observed in normal individuals. We also found that plasma proteasome activity correlated with serum carcinoembryonic antigen levels in the group of patients with rectal cancer (r=0.433, P<0.05). Elevated plasma proteasome ChT-L activity is indicative of advanced stage of rectal, gastric, and breast cancer. However, the activity does not seem to be a parameter with clinically relevant potential in terms of early detection of cancer in this subset of patients.

C-stage in colon cancer: implications of carcinoembryonic antigen biomarker in staging, prognosis, and management

BACKGROUND

The American Joint Committee on Cancer (AJCC) has proposed the inclusion of pretreatment serum carcinoembryonic antigen (CEA) level (C-stage) into the conventional TNM staging system of colon cancer. We assessed the prognosis of various stages of colon cancer after such an inclusion.

METHODS

Data for all patients (N = 17 910) diagnosed with colonic adenocarcinoma (AJCC stages I, IIA, IIB, IIC, IIIA, IIIB, IIIC, and IV, based on TNM staging system) between January 1, 2004, and December 31, 2004, with a median follow-up of 27 months (range 0-35 months), were collected from the Surveillance, Epidemiology, and End Results database. C-stage (C0-stage = normal CEA level; C1-stage = elevated CEA level) was assigned to all patients with available CEA information (n = 9083). Multivariable analyses using Cox proportional hazards models were used to identify independent factors associated with prognosis. Prognosis of overall stages (AJCC stages I-IV and C0 or C1) was analyzed using Kaplan-Meier survival curves. All statistical tests were two-sided.

RESULTS

C1-stage was independently associated with a 60% increased risk of overall mortality (hazard ratio of death = 1.60, 95% confidence interval = 1.46 to 1.76, P < .001). Overall survival was decreased in patients with C1-stage cancer compared with C0-stage cancer of the respective overall stages (P < .05). Similarly, decreased overall survival was noted in patients with stage I C1 cancer compared with stage IIA C0 or stage IIIA C0 cancer (P < .001), in patients with stage IIA C1 cancer compared with stage IIIA C0 (P < .001), and in patients with stage IIB C1 or stage IIC C1 cancer compared with stage IIIB C0 cancer (P < .001).

CONCLUSIONS

C-stage was an independent prognostic factor for colon cancer. The results support routine preoperative CEA testing and C-staging upon diagnosis of colon cancer and the inclusion of C-stage in the conventional TNM staging of colon cancer.

Predictive markers of colorectal cancer liver metastases

Liver metastases are the most common site of distant failure after curative resection of colorectal cancer and a source of significant cancer-related morbidity and mortality. Currently, imaging and conventional histopathologic features, such as T-stage and N-stage, are used by clinicians to inform prognosis and guide adjuvant treatment to reduce the risk of developing distant metastases. However, these tools only have a moderate ability to predict the development of liver metastases. Novel methods, including the detection of circulating tumor cells and carcinoembryonic antigens in serum, have been developed, and their prognostic and predictive characteristics have been assessed. In addition, several molecular and genetic markers in the primary tumor have been studied. Unfortunately, these studies are often small and their results have been mixed, yielding no consistent sets of externally validated predictors of colorectal liver metastases. For widespread clinical relevance, future tests need to be independently carried out on large independent patient samples.

The prognostic significant of percentage drop in serum CEA post curative resection for colon cancer

OBJECTIVE/BACKGROUND

This study aimed to analyze the hypothesis that increased percentage drop in serum CEA post curative resection for colon cancer is associated with improved survival.

METHODS

Five hundred thirty three patients who underwent colon resection with a curative intent were retrospectively analyzed for their pre- and postoperative CEA levels. The disease-free and overall survival curves were calculated using Kaplan Meier analysis to evaluate cancer related outcomes. For multivariate analysis, the Cox regression model was used.

RESULTS

The estimated 5-year overall survival for the preoperative serum CEA > 5 ng/mL group with respect to a postoperative CEA level drop rate of 40%, 50% and 60% were 72.9%, 80.9% and 81.8%, respectively. The estimated 5-year overall survival for the preoperative serum CEA ≤ 5 ng/mL group with respect to each postoperative CEA level drop rate were 86.6%, 97.1% and 97.7%, respectively (P = 0.257, P = 0.092 and P = 0.073, respectively). The prognostic factors for poor survival were the depth of invasion (p = 0.042, hazard ratio: 2.617, 95% CI = 1.021-3.012) and lymph node metastasis (p = 0.008, hazard ratio: 2.249, 95% CI = 1.231-4.111). A 60% drop of the CEA level was an independent prognostic factor for survival (p = 0.001, hazard ratio: 2.954, 95% CI = 1.686-5.176) for patients with a preoperative CEA level > 5 ng/mL.

CONCLUSION

Determining the preoperative CEA level and the early postoperative percent drop of the serum CEA level may be a helpful factor for the prognosis of colon cancer patients. However, the percent drop from the pre to postoperative CEA level from the normal range was not associated with survival difference.