[A case of lumbar metastases from rectal cancer successfully treated by UFT plus oral leucovorin (LV) therapy]

A 63-year-old man had undergone a low anterior resection for rectal cancer with multiple liver metastases. Oral UFT (450 mg/day) administration alone was started after the operation. After 6 months post operatively, the patient was diagnosed as anastomosis recurrence because of ileus by abdominal X-ray. Transverse loop colostomy was performed by emergency surgery. After surgery, he suffered from paraplegia for lumbar vertebrae metastases. UFT+LV therapy was started. After chemotherapy a significant reduction of the lymph node and liver metastases and an apparent decrease in CEA and CA19-9 were observed. The patient left the hospital and showed no signs of tumor exacerbation for three months. The patient died of aggravation of primary disease afterwards. The therapy was safe and effective, and has successfully maintained the quality of life (QOL) of this patient.

[A case of liver metastasis of rectal cancer demonstrating complete response for three years to 5-FU/l-leucovorin]

We report a case in which 5-fluorouracil/l-leucovorin (5-FU/l-LV) combination therapy was remarkably effective for non-resectable advanced rectal cancer with multiple liver metastasis. A 68-year-old man complaining of severe abdominal distension and abdominal pain was diagnosed as having ileus due to rectal cancer. We established a diagnosis of non-resectable rectal cancer with multiple liver metastasis and therefore performed only rectal colostomy. Systemic chemotherapy with 5-FU/l-LV was scheduled for a total of 22 courses postoperatively. After the chemotherapeutic regimen, a CT scan and colonofiberscopy revealed the primary lesions had disappeared, and a histological examination of biopsy confirmed that the patient had achieved complete response (CR).

Prognostic Factors Affecting Locally Recurrent Rectal Cancer and Clinical Significance of Hemoglobin

PURPOSE

To investigate potential prognostic factors, including hemoglobin levels before and during radiotherapy, for associations with survival and local control in patients with unirradiated locally recurrent rectal cancer.

PATIENTS AND METHODS

Ten potential prognostic factors were investigated in 94 patients receiving radiotherapy for recurrent rectal cancer: age (<or=68 vs. >or=69 years), gender, Eastern Cooperative Oncology Group performance status (0-1 vs. 2-3), American Joint Committee on Cancer (AJCC) stage (<or=II vs. III vs. IV), grading (G1-2 vs. G3), surgery, administration of chemotherapy, radiation dose (equivalent dose in 2-Gy fractions: <or=50 vs. >50 Gy), and hemoglobin levels before (<12 vs. >or=12 g/dL) and during (majority of levels: <12 vs. >or=12 g/dL) radiotherapy. Multivariate analyses were performed, including hemoglobin levels, either before or during radiotherapy (not both) because these are confounding variables.

RESULTS

Improved survival was associated with better performance status (p<0.001), lower AJCC stage (p=0.023), surgery (p=0.011), chemotherapy (p=0.003), and hemoglobin levels>or=12 g/dL both before (p=0.031) and during (p<0.001) radiotherapy. On multivariate analyses, performance status, AJCC stage, and hemoglobin levels during radiotherapy maintained significance. Improved local control was associated with better performance status (p=0.040), lower AJCC stage (p=0.010), lower grading (p=0.012), surgery (p<0.001), chemotherapy (p<0.001), and hemoglobin levels>or=12 g/dL before (p<0.001) and during (p<0.001) radiotherapy. On multivariate analyses, chemotherapy, grading, and hemoglobin levels before and during radiotherapy remained significant. Subgroup analyses of the patients having surgery demonstrated the extent of resection to be significantly associated with local control (p=0.011) but not with survival (p=0.45).

CONCLUSION

Predictors for outcome in patients who received radiotherapy for locally recurrent rectal cancer were performance status, AJCC stage, chemotherapy, surgery, extent of resection, histologic grading, and hemoglobin levels both before and during radiotherapy.

C-reactive protein as early predictor for infectious postoperative complications in rectal surgery

BACKGROUND

This study evaluated the role of the acute phase C-reactive protein (CRP) in the postoperative course of a large series of rectal resections on the basis of a prospective database. Main focus of this study was the early identification of complications.

MATERIALS AND METHODS

Three hundred eighty-three rectal resections with primary anastomosis for rectal cancer were screened for infectious postoperative complications. Forty-eight complicated cases were identified and matched with 48 patients with an uneventful postoperative course.

RESULTS

In the postoperative setting, CRP peaked on postoperative day (POD) 2 with a median serum CRP of 140 mg/l and gradually declined thereafter in uncomplicated cases. In complicated cases, CRP elevation generally persisted after POD 2, whereas white blood cells and body temperature were within normal range in the early postoperative period. A cutoff CRP value of 140 mg/dl on PODs 3 and 4 resulted in predictive values of 85.7 and 90.5% (adjusted to the prevalence: 37.6 and 50.3%), sensitivities of 80.0 and 54.3%, and specificities of 81.0 and 92.3% for a complicated postoperative course (P<0.001), respectively.

CONCLUSION

Persistent CRP elevation and elevation of serum CRP above 140 mg/dl on PODs 3-4 are predictive of infectious postoperative complications and should prompt intense clinical search for an inflammatory process, especially for an anastomotic leak if pneumonia and wound infection are unlikely or excluded.

Transforming growth factor beta-1 in rectal tumour, mucosa and plasma in relation to radiotherapy and clinical outcome in rectal cancer patients

BACKGROUND

Rectal cancer patients are treated with surgery and sometimes radiotherapy. Transforming growth factor-beta1 (TGF-beta1) acts both as an inhibitor of tumour growth and as a promoter of tumour progression. The aim of this study was to determine the levels of TGF-beta1 in tumour tissue, adjacent mucosa and plasma in rectal cancer patients and relate these to the effect of radiotherapy and clinical outcome.

MATERIALS AND METHODS

One hundred and ten patients scheduled for rectal cancer surgery were included, 49% received pre-operative radiotherapy three-field treatment 5 x 5 Gy. Blood samples and biopsies were taken during surgery and later assayed with enzyme-linked immunosorbent assay for total TGF-beta1 and active TGF-beta1. Patients were then followed for 3 years.

RESULTS

Total and active TGF-beta1 was higher in tumour tissue compared with rectal mucosa (p < 0.0001). Active TGF-beta1 in tumour tissue and rectal mucosa was lower in the irradiated group (p = 0.007; p < 0.0001). Total TGF-beta1 was higher in patients with metastases at primary diagnosis (p = 0.005) compared to patients without. In patients who later developed metastases, the levels of active TGF-beta1 in plasma were lower (p = 0.004). Local recurrence was associated with lower levels of total TGF-beta1 in the rectal mucosa (p = 0.038).

CONCLUSIONS

Higher levels of total TGF-beta1 in tumour tissue at surgery may be indicative of distant metastases, and low levels of active TGF-beta1 in plasma may indicate a risk of developing secondary metastases. Lower levels of total TGF-beta1 in rectal mucosa may influence risk of local recurrence. Measurement of TGF-beta1 in rectal cancer patients may be of clinical use in the future.

[A case of multiple liver metastases from rectal cancer in poor performance status successfully treated with hepatic arterial infusion chemotherapy plus CPT-11]

Hepatic arterial infusion (HAI) chemotherapy is one of the strategies for cases in poor performance status. This is a case report of multiple liver metastases from rectal cancer in poor performance status successfully treated with HAI plus CPT-11. A 59-year-old man who had rectal cancer, multiple liver metastases and para-aortic LN metastasis underwent a laparoscopic rectal anterior resection. He denied receiving postoperative chemotherapy and selected alternative therapy at another clinic. Four months later, he visited our hospital. His liver metastasis and performance status got worse, so HAI of 5-FU 1250 mg/m2 for 5-hour weekly (weekly high-dose 5-FU: WHF) was started at first. After 3 courses, his status improved, so systemic chemotherapy was added. HAI (WHF: 1000 mg/m2) plus CPT-11 (100 mg/m2) was effective, and liver metastases showed a significant reduction (PR) on abdominal CT. HAI plus CPT-11 was effective for a patient of the poor performance status with unresectable liver metastasis.

TIMP-1 is significantly associated with objective response and survival in metastatic colorectal cancer patients receiving combination of irinotecan, 5-fluorouracil, and folinic acid

PURPOSE

Tissue inhibitor of metalloproteinase-1 (TIMP-1) is known to protect cells against apoptosis. We raised the hypothesis that elevated tumor tissue levels and thereby plasma levels of TIMP-1 would predict resistance to apoptosis-inducing chemotherapy.

EXPERIMENTAL DESIGN

Ninety patients with metastatic colorectal cancer were included in the study. Plasma TIMP-1 and serum carcinoembryonic antigen (CEA) were measured in samples obtained before the first cycle of chemotherapy.

RESULTS

Analysis of best objective response (complete or partial response versus stable or progressive disease) showed that patients with low plasma TIMP-1 had higher probability of obtaining an objective response [odds ratio (OR), 3.5; 95% confidence interval (95% CI), 1.4-8.5, P=0.007]. CEA treated as a continuous variable was also a statistically significant predictor of no response (OR, 1.3; 95% CI, 1.0-1.7, P=0.02, area under the curve 0.66) but much less so. Plasma TIMP-1 was the only significant covariate in a multivariable analysis of best objective response (OR, 3.6; 95% CI, 1.4-9.5; P=0.001). Plasma TIMP-1 scored as a continuous variable on the log scale (log(e)) was significantly associated with overall survival [OS; hazard ratio (HR), 3.8; 95% CI, 2.4-5.9; P<0.0001] and with time to progression (TTP; HR, 1.5; 95% CI, 1.0-2.3; P=0.048). Multivariable analysis showed that plasma TIMP-1 was significant for OS when including routine clinical baseline covariates (HR, 3.5; 95% CI, 2.1-5.8; P<0.0001). A multivariable analysis including TTP instead of OS showed that only plasma TIMP-1 was retained in the model (HR, 1.5). CEA was not significantly associated with TTP or OS when TIMP-1 was included in the model.

CONCLUSION

This study shows that plasma TIMP-1 levels are significantly and independently associated with objective response, TTP, and OS in patients with metastatic colorectal cancer receiving combination chemotherapy.

Serum C-peptide, IGFBP-1 and IGFBP-2 and risk of colon and rectal cancers in the European Prospective Investigation into Cancer and Nutrition

Western style diets and lifestyles are associated with increasing rates of obesity, diabetes and insulin resistance. Higher circulating insulin levels may modulate cell proliferation and apoptosis either directly or indirectly by increasing the bioactivity of IGF-I and decreasing the bioactivity of some of its binding proteins. The objective of this study was to determine the association of increasing levels of serum C-peptide, a biomarker of pancreatic insulin secretion, and IGF binding proteins (IGFBP) -1 and -2 with colorectal cancer risk in a case-control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC), a large cohort involving 10 Western European countries. A total of 1,078 colorectal cancer cases were matched (age, date of blood donation, fasting status, gender, study center) to an equal number of control subjects. Relative cancer risks were estimated using conditional logistic regression models. Serum C-peptide concentration was positively associated with an increased colorectal cancer risk for the highest versus the lowest quintile (OR=1.56, 95% CI=1.16-2.09, p(trend)<0.01), which was slightly attenuated after adjustment for BMI and physical activity (OR=1.37, 95% CI=1.00-1.88, p(trend)=0.10). When stratified by anatomical site, the cancer risk was stronger in the colon (OR=1.67, 95% CI=1.14-2.46, p(trend)<0.01) than in the rectum (OR=1.42, 95% CI=0.90-2.25, p(trend)=0.35). The cancer risk estimates were not heterogeneous by gender or fasting status. No clear colorectal cancer risk associations were observed for IGFBP-1 or -2. This large prospective study confirms that hyperinsulinemia, as determined by C-peptide levels, is associated with an increased colorectal cancer risk.

Clinical and pathologic evaluation of patients with recurrence of colorectal cancer five or more years after curative resection

PURPOSE

This study was designed to evaluate the characteristics of recurrences that occur five or more years after curative resection for colorectal cancer.

METHODS

This study included a total of 352 patients who were confirmed as having recurrence after curative resection for colorectal cancer during the period from January 1995 to December 2000. Of the 352 patients, 231 had early recurrence (less than 2 years after operation), 103 had intermediate recurrence (2-5 years after operation), and 18 had late recurrence (more than 5 years after operation). The clinicopathologic findings of the patients with late recurrence were compared with those of the other two recurrence groups, with special reference to the pattern of recurrence.

RESULTS

The rate of late recurrence was 1.2 percent. In the late recurrence group, males outnumbered females by a ratio of 3.5:1 and the mean level of preoperative carcinoembryonic antigen was 4.5 ng/ml, whereas that of the early recurrence group was 30.5 ng/ml. All the lesions in the cases with late recurrence except one lesion were located in the left colon or rectum, the tumors were small-sized and polypoid, and well-differentiated adenocarcinomas were more frequently observed. Distant metastasis, especially lung metastasis, was most frequently observed.

CONCLUSIONS

Late recurrent colorectal cancer has some characteristics compared with early or intermediate recurrence. Although recurrence at more than five years postoperatively is not common, its possibility should be considered whenever performing follow-up, and surveillance for lung metastasis is recommended after more than five years of surgery.

[Detection of cytokeratin20 mRNA in peripheral blood from colonic cancer patients by fluorescence quantitative polymerase chain reaction]

OBJECTIVE

To investigate the expression level of cytokeratin20 mRNA (CK20 mRNA) of cancer cells in peripheral blood from colorectal cancer patients, detected by fluorescence quantitative polymerase chain reaction (FQ-PCR), and to evaluate its clinical value.

METHODS

To systemically study the reproducibility, quantitative range and amplification efficiency of CK20 mRNA detection by FQ-PCR, analyze and compare the result consistency with conventional RT-PCR and immunohistochemistry, separately. The expression level of CK20 mRNA of cancer cells in peripheral blood was examined in 136 colorectal cancer cases with or without hepatic metastasis.

RESULTS

The within-run and between-run CV of FQ-PCR to assay CK20 mRNA were 3.6% and 5.3%, respectively, quantitative range was from 10(3) copies/ml to 10(8) copies/ml and amplification efficiency was 87.4%. Comparing with traditional RT-PCR and immunohistochemistry, the Kappa value was 0.87 and 0.83, respectively. The expression level of CK20 mRNA of cancer cells in peripheral blood from colorectal cancer patients was (3.52 +/- 1.47) x 10(4) copies/ml, and the expression positive rate was 48.5%. None was found among the 75 cases in the control group. The positive rate of CK20 mRNA of cancer cells in peripheral blood was 9.5%, 25.0%, 48.8% and 87.5% in the patients at Dukes stage A, B, C and D, respectively (P < 0.05). The positive rate of CK20 mRNA was 87.5% in patients with hepatic metastasis and 32.3% in patients without hepatic metastasis (P < 0.05). CK20 mRNA showed a tendency to decline in 35 cases of colorectal cancer within the 1st, 3rd and 5th week after operation. There was no difference among the data of pre-operation cases and on the 1st, 3rd week (P > 0.05), but a significant difference between pre-operation and the 5th week (P < 0.05).

CONCLUSION

FQ-PCR is a rapid and sensitive method for quantitating CK20 mRNA. The expression of CK20 mRNA of cancer cells in peripheral blood from colorectal cancer patients has a correlation with recurrence and metastasis of the tumors. Detection of CK20 mRNA is helpful to monitor hematogenous dissemination of colorectal cancers.

Evaluation of an inflammation-based prognostic score (GPS) in patients undergoing resection for colon and rectal cancer

BACKGROUND/AIMS

The aim of the study was to examine the value of the combination of an elevated C-reactive protein and hypoalbuminaemia (GPS) in predicting cancer-specific survival after resection for colon and rectal cancer.

MATERIALS AND METHODS

The GPS was constructed as follows: Patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminaemia (<35 g/l) were allocated a score of 2. Patients in whom only one or none of these biochemical abnormalities was present were allocated a score of 1 or 0, respectively.

RESULTS

A GPS of 1 (n = 109) was mainly due to an elevated C-reactive protein concentration and the remainder due to hypoalbuminaemia. In those patients with a GPS of 1 due to hypoalbuminaemia (n = 16), the 3-year overall survival rate was 94% compared with 62% in those patients with a GPS of 1 due to an elevated C-reactive protein concentration (n = 93, p = 0.0094). Therefore, the GPS was modified such that patients with hypoalbuminaemia were assigned a score of 0 in the absence of an elevated C-reactive protein. On univariate analysis of those patients with colon and rectal cancer, the modified GPS (p < 0.0001) was significantly associated with overall and cancer specific survival. On univariate survival analysis of those patients with Dukes B colon and rectal cancer, the modified GPS (p < 0.01) was significantly associated with overall and cancer specific survival.

CONCLUSION

The results of the present study indicate that the GPS, before surgery, predicts overall and cancer-specific survival after resection of colon and rectal cancer.

Toxoplasma gondii antibodies in cancer patients

To determine Toxoplasma gondii antibodies in cancer patients, 267 cancer patients were studied using ELISA and higher positivity rates of T. gondii IgG were detected than the control. The positivity rates of T. gondii IgG in nasopharyngeal carcinoma, rectal cancer groups were significantly higher than the other cancer groups, but the differences in IgM positivity rates were not significant, demonstrating that there is a likely association between T. gondii infection and some kinds of cancer, especially nasopharyngeal carcinoma and rectal cancer.

Preoperative serum levels of c-erbB-2 do not seem to be useful in management of patients with rectal cancer

BACKGROUND AND AIM

Soluble c-erbB-2 oncoprotein has been proven as a useful marker in the management of breast cancer patients, but its value in diagnostics and follow-up of colorectal cancer patients remains controversial. The aim of this study was to evaluate the usefulness of serum c-erbB-2 monitoring in diagnostics and prediction of disease outcome in rectal cancer patients.

MATERIALS AND METHODS

Serum samples from 88 patients with rectal adenocarcinoma before surgery and from 41 healthy controls were tested for the presence of c-erbB-2 oncoprotein by ELISA, and the patients were followed up for at least 5 years after the surgery.

RESULTS

Preoperative serum c-erbB-2 levels were significantly higher in stage IV patients than in healthy controls (P<0.001) and did not show correlation with preoperative CEA levels. Elevated preoperative serum c-erbB-2 levels showed relatively high specificity (88%) and low sensitivity (44%) in the diagnosis of rectal cancer. Elevated preoperative oncoprotein levels were predictive neither for overall survival nor for development of local recurrence/distant metastases.

CONCLUSION

Although preoperative serum c-erbB-2 levels were significantly higher in rectal cancer patients than in healthy controls, the soluble c-erbB-2 does not seem to be useful in the diagnosis of rectal cancer due to its low sensitivity. Preoperative serum levels of this oncoprotein were predictive neither for overall survival nor for local recurrence/distant metastases in rectal cancer patients.

Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer

BACKGROUND

The objective of this study was to identify predictive factors for pathologic complete response and tumor downstaging after preoperative chemoradiation for rectal cancer.

METHODS

Between 1989 and 2004, 562 patients with nonmetastatic rectal adenocarcinoma received preoperative chemoradiation and underwent mesorectal excision. The median radiation dose was 45 Gray (Gy) (range, 19.8-58.6 Gy), 77% of patients received concurrent infusional 5-fluorouracil, 20% of patients received concurrent capecitabine, and 3% of patients received other regimens.

RESULTS

Nineteen percent of patients achieved a pathologic complete response (CR), whereas 20% of patients had only microscopic residual disease at surgery, and 61% of patients had macroscopic residual disease at surgery. Downstaging of the tumor stage occurred in 57% of patients. The results from a univariate analysis indicated that tumor circumferential extent>60% (P=.033) and pretreatment carcinoembryonic antigen (CEA) level>2.5 ng/mL (P=.015) were associated significantly with lower pathologic CR rates. The univariate analysis also indicated that tumor circumferential extent>60% (P=.001), pretreatment CEA level>2.5 ng/mL (P=.006), and distance from the anal verge>5 cm (P=.035) were associated significantly with lower downstaging rates. The results from a multivariate logistic regression analysis indicated that greater circumferential extent of tumor (odds ratio [OR], 0.43; P=.033) independently predicted a lower pathologic CR rate. The multivariate logistic regression analysis also indicated that greater circumferential extent of tumor (OR, 0.49; P=.020) and greater distance from the anal verge (OR, 0.46; P=.010) independently predicted a lower downstaging rate.

CONCLUSIONS

Circumferential extent of tumor, CEA level, and distance from the anal verge predicted for the pathologic response to preoperative chemoradiation for patients with rectal cancer. Therefore, these factors may be used to predict outcomes for patients, to develop risk-adapted treatment strategies, and to target patients who participate in trials of newer therapies.

Matrix metalloproteinases in rectal mucosa, tumour and plasma: response after preoperative irradiation

BACKGROUND

In rectal cancer treatment, preoperative radiotherapy has led to reduction of local recurrence, but it is associated with morbidity and increased risk for secondary tumours. Matrix metalloproteinases (MMPs) are associated with tumour progression through tissue remodeling. The aim of this study was to investigate tissue remodeling after preoperative radiotherapy and to explore possible correlations with clinical outcome.

MATERIALS AND METHODS

Ninety-one patients scheduled for rectal cancer surgery were included; 49% received preoperative radiotherapy three-field treatment, 5 x 5 Gy. Blood samples and biopsies from tumour and adjacent mucosa were taken during surgery. Biopsies and plasma were assayed with ELISA for MMP-1, MMP-2 and MMP-9. Clinical outcome was reviewed focusing on infections, perineal healing, fistula formation, anastomotic dehiscence, small bowel obstruction, local recurrence and distant metastases.

RESULTS

Compared to non-irradiated mucosa, MMP-2 (p < 0.0001), MMP-1 (p = 0.03) and MMP-9 (p = 0.04) were significantly higher in irradiated normal mucosa. Tumour tissue had higher levels of MMP-2 if irradiated (p < 0.0001). A correlation between MMP-2 levels and wound infection (p = 0.02) as well as fistula formation (p = 0.04) was found. MMP-1 in mucosa (p = 0.02) and tumour (p = 0.04) were higher in patients developing distant metastases. Plasma levels were not influenced by irradiation, but MMP-2 was higher in patients who were later developing distant metastases (p = 0.007).

CONCLUSIONS

Extracellular matrix remodeling after radiotherapy seems to be correlated to postoperative morbidity; MMP-2 is associated with both wound infections and fistula formation. High levels of MMP-1 in tumour and mucosa as well as MMP-2 in plasma may be correlated to risk of developing distant metastases.

Prognostic value of preoperative peripheral blood monocyte count in patients with colorectal liver metastasis after liver resection

Prognostic values of leukocyte subset counts in peripheral blood of cancer patients have not yet been fully investigated. We retrospectively examined the relation between preoperative absolute counts of peripheral blood leukocyte subsets and clinicopathologic factors and long-term prognosis in 97 patients with liver metastasis from colorectal cancer who underwent hepatic resection. Median preoperative peripheral blood leukocyte subset counts were as follows: neutrophils 3148/mm3; lymphocytes 1574/mm3; monocytes 380/mm3. Univariate analysis indicated significantly worse 5-year cancer-related survival for patients with a peripheral blood monocyte count >300/mm3 (67.5%) than for patients with a count <or=300/mm3 (36.8%). Multivariate analysis showed a preoperative peripheral blood monocyte count >300/mm3 and preoperative CEA level (>10 ng/ml) to be independent predictive factors for cancer-related survival after hepatic resection. The preoperative peripheral monocyte count correlated positively with white blood cell and neutrophil counts, but not with the tumor number, interval between colorectal and hepatic surgery, or preoperative serum CEA level. Our findings indicate that a preoperative absolute peripheral blood monocyte count >300/mm3 is an independent predictive factor for cancer-related survival of patients with colorectal liver metastasis who have undergone hepatic resection.

Carcinoembryonic antigen (CEA) measurement during follow-up for rectal carcinoma is useful even if normal levels exist before surgery. A retrospective study of CEA values in the TME trial

BACKGROUND

Carcinoembryonic antigen (CEA) as a marker in the follow-up after curative resection of colorectal carcinoma (CRC) is often omitted from follow-up despite guideline recommendations. One reason is the assumption that when a normal CEA value exists before curative resection of CRC, it will neither rise during follow-up. This study investigates this relationship.

METHOD

Data were derived from a study initiated to evaluate treatment regimes for rectal carcinoma (Dutch TME trial, n=1861) from which 954 were eligible for analysis. Recurrent disease occurred in 272 of these patients (29.5%). The pre-operative CEA value was compared to CEA values during follow-up, using threshold values of 2.5 and 5.0 ng/ml.

RESULTS

Normal pre-operative CEA values were present in 63% (CEA<5.0) and 39% (CEA<2.5) of patients with recurrent disease. Patients with a normal pre-operative CEA and recurrent disease had elevated CEA values during follow-up in 41% (CEA<5.0), 50% (CEA<2.5) and in 60% with both threshold values when the last measurement was done within 3 months before recurrent disease was diagnosed.

CONCLUSION

A normal pre-operative CEA is common in patients with rectal carcinoma. CEA does rise due to recurrent disease in at least 50% of patients with normal pre-operative values. Serial post-operative CEA testing cannot be discarded based on a normal pre-operative serum CEA.

Combination of SELDI-TOF-MS and data mining provides early-stage response prediction for rectal tumors undergoing multimodal neoadjuvant therapy

OBJECTIVE

We investigated whether proteomic analysis of the low molecular weight region of the serum proteome could predict histologic response of locally advanced rectal cancer to neoadjuvant radiochemotherapy (RCT).

SUMMARY BACKGROUND DATA

Proteomic analysis of serum is emerging as a powerful new modality in cancer, in terms of both screening and monitoring response to treatment. No study has yet assessed its ability to predict and monitor the response of rectal cancer to RCT.

METHODS

Sequential serum samples from 20 patients undergoing RCT were prospectively collected. Time points sampled were as follows: pretreatment, 24/48 hours, 1 week, 2 weeks, 3 weeks, 5 weeks (last day of RCT), and presurgery. Response to treatment was measured using a 5-point tumor regression grade (TRG) based on the degree of residual tumor to fibrosis. All serum samples were analyzed in duplicate using surface-enhanced laser desorption/ionization-time of flight mass spectrometry (SELDI-TOF-MS). Support vector machine (SVM) analysis of spectra was used to generate a predictive algorithm for each time point based on proteins that were maximally differentially expressed between good and poor responders. This algorithm was then tested using leave-one-out cross validation.

RESULTS

In total, 230 spectra were generated representing all available time points from 9 good responders (TRG 1+2) and 11 poor responders (TRG 3-5). SVM analysis indicated that changes within the serum proteome at the 24/48 hours time point into treatment provided optimal classification accuracy. In more detail, a cohort of 14 protein peaks were identified that collectively differentiated between good and poor responders, with 87.5% sensitivity and 80% specificity.

CONCLUSIONS

Serum proteomic analysis may represent an early response predictor in multimodal treatment regimens of rectal cancer. These data suggest that this novel, minimally invasive modality may be a useful adjunct in the multimodal management of rectal cancer, and in the design of future clinical trials.

[Survival of patients with liver metastasis from colorectal cancer by different modes of therapy: a report of 363 cases]

OBJECTIVE

To evaluate the correlation between different therapies and survival of liver metastasis from colorectal cancer ( LMCC) , and to compare the clinical outcome of synchronous liver metastasis (SLM) with that of metachronous liver metastasis (MLM).

METHODS

The clinical data of 363 patients with LMCC were retrospectively reviewed with focus on the correlation between different therapy and survival.

RESULTS

Of these 363 patients, 160 had SLM and 203 had MLM. Between the SLM and MLM group, there was no significant difference in age, or gender or primary cancer site (P > 0. 05 ), but significant differences were observed in condition of liver metastasis including liver lobe involved, focus number, maximum focus diameters and level of serum CEA and CA199 before therapy(P <0. 05). Ninety-one patients underwent curative hepatic resection, 22 of them in the SLM group and 69 in the MLM group. Mortality rate related to operation was 4. 5% (1/22) in SLM group and 2. 9% (2/69) in MLM group( P < 0.05). All patients were followed until 31/6/2005. The 3-year survival rate was 5. 2% with a median survival time of 10 +/- 1 months for the SLM group, and it wasl6. 4% and 17 +/- 1 months for the MLM group (P<0.01). Regarding to the treatment modalities, the 3-year survival rate was 30. 2% with a median survival time of 26 months for curative hepatic resection group, and it was 0% - 16. 7% and 10 - 17 months for non-operation groups treated by intervention, chemotherapy, radiofrequency therapy, percutaneous ethanol injection and Chinese traditional drugs (P <0. 05, P <0. 01 ).

CONCLUSION

Curative hepatic resection is still the first choice for liver metastasis from colorectal cancer improving the survival significantly. Other non-operative methods also can improve phase II resection rate. Metachronous liver metastasis has higher resection rate and better survival than the synchronous liver one.

Disseminated tumor cells in peripheral blood: a novel marker for therapy response in locally advanced rectal cancer patients undergoing preoperative chemoradiation

PURPOSE

This study was designed to examine whether disseminated tumor cells in peripheral blood of locally advanced rectal cancer patients undergoing preoperative chemoradiation have the potential to serve as a marker for therapy response. Studies suggest that patients with advanced rectal cancer who respond to preoperative chemoradiation most likely benefit from this treatment.

METHODS

From advanced rectal cancer patients undergoing preoperative chemoradiation, peripheral blood was obtained at defined times: before, during, and after chemoradiation and during surgery. Patients were divided into histopathologic responders (ypT0-T2) and nonresponders (ypT3-T4). Cytokeratin 20 and carcinoembryonic antigen reverse transcriptase-polymerase chain reaction were performed to detect disseminated tumor cells. A blood sample was deemed positive for disseminated tumor cells if both carcinoembryonic antigen and cytokeratin 20 were detected.

RESULTS

The overall population (n = 26) showed a positivity rate of 32 percent for disseminated tumor cells before initiation of chemoradiation. Of the responders (n = 8), 63 percent were positive for disseminated tumor cells before chemoradiation, whereas only 18 percent of nonresponders (n = 18) were positive (P = 0.026). From initiation of chemoradiation to the end of surgery, a significant decrease was seen in tumor cell positivity in the blood of responders (P = 0.042). Moreover, the responders represented a trend toward a decrease in tumor cell positivity during chemoradiation (P = 0.079). In contrast, there were no noticeable alterations within the treatment course in nonresponders.

CONCLUSIONS

This prospective proof of principle study demonstrates that locally advanced rectal cancer with preoperative chemoradiation shows different biologic behavior in terms of tumor cell dissemination in peripheral blood when therapy responders compared with nonresponders.

[A case of local recurrence of rectal cancer in long-term responding to combined therapy of low-dose CPT-11 and 5'-DFUR]

A 68-year-old man underwent Miles'operation for advanced rectal cancer. Local recurrence occurred 9 months following the operation. We started the combined therapy of low-dose CPT-11 and doxifluridine (5'-DFUR). CPT-11 was administered at 80 mg/body biweekly and 5'-DFUR was orally administered at 800 mg/day/body on day 3-7. We then reduced the CPT-11 dose to 60 mg/body because of neutropenia. Four months later,we obtained a decrease in the tumor marker (carcinoembryonic antigen: CEA) to the normal serum level, and stopped the medication. However, 3 months later the serum CEA level was increased, and we restarted the same therapy. Six months after restarting this therapy, the serum CEA level decreased to the normal level,and the local recurrence was decreased in size. We finished this combined therapy and changed to 5'-DFUR only. No tumor progression or recurrences in this patient are seen 2 years after completing this combined therapy.

[Multivariate regressive analysis of prognosis of liver metastases from colorectal cancer]

BACKGROUND & OBJECTIVE

It is not very clear about the factors that affect the prognosis of liver metastases from colorectal cancer. This study was to investigate the clinicopathologic factors related to the prognosis of liver metastases from colorectal cancer.

METHODS

The clinicopathologic factors and follow-up data of 197 patients with liver metastases from colorectal cancer, treated from Jan. 1996 to Dec. 2000, were analyzed retrospectively. The prognostic index (PI) of patients was calculated based on the results of multivariate analysis and patients were classified into different hazard groups accordingly.

RESULTS

The overall 1-, 3-, and 5-year survival rates were 59.04%, 17.73%, and 11.48%. Univariate analysis revealed that extrahepatic invasion, primary tumor resection, liver metastasis resection, type of primary tumor, serum CEA concentration, number and size of liver metastases, and distribution of liver metastases were associated with prognosis. Multivariate analysis identified that the resection of liver metastases, serum CEA concentration, number and size of liver metastases were prognostic factors. The patients were classified into high risk, moderate risk, and low risk groups according to the PI value, and there was significant difference in survival rates between each two groups.

CONCLUSIONS

Liver metastasis resection, serum CEA concentration, number and size of liver metastases are important prognostic factors for liver metastases from colorectal cancer. In order to improve the survival rate, liver metastases should be resected for suitable patients. Moreover, PI value could be used to predict the prognosis of patients with liver metastases from colorectal cancer.

Effects of the incubation in vitro with sorbents on serum proteomic pattern and cytokine concentration in cancer patients during chemotherapy--preliminary results

INTRODUCTION

Cancer and treatment by chemotherapy often produce abnormalities in endogenous cytokine, chemokine, and inflammatory mediator production. Sorbent-based adsorption therapies have been used to remove cytokines in diverse human diseases.

AIM

The aim of this study was to evaluate the effects of chemotherapy on serum proteomic pattern and cytokine concentration, and to evaluate the ex vivo feasibility of using sorbents to remove cytokines, chemokines and other proteins in adult cancer patients undergoing chemotherapy with fluorouracil or carboplatin-taxane combinations.

PATIENTS AND METHODS

Serum samples of three female adult patients (one affected by rectal cancer and two by ovarian cancer) were examined before and on the fourth day of the first cycle of chemotherapy with fluorouracil (rectal cancer patient) or carboplatin-taxane combination (ovarian cancer patients). The analysis was performed, by means of luminex technology and with a proteomic approach, on native serum samples, and on the same sera after 2 hours of in vitro incubation with a synthetic based styrenic divinylbenzene resin.

RESULTS

Chemotherapy determined variable effects on serum concentration of cytokines, while the incubation in vitro of patients serum samples with the resin induced a significant decrease (>80%) in serum concentration of different chemokines, cytokines, growth factors and proteins. The proteomic approach, using SDS PAGE and 2-DE highlighted differences in protein expression between sera from healthy controls and cancer patients. Proteomic analysis demonstrated also variations in the expression of proteins, particularly those with low-molecular weight, due to chemotherapy. Finally, the incubation in vitro of serum samples with sorbents induced a general reduction of protein expression. Within the cancer patients maps, 10 spots were chosen for identification with MALDI-TOF analysis.

CONCLUSION

The incubation in vitro with sorbents normalized the over-expression of different proteins and cytokines induced by chemotherapy, suggesting further evaluation as a possible adjuvant treatment.

Prediction of prognosis and surgical indications for pulmonary metastasectomy from colorectal cancer

BACKGROUND

Treatment of pulmonary metastases from colorectal cancer by excision has increased rapidly, but reports on indications and prognostic factors are inconsistent. We sought to identify poor prognostic factors preoperatively and to retrospectively evaluate preoperative clinical indications for surgery.

METHODS

A total of 75 patients with colorectal cancer had pulmonary metastases excised from 1986 to 2003. Tumor size, number, laterality, hilar or mediastinal lymphadenopathy, and carcinoembryonic antigen level were possible risk factors for metastatic tumors, with primary site of colorectal tumor, disease-free interval, and hepatectomy for liver metastasis possible risk factors for primary tumors. Prognostic factors in univariate and multivariate analyses also included age and sex.

RESULTS

Five-year survival rates were 41.3% after pulmonary excision and 73.1% after primary colorectal resection. Three factors identified as significant by univariate log-rank test for overall survival after pulmonary resection were carcinoembryonic antigen (p < 0.0001), tumor laterality (p = 0.0205), and number of pulmonary metastases (p = 0.0028). Multivariate analysis found that carcinoembryonic antigen, tumor number, tumor size, and patient's age were also independent prognostic factors. In contrast, carcinoembryonic antigen, number of metastases, and disease-free interval predicted prognosis after primary colorectal resection. Prior hepatectomy for metastases did not influence prognosis after pulmonary metastasectomy.

CONCLUSIONS

Elevated carcinoembryonic antigen level and multiple metastases are preoperative predictors of poor prognosis after resection of pulmonary metastases from colorectal cancer. Survival rate is sufficient to justify pulmonary metastasectomy if there is no local or distant metastatic lesion other than in the liver; if needed, sequential pulmonary and hepatic metastasectomy can be performed.

Preoperative carcinoembryonic antigen and albumin in predicting survival in patients with colon and rectal carcinomas

OBJECTIVE

To examine the relationship between postoperative outcomes of colorectal carcinoma patients and preoperative serum carcinoembryonic antigen (CEA) and albumin (ALB) levels and evaluate if these levels can accurately predict outcomes and/or be factor indicating adjuvant chemotherapy.

BACKGROUND

CEA is a marker for colorectal carcinoma and its level usually increases before a distant metastasis is detected. Also, a low level of serum ALB is usually found in metastatic colorectal carcinoma patients.

STUDY

A retrospective cohort study of patients with colorectal carcinomas who were treated with curative surgery in Songklanagarind Hospital between 1998 and 2002.

RESULTS

One hundred seventy patients were identified with a median survival of 1131 days (range 71 to 2293 d) and with an overall 5-year survival rate of 54%. Patients were stratified using CEA at 5 ng/mL and an ALB level at 3.5 g/dL into 4 groups: (1) low CEA, high ALB; (2) low CEA, low ALB; (3) high CEA, high ALB; and (4) high CEA, low ALB. The 5-year survival rates for groups 1 to 4 were 66%, 63%, 46%, and 34%, respectively. There was statistically significant difference in 5-year survival between the well-differentiated tumor with low CEA and the poorly differentiated tumor with high CEA (P=0.0115). The high CEA patients who had the well-differentiated tumor had longer survival than those with a poorly differentiated tumor (P=0.0412).

CONCLUSIONS

A preoperative CEA level greater than or equal to 5 ng/mL and ALB level less than 3.5 g/dL predict a poor survival chance for colorectal carcinoma patients. In high CEA patients, tumor differentiated is an independent factor affecting survival.