Predictive value of carcinoembryonic antigen and carbohydrate antigen 19-9 related to downstaging to stage 0-I after neoadjuvant chemoradiotherapy in locally advanced rectal cancer

Promises and Challenges of Predictive Blood Biomarkers for Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy

The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer both the advantage to be easily accessed and followed over time. In recent years, biomarkers such as proteins, blood cells, or nucleic acids have been investigated for their predictive value in oncology. We conducted a comprehensive literature review with the aim to summarize the status of circulating biomarkers predicting response to CRT in LARC. Forty-nine publications, of which forty-seven full-text articles, one review and one systematic review, were retrieved. These studies evaluated circulating markers (CEA and CA 19-9), inflammatory biomarkers (CRP, albumin, and lymphocytes), hematologic markers (hemoglobin and thrombocytes), lipids and circulating nucleic acids (cell-free DNA [cfDNA], circulating tumor DNA [ctDNA], and microRNA [miRNA]). Post-CRT CEA levels had the most consistent association with tumor response, while cfDNA integrity index, MGMT promoter methylation, ERCC-1, miRNAs, and miRNA-related SNPs were identified as potential predictive markers. Although circulating biomarkers hold great promise, inconsistent results, low statistical power, and low specificity and sensibility prevent them from reliably predicting tumor response following CRT. Validation and standardization of methods and technologies are further required to confirm results.

Multiparametric MRI-based Radiomics approaches on predicting response to neoadjuvant chemoradiotherapy (nCRT) in patients with rectal cancer

PURPOSE

To investigate the value of multiparametric MRI-based radiomics on predicting response to nCRT in patients with rectal cancer.

METHODS

This study enrolled 193 patients with pathologically confirmed LARC who received nCRT treatment between Apr. 2014 and Jun. 2018. All patients underwent baseline T1-weighted (T1W), T2-weighted (T2W) and T2-weighted fat-suppression (T2FS) MRI scans before neoadjuvant chemoradiotherapy. Radiomics features were extracted and selected from the MRI data to establish the radiomics signature. Important clinical predictors were identified by Mann-Whitney U test and Chi-square test. The nomogram integrating the radiomics signature and important clinical predictors was constructed using multivariate logistic regression. Prediction capabilities of each model were assessed with receiver operating characteristic (ROC) curve analysis. Performance of the nomogram was evaluated by its calibration and potential clinical usefulness.

RESULTS

For the prediction of good response (GR) and pathologic complete response (pCR), the developed radiomics signature comprising 10 and 7 features, respectively, were significantly associated with the therapeutic response to nCRT. The nomogram incorporating the radiomics signature and important clinical predictors (CEA and CA19-9 for predicting GR; CEA, posttreatment length and posttreatment thickness for predicting pCR) achieved favorable prediction efficacy, with AUCs of 0.918 (95% confidence interval [CI]: 0.867-0.971, Sen = 0.972, Spe = 0.828) and 0.944 (95% CI: 0.891-0.997, Sen = 0.943, Spe = 0.828) in the training and validation cohort for predicting GR, respectively; with AUCs of 0.959 (95% CI: 0.927-0.991, Sen = 1.000, Spe = 0.833) and 0.912 (95% CI: 0.843-0.982, Sen = 1.000, Spe = 0.815) in the training and validation cohort for predicting pCR, respectively. Decision curve analysis confirmed potential clinical usefulness of our nomogram.

CONCLUSIONS

This study demonstrated that the MRI-based radiomics nomogram is predictive of response to nCRT and can be considered as a promising tool for facilitating treatment decision-making for patients with LARC.

Prognostic Impact of Pretreatment Elevated and Normalized Carcinoembryonic Antigen Levels After Neoadjuvant Chemoradiotherapy in Resected Locally Advanced Rectal Cancer Patients

Purpose

The prognostic significance of pretreatment elevated and normalized CEA after neoadjuvant chemoradiotherapy (nCRT) was evaluated.

Materials and Methods

The characteristics of 951 locally advanced rectal cancer patients with nCRT were retrieved and were analyzed retrospectively. Pretreatment CEA levels were defined as CEA evaluated one week prior to the nCRT. CEA after nCRT was deemed as CEA measured one week before surgery. The normal CEA levels were set at <5 ng/mL. The normal CEA group was defined as patients with normal pretreatment CEA levels. The normalized CEA group was defined as patients with elevated pretreatment CEA levels and normal CEA levels after nCRT. The elevated CEA group was defined as patients with elevated pretreatment CEA levels and elevated CEA levels after nCRT.

Results

Compared with the elevated CEA group, the normalized CEA group was associated with better overall survival (OS) (HR: 0.625, 95%CI: 0.416-0.938, P=0.022). There was no difference between the normalized CEA group and the normal CEA group (HR: 1.143, 95%CI: 0.84-1.557, P=0.395).

Conclusion

In conclusion, the study indicated that OS of the normalized CEA group and the normal CEA group was better than the elevated CEA group.

Serum Apolipoprotein A-I Predicts Response of Rectal Cancer to Neoadjuvant Chemoradiotherapy

Background

Serum lipids have been reported as prognosticators for malignancies, including rectal cancer (RC). Yet, their value in predicting the response of RC to neoadjuvant chemoradiotherapy (NACRT) remains unknown. This study aimed to assess the predictive abilities of serum lipids for a bad response, and to build a serum lipid-based prediction model.

Methods

In total, 751 patients diagnosed with stage cII–III RC and treated with NACRT plus surgery from January 2007 to August 2018 were retrospectively reviewed and randomly divided into two data sets, in a ratio of 1:1. Receiver operating characteristics (ROC) analysis was conducted in the development set to select possible predictors of bad NACRT response from pathoclinical factors, including serum lipids. Multivariate logistic regression was conducted to further determine independent predictors, which were then used to develop a prediction index (PI). Finally, the PI was verified in the validation set, through ROC analysis and chi-squared test.

Results

Five independent predictors were identified: tumor length ≥4 cm, cT4 stage, carcinoembryonic antigen ≥5.0 ng/mL, irradiation with three-dimensional conformal radiotherapy technique, and apolipoprotein A-I ≤1.20 g/L. Each of them was assigned a number of points. In the validation set, the area under the curve of PI appeared as 0.642 (95% confidence interval 0.586–0.697). The sensitivity, specificity, positive and negative predictive values, and concordance were 72.3%, 52.3%, 63.8%, 61.9%, and 63.0%, respectively.

Conclusion

Serum apolipoprotein A-I was found to correlate negatively with the RC response to NACRT. It could serve as a biomarker for guiding individualized treatment and a potential target for improving sensitivity to chemoradiation.

Prognostic Value of Pretreatment Serum CA199 in Patients with Locally Advanced Rectal Cancer Treated with CRT Followed by TME with Normal Pretreatment Carcinoembryonic Antigen Levels

BACKGROUND

Elevated pretreatment carcinoembryonic antigen (CEA) levels are related to poor prognosis in patients with locally advanced rectal cancer (LARC) treated with neo-CRT followed by TME. In patients with normal pretreatment CEA levels, the prognostic significance of carbohydrate antigen 199 (CA199) is controversial.

OBJECTIVES

The aim of this study was to explore the prognostic value of pretreatment serum CA199 in patients with LARC who had normal pretreatment CEA levels treated with neo-CRT followed by curative surgery.

METHODS

A retrospective study of 456 patients with LARC treated with neo-CRT followed by TME between January 2006 and May 2017 was performed. We employed the maximal χ2 method to determine the CA199 threshold of 9.1 U/mL based on the difference in survival and divided patients into 2 groups. Group 1: patients with pretreatment s-CEA < 5 ng/mL and CA199 ≥ 9.1 U/mL. Group 2: patients with pretreatment s-CEA < 5 ng/mL and CA199 < 9.1 U/mL. Overall survival (OS) across CA199 was assessed using Cox proportional hazard regression models (PS:CEA ≥ 5 ng/mL was seen as elevated).

RESULTS

Multivariate analyses demonstrated that the following factors were significantly related to OS in patients with LARC with normal pretreatment CEA levels: ypT (odds ratio [OR] 1.863, p = 0.030), ypN (OR 1.622, p = 0.026), and pretreatment CA199 levels (OR 1.886, p = 0.048).

CONCLUSION

Pretreatment CA199 is an independent factor for OS in patients with LARC with normal pretreatment CEA levels, which may reach the clinic to guide individualized decision-making.

Correlation Between Baseline Serum Tumor Markers and Clinical Characteristic Factors in Patients with Advanced Pancreatic Cancer

PURPOSE

In pancreatic cancer (PC), CA 19-9, CEA and CA 125 are the most widely used tumor markers. The aim of this study was to explore the prognostic significance of baseline levels of serum CA 19-9, CEA, and CA 125, and to evaluate the clinical significance of these markers in PC patients.

PATIENTS AND METHODS

A total of 278 patients with advanced PC that had received first-line chemotherapy treatments were examined. Correlation analysis between the tumor markers and clinical characteristics was performed using a Pearson's Chi-squared test or Fisher's exact test. A Pearson's correlation test was utilized to investigate the relationship between tumor markers and peripheral blood parameters. Univariate analysis was estimated using a Kaplan-Meier analysis and compared using a Log rank test. Multivariate analysis was performed using a Cox proportional hazards regression model.

RESULTS

Both individually and collectively, the baseline CA 19-9, CEA and CA 125 levels were positively associated with the primary tumor site (p < 0.01), liver metastasis (p < 0.05), and number of organ metastases (p < 0.05). Furthermore, CA 19-9, CEA and CA 125 were correlated to baseline WBC (p < 0.001) and LDH (p < 0.01) levels. Additionally, CA 19-9 was correlated with years of smoking (p = 0.024); diabetes and years of diabetes (p = 0.012); baseline glycemic levels (p = 0.004); and neutrophil counts (p < 0.001). Moreover, CA 125 levels were associated with the baseline neutrophil counts (p < 0.001) and peritoneal metastasis (p = 0.008). When examining neutrophil, LDH, CA 19-9 and CA 125 levels were found to be associated with overall survival (OS) and shown to be independent prognostic factors.

CONCLUSION

CA 19-9, CEA and CA 125 are correlated with multiple clinical factors. Baseline neutrophil, LDH, CA 19-9 and CA 125 levels are associated with OS and may potentially serve as prognostic factors.

BMI May Be a Prognostic Factor for Local Advanced Rectal Cancer Patients Treated with Long-Term Neoadjuvant Chemoradiotherapy

OBJECTIVE

This study aims to develop feasible nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of the local advanced rectal cancer (LARC) patients who were treated with neoadjuvant chemoradiotherapy (nCRT) and operation.

METHODS

A total of 243 LARC patients undergoing nCRT followed by total mesorectal excision (TME) were enrolled. Preoperative clinical features and postoperative pathological characteristics were collected. A Cox regression analysis was performed, and Cox-based nomograms were developed to predict the OS and CSS. We assessed the predictive performance of the nomogram with concordance index and calibration plots.

RESULTS

A total of 243 patients were included with a median follow-up period of 46 months (range from 9 to 86 months). Cox regression analysis showed that low BMI (BMI < 18.5, HR= 21.739, P < 0.05), high level of preoperative CA19-9 (HR = 3.369, P = 0.036), high ypStage (HR = 19.768, P < 0.001), positive neural invasion (HR = 4.218, P = 0.026) and no adjuvant chemotherapy (HR = 5.495, P < 0.001) were independent predictors of poor OS. Age ≥70 (HR = 2.284, P <0.001), low BMI (BMI < 18.5, HR = 3.906, P < 0.05), positive preoperative CA19-9 (HR = 1.920, P = 0.012), high ypStage (HR = 5.147, P <0.001) and positive neural invasion (HR = 2.873, P = 0.022) were independent predictors of poor CSS. The predictive nomograms were developed to predict the OS and CSS with a C-index of 0.837 and 0.760. Good statistical performance on internal validation was shown by calibration plots.

CONCLUSION

In conclusion, this study demonstrated that BMI was an independent prognostic factor for OS and CSS in LARC patients treated with nCRT followed TME. A nomogram incorporating BMI, neural invasion, pre-CA19-9, ypStage, age, and adjuvant chemotherapy could be helpful to predict the OS and CSS.

Nomogram Predicting Overall Survival of Resected Locally Advanced Rectal Cancer Patients with Neoadjuvant Chemoradiotherapy

PURPOSE

The overall survival (OS) of resected locally advanced rectal cancer patients who underwent neoadjuvant chemoradiotherapy (nCRT) was significantly different, even among patients with the same tumor stage. The nomogram was designed to predict OS of rectal cancer with nCRT and divide the patients into different risk groups.

MATERIALS AND METHODS

Based on materials from 911 rectal cancer patients with nCRT, the multivariable Cox regression model was carried out to select the significant prognostic factors for overall survival. And then, the nomogram was formulated using these independent prognostic factors. The discrimination of the nomogram was assessed by concordance index (C-index), calibration curves and time-dependent area under curve (AUC). The patients respective risk scores were calculated through the nomogram. The best cut-off risk score was calculated to stratify the patients. The survival curves of the two different risk cohorts were performed, which assessed the predictive ability of the nomogram.

RESULTS

Age, cT stage, pretreatment CEA, pretreatment CA19-9, surgery, posttreatment CEA, posttreatment CA19-9, pT stage, pN stage and adjuvant chemotherapy were selected for the construction of the nomogram. And then the nomogram was constructed with independent prognostic factors. The C-index of the nomogram was 0.724, which showed the nomogram provided good discernment. The acceptable agreement between the predictions of nomogram and actual observations was illustrated by calibration plots for 3-, 5- and 10-year OS in the cohort. Time-dependent AUC with 6-fold cross-validation also showed consistent results of the nomogram. Risk group stratification confirmed that the nomogram had great capacity for distinguishing the prognosis.

CONCLUSION

The nomogram was developed and validated to predict overall survival of resected locally advanced rectal cancer patients with nCRT. The proposed nomogram might help clinicians to develop individualized treatment strategies. However, further studies are warranted to optimize the nomogram by finding out other unknown prognostic factors, and more external validation is still required.