The clinical significance of ascitic fluid CEA in advanced gastric cancer with ascites

Palliative Gastrectomy versus Gastrojejunostomy for advanced Gastric cancer with outlet obstruction: a propensity score matching analysis

Background

Gastric outlet obstruction (GOO) is a late complication of advanced gastric cancer, and it is controversial how to select the therapeutic strategies: gastrojejunostomy and palliative gastrectomy? Therefore, this study was to compare the surgical and survival outcomes of gastrojejunostomy and palliative gastrectomy.

Methods

In total, 199 gastric cancer patients with outlet obstruction treated by surgery between January 2000 and December 2015 at Sun Yat-sen University Cancer Center were retrospectively reviewed. Patients were divided into gastrojejunostomy group and palliative gastrectomy group. Propensity score matching (PSM) was performed to balance the selection bias.

Results

After 1:1 PSM, a total of 104 patients were included for final analysis. The median overall survival (OS) times in the gastrojejunostomy group and palliative gastrectomy group were 8.50 and 11.87 months, respectively (P = 0.243). The postoperative complication rates in the gastrojejunostomy group and palliative gastrectomy group were 19.23% (10/52) and 17.31% (9/52), respectively (P = 0.800), and no treatment-related death was observed. Multivariate analysis showed that periton0eal seeding (P = 0.014) and chemotherapy (P < 0.001) were independent prognostic factors. Among them, peritoneal seeding was a risk factor and postoperative chemotherapy was a protective factor.

Conclusions

Our results indicated that although the surgical complications of palliative gastrectomy were manageable, it showed no survival benefit. Therefore, relieving obstruction symptom, improving patients’ quality of life and creating better conditions for chemotherapy appear to be the main therapeutic strategies for advanced gastric cancer with GOO.

Exosomal miR-181b-5p Downregulation in Ascites Serves as a Potential Diagnostic Biomarker for Gastric Cancer-associated Malignant Ascites

Purpose

Peritoneal carcinomatosis in gastric cancer (GC) patients results in extremely poor prognosis. Malignant ascites samples are the most appropriate biological material to use to evaluate biomarkers for peritoneal carcinomatosis. This study identified exosomal MicroRNAs (miRNAs) differently expressed between benign liver cirrhosis-associated ascites (LC-ascites) and malignant gastric cancer-associated ascites (GC-ascites), and validated their role as diagnostic biomarkers for GC-ascites.

Materials and Methods

Total RNA was extracted from exosomes isolated from 165 ascites samples (73 LC-ascites and 92 GC-ascites). Initially, microarrays were used to screen the expression levels of 2,006 miRNAs in the discovery cohort (n=22). Subsequently, quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) analyses were performed to validate the expression levels of selected exosomal miRNAs in the training (n=70) and validation (n=73) cohorts. Furthermore, carcinoembryonic antigen (CEA) levels were determined in ascites samples.

Results

The miR-574-3p, miR-181b-5p, miR-4481, and miR-181d were significantly downregulated in the GC-ascites samples compared to the LC-ascites samples, and miR-181b-5p showed the best diagnostic performance for GC-ascites (area under the curve [AUC]=0.798 and 0.846 for the training and validation cohorts, respectively). The diagnostic performance of CEA for GC-ascites was improved by the combined analysis of miR-181b-5p and CEA (AUC=0.981 and 0.946 for the training and validation cohorts, respectively).

Conclusions

We identified exosomal miRNAs capable of distinguishing between non-malignant and GC-ascites, showing that the combined use of miR-181b-5p and CEA could improve diagnosis.

Rapid Staining Using the Shorr Method for Intraoperative Peritoneal Washing Cytology in Advanced Gastric Cancer: a Pilot Study from a Single Institution

PURPOSE

Intraoperative peritoneal washing cytology (PWC) is used to determine treatment strategies for gastric cancer with suspected serosal invasion. However, a standard staining method for intraoperative PWC remains to be established. We evaluated the feasibility of a rapid and simple staining method using Shorr's stain for intraoperative PWC in advanced gastric cancer.

MATERIALS AND METHODS

Between November 2012 and December 2014, 77 patients with clinical T3 or higher gastric cancer were enrolled. The sensitivity, specificity, and concordance between the Shorr staining method and conventional Papanicolaou (Pap) staining with carcinoembryonic antigen (CEA) immunohistochemistry (IHC) were analyzed.

RESULTS

Intraoperative PWC was performed laparoscopically in 69 patients (89.6%). The average time of the procedure was 8.3 minutes, and the average amount of aspirated fluids was 83.3 mL. The average time for Shorr staining and pathologic review was 21.0 minutes. Of the 77 patients, 16 (20.7%) had positive cytology and 7 (9.1%) showed atypical findings; sensitivity and specificity were 73.6% and 98.2% for the Shorr method, and 78.9% and 98.2% for the Pap method with CEA IHC, respectively. Concordance of diagnosis between the 2 methods was observed in 90.9% of cases (weighted κ statistic=0.875) and most disagreements in diagnoses occurred in atypical findings (6/7). In overall survival, there was no significant difference in C-index between the 2 methods (0.459 in Shorr method vs. 0.458 in Pap with CEA IHC method, P=0.987).

CONCLUSIONS

Shorr staining could be a rapid and reliable method for intraoperative PWC in advanced gastric cancer.

Diagnostic Value of Carcinoembryonic Antigen in Ascites for Colorectal Cancer with Peritoneal Carcinomatosis

BACKGROUND/AIMS

Diagnostic tests for carcinoembryonic antigen (CEA) in ascites have been performed in various malignant cases, but there is only few data on the applicability of CEA for colorectal cancer (CRC) patients with peritoneal carcinomatosis. We aimed to determine the usefulness of CEA in ascites (aCEA) as a diagnostic parameter for CRC with peritoneal carcinomatosis.

METHODS

Between January 2000 and May 2013, the medical records of 259 patients who underwent paracentesis for the evaluation of ascites were retrospectively reviewed. CRC patients with ascites (n=82) and patients with non-malignant ascites (n=177) were evaluated. Patients who had other malignancies, including gastric or ovarian cancer, with ascites were excluded. The optimal diagnostic cut-off value of aCEA for CRC with peritoneal carcinomatosis was determined using receiver operating characteristic curve analysis. The value of aCEA for predicting the occurrence of peritoneal carcinomatosis was evaluated using a logistic regression model.

RESULTS

The optimal cut-off value of aCEA to diagnose CRC with peritoneal carcinomatosis was 3.89 ng/mL, and the area under the curve for aCEA was 0.996 (sensitivity 96.3%, specificity 100%, positive predictive value 100%, negative predictive value 98.3%). Multivariate logistic regression analysis showed that aCEA was an independent factor predicting the occurrence of peritoneal carcinomatosis.

CONCLUSIONS

In this study, we showed that aCEA may be a useful parameter for diagnosing CRC with peritoneal carcinomatosis, and we propose an optimal aCEA cut-off value of 3.89 ng/mL. Further study that includes patients with other malignant ascites may be necessary to validate these findings.

Use of serum and peritoneal CEA and CA19-9 in prediction of peritoneal dissemination and survival of gastric adenocarcinoma patients: are they prognostic factors?

Introduction To evaluate the impact of serum and peritoneal levels of tumour markers on peritoneal carcinomatosis and survival in gastric adenocarcinoma. Materials and methods Patients with gastric adenocarcinoma were evaluated with regard to serum and peritoneal carcinoembryonic antigen (CEA) and CA19-9. Numeric values and groupings based on serum and peritoneal cutoff values were used. Development of peritoneal carcinomatosis, including positive washing cytology, was regarded as main outcome. Gastric cancer outcomes as disease free and overall survival were analysed. Results There were 67 patients with a mean age of 60 ± 11 years. Positive peritoneal washing cytology was significantly associated with serum CA19-9 and high serum CA 19-9 group (P = 0.033 and P = 0.011, respectively). High peritoneal CEA was shown to be significantly associated with peritoneal carcinomatosis (P = 0.032). After a median follow up of 17 months, 48 patients (71.7%) were alive. Patients with peritoneal carcinomatosis showed significant poorer prognosis as shown by overall survival rate of 28.6%. Only serum CEA was significantly associated with lower disease free and overall survival (P = 0.002 and P = 0.001, respectively). Discussion and conclusion Serum CEA is shown to be significantly associated with poor prognosis for gastric cancer patients. Serum level of CA19-9 and high peritoneal CEA levels are significant predictors for positive peritoneal washing cytology and the development of peritoneal carcinomatosis, respectively. Therefore, the possible impact of serum and peritoneal tumor markers especially on the staging and prognosis of gastric cancer remains to be clarified by future studies.

Evaluation of the Clinical Significance of Serum Carcinoembryonic Antigen in Patients with Resectable Gastric Adenocarcinoma

BACKGROUND AND AIMS

Carcinoembryonic antigen (CEA) is the most commonly used tumor marker for gastrointestinal cancers but its value for resectable gastric adenocarcinoma (RGA) patients in areas of high GA incidence is uncertain.

METHODS

We retrospectively studied 400 subjects with RGA from the Fujian Province in China, which has a high incidence of GA. Patients had surgery between January 2010 and December 2013. CEA was measured and correlated to pathology.

RESULTS

High pretreatment serum CEA (>5 ng/mL) was associated with patient age (p = 0.000), tumor size (p = 0.008), and T and N stages (p = 0.002, p = 0.032, respectively), alpha fetoprotein (p = 0.014), and CA19-9 (p = 0.000). High CEA was significantly associated with poor overall survival. Overall survival in the whole group of patients was 63.8%, whereas it was only 42.9% in the high CEA group (p = 0.0001). Mean overall survival for high CEA patients was significantly shorter than patients with low CEA (36.5 ± 2.63 months vs. 47.4 ± 0.98 months, p = 0.000). Multivariate analysis confirmed that pretreatment serum CEA was an independent prognostic factor for increased death risk. Additionally, mean CEA in 45 high CEA patients was reduced after surgery.

CONCLUSIONS

Pretreatment serum CEA may help to predict survival for patients with RGA in high GA incidence areas.

Clinical features of colorectal neoplasm patients with metabolic syndrome

AIM: To investigate the clinical features of colorectal neoplasm patients with metabolic syndrome (MS).

METHODS: A retrospective analysis was performed of clinical data for patients who were diagnosed with colorectal neoplasm with MS from May 2012 to May 2015.

RESULTS: A total of 107 patients were included. There were 72 males and 35 females, and their mean age was 66.84 years ± 10.58 years. There were 40 cases of adenomas and 67 cases of colorectal cancer. There was no significant difference (P > 0.05) in the rate of reduced high density lipoprotein-cholesterol (HDL-C) [29 (72.5%) vs 53(79.1%)] between patients with adenomas and those with colorectal cancer, but the rate of elevated triacylglycerol [14 (35.0%) vs 45 (67.2%)] differed significantly (P < 0.05). The rates of elevated CEA and CA199 showed no significant difference between patients with adenomas and colorectal cancer (P > 0.05); however, the rate of elevated CA125 and the rate of elevation of two or more of the three tumor markers were significantly higher in the colorectal cancer group than in the adenoma group (P < 0.05). In colorectal neoplasm patients with MS, 20 developed carcinoma metastases, and 16 cases died; the median survival time was 33 mo.

CONCLUSION: Colorectal neoplasm patients with metabolic syndrome are always diagnosed at old ages, and high level of TG may play a role in the evolution of colorectal adenomas to colorectal cancer. Joint detection of multiple tumor markers can be used to distinguish benign and malignant lesions in these patients.

Evaluation and treatment of malignant ascites secondary to gastric cancer

Malignant ascites affects approximately 10% of patients with gastric cancer (GC), and poses significant difficulties for both patients and clinicians. In addition to the dismal general condition of affected patients and the diversity of associated complications such as jaundice and ileus, problems in assessing scattered tumors have hampered the expansion of clinical trials for this condition. However, the accumulation of reported studies is starting to indicate that the weak response to treatment in GC patients with malignant ascites is more relevant to their poor prognosis rather than to the ascites volume at diagnosis. Therefore, precise assessment of initial state of ascites, repetitive evaluation of treatment efficacy, selection of suitable treatment, and swift transition to other treatment options as needed are paramount to maximizing patient benefit. Accurately determining ascites volume is the crucial first step in clinically treating a patient with malignant ascites. Ultrasonography is commonly used to identify the existence of ascites, and several methods have been proposed to estimate ascites volume. Reportedly, the sum of the depth of ascites at five points (named “five-point method”) on three panels of computed tomography images is well correlated to the actual ascites volume and/or abdominal girth. This method is already suited to repetitive assessment due to its convenience compared to the conventional volume rendering method. Meanwhile, a new concept, “Clinical Benefit Response in GC (CBR-GC)”, was recently introduced to measure the efficacy of chemotherapy for malignant ascites of GC. CBR-GC is a simple and reliable patient-oriented evaluation system based on changes in performance status and ascites, and is expected to become an important clinical endpoint in future clinical trials. The principal of treatment for GC patients with ascites is palliation and prevention of ascites-related symptoms. The treatment options are various, including a standard treatment based on the available guidelines, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), laparoscopic HIPEC alone, intravenous chemotherapy, intraperitoneal chemotherapy, and molecular targeting therapy. Although each treatment option is valid, further research is imperative to establish the optimal choice for each patient.

Clinical significance of serum tumor markers for gastric cancer: a systematic review of literature by the Task Force of the Japanese Gastric Cancer Association

The aim of this review was to evaluate the clinical significance of serum tumor markers, particularly CEA, CA19-9, and CA72-4, in patients with gastric cancer. A systematic literature search was performed using PubMed/MEDLINE with the keywords "gastric cancer" and "tumor marker," to select 4,925 relevant reports published before the end of November 2012. A total of 187 publications contained data for CEA and CA19-9, and 19 publications contained data related to all three tumor markers. The positive rates were 21.1 % for CEA, 27.8 % for CA19-9, and 30.0 % for CA72-4. These three markers were significantly associated with tumor stage and patient survival. Serum markers are not useful for early cancer, but they are useful for detecting recurrence and distant metastasis, predicting patient survival, and monitoring after surgery. Tumor marker monitoring may be useful for patients after surgery because the positive conversion of tumor markers usually occurs 2-3 months before imaging abnormalities. Among other tumor markers, alpha-fetoprotein (AFP) is useful for detecting and predicting liver metastases. Moreover, CA125 and sialyl Tn antigens (STN) are useful for detecting peritoneal metastases. Although no prospective trial has yet been completed to evaluate the clinical significance of these serum markers, this literature survey suggests that combinations of CEA, CA19-9, and CA72-4 are the most effective ways for staging before surgery or chemotherapy. In particular, monitoring tumor markers that were elevated before surgery or chemotherapy could be useful for detection of recurrence or evaluation of the response.

Clinical significance of carcinoembryonic antigen in peritoneal lavage from patients with gastric cancer

BACKGROUND

Peritoneal carcinomatosis is the most common pattern of recurrence of gastric cancer, and it is important to identify patients at high risk for recurrence. Although the carcinoembryonic antigen level in peritoneal lavage (pCEA) was reported to be a useful biomarker to predict peritoneal recurrence in a small series, its clinical significance has not been fully validated. We evaluated the clinical significance of pCEA in a large cohort of patients with gastric cancer.

METHODS

We prospectively analyzed the pCEA level in 597 patients with histologically proven gastric cancer who underwent laparotomy.

RESULTS

A significant relationship was demonstrated between the value of pCEA and clinicopathologic features, such as the peritoneal lavage cytology, peritoneal metastasis, the depth of tumor invasion, and the lymph node metastasis. The cutoff value was set at 100 ng/g of protein, and 134 of the 462 patients who underwent curative surgery had positive pCEA findings. The overall and the intraperitoneal-recurrence-related survival of patients positive for pCEA were significantly poorer than those of pCEA-negative patients. When we analyzed the patients with pathologic stage I through III gastric cancers separately, the pCEA-positive patients had poorer prognoses than the pCEA-negative patients who had stage III gastric cancer. In a univariate analysis, the tumor size, depth of tumor invasion, lymph node metastasis, histologic type, serum CEA (sCEA), and pCEA were found to affect the patients' outcomes, although a multivariate analysis found only the extent of lymph node metastasis to be an independent prognostic factor.

CONCLUSION

The pCEA level is a useful biomarker to predict gastric cancer-related death. Moreover, the pCEA level may be useful to identify a cohort of patients with gastric cancer who need more intensive adjuvant chemotherapy to improve their prognoses.

The detection of gastric cancer cells in intraoperative peritoneal lavage using the reverse transcription--loop-mediated isothermal amplification method

INTRODUCTION

To detect a small number of malignant cells, we used a highly sensitive detection system that measures the expression levels of cytokeratin (CK) 19 messenger RNA by reverse transcription-loop-mediated isothermal amplification (RT-LAMP).

MATERIALS AND METHODS

We evaluated the clinical relevance of our novel diagnostic method with an RT-LAMP assay using CK19 as a target gene for the detection of free cancer cells in peritoneal lavage and assessed the clinical significance of the molecular diagnosis by survival analysis and frequency of recurrence, with a median follow-up period of 39 mo. We observed 52 patients with gastric cancer who underwent gastrectomy, bypass operation, and exploratory laparotomy.

RESULTS

Those 52 patients, who were subjected to both RT-LAMP and cytologic examination, were divided into the following three groups: (1) patients positive by cytology and RT-LAMP (CY+/LAMP+) (n = 9), (2) patients positive by LAMP and negative by cytology (CY-/LAMP+) (n = 12), and (3) patients negative by both cytology and LAMP (CY-/LAMP-) (n = 31). All patients with simultaneous peritoneal dissemination and positive cytology were positive on RT-LAMP. The results of RT-LAMP were statistically significant for recurrence by univariate analysis (P < 0.005). Cytology-positive cases had a very poor prognosis, and RT-LAMP-positive cases had a worse prognosis than RT-LAMP-negative cases.

CONCLUSIONS

Our findings suggest that CK19 RT-LAMP would be useful as an intraoperative diagnostic modality to detect patients with a high risk of recurrence even after clinically curative surgery, who thus require proper adjuvant therapy.

Immunological milieu in the peritoneal cavity at laparotomy for gastric cancer

AIM: To investigate the immunological repertoire in the peritoneal cavity of gastric cancer patients.

METHODS: The peritoneal cavity is a compartment in which immunological host-tumor interactions can occur. However, the role of lymphocytes in the peritoneal cavity of gastric cancer patients is unclear. We observed 64 patients who underwent gastrectomy for gastric cancer and 11 patients who underwent laparoscopic cholecystectomy for gallstones and acted as controls. Lymphocytes isolated from both peripheral blood and peritoneal lavage were analyzed for surface markers of lymphocytes and their cytokine production by flow cytometry. CD4⁺CD25^high T cells isolated from the patient’s peripheral blood were co-cultivated for 4 d with the intra-peritoneal lymphocytes, and a cytokine assay was performed.

RESULTS: At gastrectomy, CCR7^- CD45RA^- CD8⁺ effector memory T cells were observed in the peritoneal cavity. The frequency of CD4⁺ CD25 ^high T cells in both the peripheral blood and peritoneal cavity was elevated in patients at advanced stage [control vs stage IV in the peripheral blood: 6.89 (3.39-10.4) vs 15.34 (11.37-19.31), P < 0.05, control vs stage IV in the peritoneal cavity: 8.65 (5.28-12.0) vs 19.56 (14.81-24.32), P < 0.05]. On the other hand, the suppression was restored with CD4⁺ CD25^high T cells from their own peripheral blood. This study is the first to analyze lymphocyte and cytokine production in the peritoneal cavity in patients with gastric cancer. Immune regulation at advanced stage is reversible at the point of gastrectomy.

CONCLUSION: The immunological milieu in the peritoneal cavity of patients with advanced gastric cancer elicited a Th2 response even at gastrectomy, but this response was reversible.

Body fluid MMP-2 as a putative biomarker in metastatic breast cancer

In the present study, we investigated the role of matrix metalloproteinase (MMP)-2 and -9 as novel biomarkers in the body fluid of patients with metastatic breast cancer. We measured the expression of MMPs in 37 samples of body fluid (10 peritoneal and 27 pleural fluids) from metastatic breast cancer patients between 2000 and 2009. Zymography and ELISA assays were used to determine the cut-off level and to quantify MMP expression from a positive control, HT-1080 conditioned media. MMP expression in patient samples was measured with ELISA and compared with other clinical parameters. Ascitic carcinoembryonic antigen (CEA) and pleural CEA were measured in patient samples with a chemiluminescent enzyme immunoassay. Body fluid cytology had a positivity of 45% (9/20) for pleural fluid and 28.6% (2/7) for ascites. However, MMP-2 had a positivity of 85.2% (23/27) in 27 pleural fluid samples and 100% (10/10) in ascitic fluid with cut-off levels of 8.6 and 0.14 ng/ml for MMP-2 and -9, respectively. When body fluid CEA and MMP-2 were combined, the positivity improved to 96% in pleural fluid and 100% in ascites. MMP-2 expression in body fluid did not show any significant differences, but MMP-9 expression was lower in ascites than in pleural fluids (p<0.005). Our results suggest that MMP-2 expression in body fluid be used as an additive diagnostic marker for metastatic breast cancer patients.

Immune clearance gastric carcinoma cells in ascites by activating caspase-9-induced apoptosis

Floating gastric adenocarcinoma cells in ascitic fluid are the main cause of peritoneal dissemination. Activation of apoptosis is an important mechanism by which tumor cells are eliminated by the immune surveillance system. Hence, we examined caspase-9 expression and the apoptosis in gastric adenocarcinoma cells in ascitic fluid using immunohistochemistry, real-time polymerase chain reaction and in situ cell death detection kits, flow cytometry. The results revealed strong expression of caspase-9 in 58.49% (31/53) malignant cells and a relatively weak expression of caspase-9 in 41.51% (22/53) malignant cells. The proportion of apoptotic cells in 31 malignant cases with strong caspase-9 expression (35.14 ± 3.42)% was significantly higher than that in 22 malignant cases with relatively weak caspase-9 expression (17.29 ± 7.62)% or in mesothelial cells (10.76 ± 4.21%; p < 0.05). Kaplan-Meier survival curves demonstrated that the patients with low caspase-9 expression showed significantly shorter survival (p < 0.05) than those with high caspase-9 expression. These findings suggest that immune clearance gastric carcinoma cells in ascites activated by caspase-9 helped to improve the prognosis of patients with gastric cancer.