Comparison of doubling times of serum carcinoembryonic antigen produced by various metastatic lesions in recurrent gastric and colorectal carcinomas

Variations in tumor growth, intra-individual biological variability, and the interpretation of changes

OBJECTIVES

The identification of changes in tumor markers (TMs) in cancer patients that indicate response to treatment, stabilization or disease progression is a challenge for laboratory medicine. Several approaches have been proposed: assessing percentage increases, applying discriminant values, and estimating half-life (t1/2) or doubling time (DT). In all of them it is assumed that the TM is a surrogate of the variation in tumor size. In general this variation is time-dependent, but this is not the case of intraindividual biological variability (CVi), which can range from 6 % in CA15-3 to 22 % in CA125. When decisions are made on the basis of DT or t1/2, these values can be affected by the CVi; if it is very large, the growth rate very slow and the period of time between determinations very short, the result obtained for DT may be due mainly to the CVi. The aim of this study is to establish the relationship between the CVi and temporal variables.

METHODS

We related equations for calculating DT and t1/2 to the reference change values in tumor markers.

RESULTS

The application of the formula obtained allows the calculation of the optimal time between measurements to ensure that the influence of the CVi is minimal in different types of tumors and different scenarios.

CONCLUSIONS

Intraindividual variation affects the calculation of DT and t1/2. It is necessary to establish the minimum time between two measurements to ensure that the CVi does not affect their calculation or lead to misinterpretation.

The Role of High Frequency Dynamic Threshold (HiDT) Serum Carcinoembryonic Antigen (CEA) Measurements in Colorectal Cancer Surveillance: A (Revisited) Hypothesis Paper

Following curative treatment for colorectal cancer (CRC), 30% to 50% of patients will develop recurrent disease. For CRC there are several lines of evidence supporting the hypothesis that early detection of metachronous disease offers a second opportunity for cure. This paper revisits the potential role of serum carcinoembryonic antigen (CEA) in follow-up. A comprehensive review of the literature (1978–2008) demonstrates that the initial promise of serum CEA as an effective surveillance tool has been tarnished through perpetuation of poorly designed studies. Specific limitations included: testing CEA as only an ‘add-on’ diagnostic tool; lack of standardization of threshold values; use of static thresholds; too low measurement frequency. Major changes in localizing imaging techniques and treatment of metastatic CRC further cause a decrease of clinical applicability of past trial outcomes. In 1982, Staab hypothesized that the optimal benefit of serum CEA as a surveillance tool is through high-frequency triage using a dynamic threshold (HiDT). Evidence supporting this hypothesis was found in the biochemical characteristics of serum CEA and retrospective studies showing the superior predictive value of a dynamic threshold. A multi-centred randomized phase III study optimizing the usage of HiDT against resectability of recurrent disease is commencing recruitment in the Netherlands.

Transient carcinoembryonic antigen elevations during adjuvant chemotherapy for colorectal cancer reflect the burden of residual micrometastatic disease

BACKGROUND

Carcinoembryonic antigen (CEA) testing is routinely used to monitor the progress of patients with advanced cancer on treatment, or else to detect relapse during follow-up, particularly in colorectal cancer (CRC). Although CEA levels have been reported to rise during adjuvant drug therapies, the mechanism of such 'surges' is not clear. This study was conducted to clarify the clinical significance of this phenomenon.

PATIENTS AND METHODS

We conducted a retrospective analysis of CEA levels in 88 consecutive patients receiving adjuvant chemotherapy in our center: 39 patients with primary CRC and a comparison cohort of 49 patients with breast cancer treated with adjuvant chemotherapy. In the event of 2 serial CEA increases, endoscopic and/or imaging investigations were performed to exclude recurrence. Subset analyses were based on nodal status and primary tumor type.

RESULTS

Primary resection was associated with significant CEA decline in patients with CRC but not in those with breast cancer. Forty-three patients (48.9%) experienced CEA fluctuations exceeding 0.5 ng/mL during adjuvant chemotherapy; CEA increases indicated true recurrence in 2 patients (4.7%). Adjuvant CEA surges occurred both more often and more extensively in disease associated with >or= 4 positive nodes in patients with CRC but not in patients with breast cancer (P < .05).

CONCLUSION

Both the frequency and extent of CEA surges during adjuvant chemotherapy parallel the severity of preoperative nodal involvement in CRC but not in breast cancer, suggesting that such surges reflect tumorilytic effects on occult disease in patients with CRC only. However, whether these CEA surges predict survival that is inferior (ie, because of greater burden of residual disease) or superior (ie, because of greater tumorilytic efficacy) to that of stagematched 'nonsurge' patients, remains to be determined by larger, prospective CRC studies.

Carcinoembryonic Antigen in the Staging and Follow-up of Patients with Colorectal Cancer

CEA is a complex glycoprotein produced by 90% of colorectal cancers and contributes to the malignant characteristics of a tumor. It can be measured in serum quantitatively, and its level in plasma can be useful as a marker of disease. Because of its lack of sensitivity in the early stages of colorectal cancer, CEA measurement is an unsuitable modality for population screening. An elevated preoperative CEA is a poor prognostic sign and correlates with reduced overall survival after surgical resection of colorectal carcinoma. A failure of the CEA to return to normal levels after surgical resection is indicative of inadequate resection of occult systemic disease. Frequent monitoring of CEA postoperatively may allow identification of patients with metastatic disease for whom surgical resection or other localized therapy might be potentially beneficial. To identify this group, serial CEA measurement appears to be more effective than clinical evaluation or any other diagnostic modality, although its sensitivity for detecting recurrent disease is not as high for locoregional or pulmonary metastases as it is for liver metastases. Several studies have shown that a small percentage of patients followed postoperatively with CEA monitoring and who undergo CEA-directed salvage surgery for metastatic disease will be alive and disease-free 5 years after surgery. Furthermore, CEA levels after salvage surgery do appear to predict survival in patients undergoing resection of liver or pulmonary metastases. However, several authors argue that CEA surveillance is not cost-effective in terms of lives saved. In support of this argument, there is no clear difference in survival after resection of metastatic disease with curative intent between patients in whom the second-look surgery was performed on the basis of elevated CEA levels and those with other laboratory or imaging abnormalities. There is also no clear consensus on the frequency or duration of CEA monitoring, although the ASCO guidelines currently recommend every 2-3 months for at least 2 years after diagnosis. In the follow-up of patients undergoing palliative therapy, the CEA level correlates well with response, and CEA is indicative of not only response but may also identify patients with stable disease for whom there is also a demonstrated benefit in survival and symptom relief with combination chemotherapy. More recently, scintigraphic imaging after administration of radiolabeled antibodies afforded an important radionuclide technique that adds clinically significant information in assessing the extent and location of disease in patients with colorectal cancer above and beyond or complementary to conventional imaging modalities. Immunotherapy based on CEA is a rapidly advancing area of clinical research demonstrating antibody and T-cell responses.

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.

Metastatic tumor doubling time: most important prehepatectomy predictor of survival and nonrecurrence of hepatic colorectal cancer metastasis

We determined the relative value of the metastatic colorectal cancer doubling time as a predictor of recurrence and survival after hepatectomy in comparison with other established predictors. Consecutive patients who underwent hepatic resection ( n = 144) for colorectal cancer liver metastases were studied retrospectively to identify factors that influence overall survival and recurrence in the remnant liver. Overall 5-year survival and nonrecurrence rates were 49.8% and 50.8%, respectively. By multivariate analysis, large liver tumors ( p = 0.038), p53 expression by the liver tumor (p = 0.011), and a short liver metastasis doubling time (< or = 45 days, p = 0.013) negatively affected survival; doubling times > 45 days (adjusted relative risk 0.06; p < 0.001) positively influenced disease-free survival. In patients with remnant liver recurrence, a short doubling time was associated with short disease-free intervals (7.3 +/- 6.2 months), multiple metastases (63.6%), and fewer attempts at repeat hepatectomy (22.7%). The doubling time determines tumor size and reflects the patient's immune and nutritional status. A short doubling time is the most reliable risk factor for multiple metastases, early recurrence, and poor prognosis. Further studies with a larger number of patients are needed to confirm this conclusion.

Significance of serum and tissue carcinoembryonic antigen for the prognosis of gastric carcinoma patients

BACKGROUND AND OBJECTIVES

Carcinoembryonic antigen (CEA) has been widely accepted as a tumor marker useful in the diagnosis and management of colorectal carcinoma. When CEA levels are positive in patients with gastric carcinoma, they could be useful prognostic indicators. The value of CEA as a tumor marker for gastric carcinoma, however, remains a matter of controversy. The purpose of this study was to determine whether preoperative serum CEA value and tissue CEA staining are useful prognostic indicators for gastric carcinoma.

METHODS

We measured preoperative serum CEA levels by radioimmunoassay and stained tissue CEA production by tumor cells from gastric carcinomas using immunohistochemical staining in patients with gastric carcinoma.

RESULTS

The patients with preoperative serum CEA levels >10.0 ng/mL had a more prominent serosal invasion, much more lymph node involvement, more advanced stage and more poorly differentiated than did the patients with preoperative serum CEA levels <5.0 ng/mL. The survival rate of patients with serum CEA levels >10.0 ng/mL was poorer than those of patients with serum CEA levels between 5.0 and 10.0 ng/mL, and those of patients with serum CEA levels <5.0 ng/mL (P < 0.05). The preoperative serum CEA levels and tumor CEA-positivity were correlated (P < 0.05). In patients with lymph node metastases, the CEA-positivity (78.0%) was higher than in patients without lymph node metastasis (63.2%) (P < 0.05). A correlation was also found between the depth of tumor invasion and tissue CEA-positivity (P < 0.001). The postoperative survival rate was significantly better in the CEA-negative staining group (78.0%) than in the CEA-positive staining group (60.0%).

CONCLUSIONS

These data suggest that preoperative serum CEA levels and staining for CEA in gastric carcinoma tissue sections may have a predictive value in determining prognostic information for patients with resectable gastric carcinoma.

Kinetics of Serum Tumor Marker Concentrations and Usefulness in Clinical Monitoring

Only a few markers have been instrumental in the diagnosis of cancer. In contrast, tumor markers play a critical role in the monitoring of patients. The patient’s clinical status and response to treatment can be evaluated rapidly using the tumor marker half-life (t1/2) and the tumor marker doubling time (DT). This report reviews the interest of determining these kinetic parameters for prostate-specific antigen, human chorionic gonadotropin, α-fetoprotein, carcinoembryonic antigen, cancer antigen (CA) 125, and CA 15-3. A rise in tumor markers (DT) is a yardstick with which benign diseases can be distinguished from metastatic disease, and the DT can be used to assess the efficacy of treatments. A decline in the tumor marker concentration (t1/2) is a predictor of possible residual disease if the timing of blood sampling is soon after therapy. The discrepancies in results obtained by different groups may be attributable to the multiplicity of immunoassays, the intrinsic characteristics of each marker (e.g., antigen specificity, molecular heterogeneity, and associated forms), individual factors (e.g., nonspecific increases and renal and hepatic diseases) and methods used to calculate kinetics (e.g., exponential models and timing of blood sampling). This kinetic approach could be of interest to optimize patient management.

Influence of smoking on serum carcinoembryonic antigen levels in subjects who underwent multiphasic health testing and services

We quantified the effect of smoking on serum carcinoembryonic antigen (CEA) levels in 1341 subjects who underwent the multiphasic health testing and services in our center. Four hundred and sixty seven of them were smokers and the rest were nonsmokers. In males subjects, serum CEA levels were significantly higher in smokers (3.11 +/- 1.8 ng/ml) than in nonsmokers (2.14 +/- 1.8 ng/ml) (mean +/- SD; p < 0.01). For females, however, the levels had no significant differences between smokers (2.11 +/- 0.91 ng/ml) and nonsmokers (1.87 +2- 1.3 ng/ml). The CEA-positive subjects were 44, of whom 32 were male custom heavy smokers, and only 2 of them had gastrointestinal cancer. We concluded that the serum CEA level was influenced by smoking especially in males and its clinical significance for detection of carcinoma was doubtful.

Prognostic value of the doubling time of serum C-reactive protein and alkaline phosphatase levels in primary bone and soft tissue tumors

We investigated the clinical relevance of doubling time (DT) of serum laboratory data obtained in routine clinical examination of patients with primary bone and soft tissue tumors, in comparison with major clinical and pathological parameters (age at presentation, sex, tumor size, location, clinical stage and histologic grade) by uni- and multivariate analyses. In 64 patients with primary bone and soft tissue tumors (primary bone tumors: 39, primary soft tissue tumors: 25) and 68 cancer patients, the pretreatment DT values of serum C-reactive protein (CRP), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), calcium (Ca), phosphate (P) levels were measured, as well as the erythrocyte sedimentation rate (ESR: mm/60 min); these values were then compared with overall survival, local recurrence-free survival and metastasis-free survival. Only DT of CRP and ALP (CRP-DT, ALP-DT) were found to be correlated with disease outcome in patients with primary bone and soft tissue tumors. In cancer patients, only CRP-DT showed a relation with clinical stage and histologic grade, but the ALP-DT in patients with bone metastasis was significantly shorter than that in patients with metastases at other sites or in those with no metastasis. Among all tumor patients, those with bone metastasis showed the shortest ALP-DT compared with those with lung, liver and brain metastasis. Univariate analysis showed that shorter CRP-DT and ALP-DT are associated with poor overall survival, and the development of local recurrence and metastasis. These findings suggest that pretreatment CRP- and ALP-DT could be additional prognostic parameters for disease outcome in patients with primary malignant bone and soft tissue tumors. However, in multivariate analysis, only ALP-DT, but not CRP-DT, was an independent prognostic parameter for these disease outcomes.

Serum carcinoembryonic antigen levels and proliferating cell nuclear antigen labeling index for patients with colorectal carcinoma. Correlation with tumor progression and survival

BACKGROUND

Clinicopathologic variables, carcinoembryonic antigen (CEA), nuclear DNA ploidy, and proliferating cell nuclear antigen labeling index (PCNA LI) have been studied for their effect on patients with various types of cancer.

METHODS

Thirteen clinicopathologic variables, preoperative serum CEA levels, PCNA LI, DNA ploidy patterns, and survival were studied for 57 colorectal carcinoma patients, and the mutual relation between these variables, tumor progression, and survival were analyzed.

RESULTS

Seven variable including undifferentiated adenocarcinoma, deep invasion, lymphatic and venous invasion, node metastasis, liver metastasis, and advanced stages were significantly greater for patients with positive CEA ( > 5.0 ng/mL) than for patients with negative CEA ( < 5.0 ng/ML). Three variables including deep invasion, liver metastasis, and advanced stages were significantly greater for patients with high PCNA LI ( > 49.4%) than for patients with low PCNA LI ( < 49.4%). No significant difference was observed in any of the variable for patients with DNA diploid or aneuploid cancer. A close relationship representing a formula, Y (log CEA, ng/mL) = 0.026X (PCNA LI, %) - 0.478, was found between CEA level and PCNA LI: Survival curves for patients with negative CEA and low PCNA LI were significantly greater than those for patients with positive CEA and high PCNA LI: Survival curves were significantly greater for patients with positive CEA and low PCNA LI than for patients with positive CEA and high PCNA LI: However, no significant difference was observed in the survival curves of patients with different DNA ploidy patterns.

CONCLUSIONS

Serum CEA and PCNA LI for cancer patients is useful in the evaluation of tumor progression and in prognosis. Analysis of DNA ploidy appears to be unavailable for this evaluation.

Comparison by carcinoembryonic antigen doubling time of hepatic injection and infusion for unresectable hepatic metastasis from colorectal cancer

This study explored the efficacy of hepatic arterial therapy, comparing both injection and infusion of 5-fluorouracil (5-FU) in prolonging the survival of 92 patients with recurrent unresectable hepatic metastasis from colorectal cancer. With respect to pretreatment carcinoembryonic antigen doubling time (CEA-DT), 56 patients were treated with intra-arterial injection, and 36 with intra-arterial infusion. In 21 patients with a CEA-DT of less than 40 days, the cumulative survival of patients treated with arterial injection was significantly longer than that of patients treated with arterial infusion. In 45 patients with a CEA-DT of 40-80 days, the survival curves of patients did not differ from each other. Of the remaining 26 patients with a CEA-DT of more than 80 days, those treated using arterial infusion had an excellent prognosis, in contrast to those treated using arterial injection, with statistical significance. CEA-DT may be useful when choosing a chemotherapy regimen, and may help to accurately establish the prognosis of patients with unresectable hepatic metastasis from colorectal cancer.

CEA reduction after cryotherapy for liver metastases from colon cancer predicts survival

Serum carcinoembryonic antigen (CEA) levels in 33 Australian patients with hepatic metastases from colorectal cancer were measured before and after treatment with hepatic cryotherapy and intra-arterial chemotherapy. Pre-operative and monthly postoperative CEA measurements were made and the lowest postoperative reading was recorded as a percentage fall from the pre-operative level. There was a highly significant association between the maximum percentage fall in CEA and survival. A 50% increase in the maximum percentage fall in CEA level was associated with one-tenth the risk of death (95% CI RR 0.03 to 0.32, Cox regression). It is estimated that an increase in the maximum percentage fall in CEA of 50% from 25 to 75% was associated with an increase in the median survival from 240 days to over 2 years.