Use of serial carcinoembryonic antigen assays in detecting relapses in breast cancer involving high risk of metastasis

Carcinoembryonic Antigen (CEA) in the Follow-Up of Disease-Free Breast Cancer Patients

Carcinoembryonic antigen (CEA) assays (2536) were performed in 380 disease-free breast cancer patients after radical mastectomy. In the 334 evaluable patients with 3 or more determinations, the overall relapse rate after a median follow-up of 29 months was 11 %. Of 203 patients with normal CEA values, 19 (9.3 %) relapsed. In the 50 patients with the highest CEA value greater than 20 ng/ml, the relapse rate was 26 %; in the 12 patients with gradually increasing CEA elevations it was 50 %. However, CEA was unable to predict recurrence in N- patients. Premastectomy N+ was significantly associated with greater than 20 ng/ml or gradually increasing CEA values, suggesting the lack of an independent prognostic value of CEA in our patient population.

CEA Determination in the Follow-Up of Extracolorectal Neoplasms

CEA was initially described as a tumor and organ specific colorectal antigen, but later found by more sensitive methods in other tumors (stomach, pancreas, lung, breast) and in minor amounts in inflammatory, normal adult and fetal organs of the gastrointestinal tract. The main clinical application of CEA concerns its pretherapeutic and serial determination as circulating antigen in serum and other body fluids by means of CEA-specific, commercially available test kits. By clinical studies a significant correlation has been proven between the pretherapeutic serum CEA level and tumor stages and prognosis. Moreover, serial CEA level changes have been shown a valuable monitor following operation or during radio/chemotherapy anticipating and reflecting the clinical course of disease. In combination with newly established tumor markers, the main clinical indication for CEA determination in addition to colorectal cancer concerns monitoring of patients with stomach (+ CA 72-4), lung (+ NSE/SCC) and breast cancer (+ CA 15-3/MCA).

Description of a Computer Program to Assess Cancer Antigen 15.3, Carcinoembryonic Antigen, and Tissue Polypeptide Antigen Information during Monitoring of Metastatic Breast Cancer

It is time-consuming to process and compare the clinical and marker information registered during monitoring of breast cancer patients. To facilitate the assessment, we developed a computer program for interpreting consecutive measurements. The intraindividual biological variation, the analytical precision profile, the cutoff limit, and the detection limit for each marker are entered and stored in the program. The assessment procedure for marker signals considers the analytical and biological variation of the applied markers. The software package contains a database that can store the interpretation of the measurements as evaluation codes together with patient demographics, information about treatment type, dates for treatment periods, control periods, and evaluation codes for clinical activity of disease. The consecutive concentrations for a patient are imported temporarily into the program from outside sources and presented graphically. Marker concentrations to be compared are selected with the computer mouse and the significance of the difference is calculated by the program. The program has an option for calculating the lead time of marker signals vs clinical information. The program facilitates the monitoring of individual breast cancer patients with tumor marker measurements. It may also be implemented in trials investigating the utility of potential new markers in breast cancer as well as in other malignancies.

Utility of C-erbB-2 in tissue and in serum in the early diagnosis of recurrence in breast cancer patients: comparison with carcinoembryonic antigen and CA 15.3

To evaluate the utility of c-erbB-2, carcinoembryonic antigen (CEA) and CA 15.3 in the early diagnosis of recurrence, serial serum determinations of these antigens were performed in 200 patients (follow-up 1-4 years, mean 2.2 years) with primary breast cancer and no evidence of residual disease (NED) after radical treatment (radical mastectomy or simple mastectomy and radiotherapy). Eighty-nine patients developed metastases during follow-up. C-erbB-2, CEA and CA 15.3 were elevated (> 20 U ml-1, > 10 ng ml-1 or > 60 U ml-1 respectively) before diagnosis in 28%, 30% and 47% of the 89 patients with recurrence, with a lead time of 4.5 +/- 2.4, 4.9 +/- 2.4 and 4.8 +/- 2.4 months respectively. Tumour marker sensitivity was clearly related to the site of recurrence, with the lowest sensitivity found in locoregional relapse and the highest in patients with liver metastases. When patients with locoregional recurrences were excluded, sensitivity improved: 31% (c-erbB-2), 33% (CEA) and 56% (CA 15.3), with 76% having at least one of the three tumour markers. C-erbB-2 sensitivity in early diagnosis was significantly higher in patients with c-erbB-2 overexpression in tissue (8/10, 80%) than in those without overexpression (1/30, 3.3%) (P = 0.0001). Likewise, higher levels of both, c-erbB-2 and CA 15.3 at diagnosis of recurrence, higher sensitivity in early diagnosis of relapse and a higher lead time were found in PR+ patients (CA 15.3, P < 0.0001) or in PR- patients (c-erbB-2, P = 0.009). Specificity of the tumour markers was 100% for all three markers (111 NED patients). In conclusion, c-erbB-2 is a useful tool for early diagnosis of metastases, mainly in those patients with c-erbB-2 overexpression in tissue. Using all three markers simultaneously it is possible to increase the sensitivity in the early diagnosis of recurrence by 11.2%.

Use of serial carcinoembryonic antigen and CA 15.3 assays in detecting relapses in breast cancer patients

To evaluate the utility of CEA and CA 15.3 for early diagnosis of recurrence, serial serum determinations of both antigens were performed in 1023 patients (follow-up: 1-10 years, mean 6.2 years) with primary breast cancer (CA 15.3 in 533 cases) and no evidence of residual disease (NED) after radical treatment (radical mastectomy or simple mastectomy and radiotherapy). 246 patients developed metastases during follow-up.

RESULTS

CEA and CA 15.3 were elevated ( > 10 ng/ml or > 60 U/ml, respectively) prior to diagnosis in 40% (98/246) and 41% (37/91) of the patients with recurrence, with a lead time of 4.9 +/- 2.2 and 4.2 +/- 2.3 months, respectively. When patients with locoregional recurrences were excluded, sensitivity improved to 46% (CEA) and 54% (CA 15.3), and to 64% with both tumor markers (CEA and/or CA 15.3). Higher levels of both CEA and CA 15.3 at diagnosis of recurrence, higher sensitivity in early diagnosis of relapse, and a higher lead time were found in ER+ (CEA) or PgR+ patients (CA 15.3) than in those that were negative for these receptors in the primary tumor (p < 0.001). Specificity of the tumor markers was 99% for both CEA (777 NED patients) and for CA 15.3 (444 NED patients), respectively. In conclusion, CEA and CA 15.3 are useful tools for early diagnosis of metastases, mainly in those patients with ER+ or PR+ tumors.

Tumor markers in breast cancer follow-up: a potentially useful parameter still awaiting definitive assessment. Forza Operativa Nazionale sul Carcinoma Mammario (FONCaM)

BACKGROUND

Although tumor markers are frequently used in the follow-up of patients with breast cancer, two points are still being debated: 1) their cost/effectiveness has been neither demonstrated nor disproved; 2) the reliability of the currently used dichotomous division into a positive/negative cut-off should be definitely validated. Dynamic criteria of interpretation based on serial serum samples would probably be more effective for early detection of relapse.

PATIENTS AND METHODS

The aim of the present study was to compare the dichotomous cut-off based decision criteria to a dynamic serial sample based assessment of tumor markers. Since 1989, 794 patients have been followed in 11 institutions. CEA and CA15.3 were measured once a month for three months before every clinical examination. The present paper concerns the evaluation variability in 405 patients without evidence of disease in the first three institutions joining the study.

RESULTS

In patients without evidence of disease, the coefficient of variation of all samples for every patient showed a median value of 19 for CEA and 21 for CA15.3. Variability was negatively associated with the antigen level and was most likely due to the analytical component. This was also confirmed by the significant difference in variability among the three institutions evaluated. The median value of the critical difference was 53% for CEA and 57% for CA15.3.

CONCLUSIONS

1) Individually tailored dynamic decision criteria are applicable in about 50% of the cases. 2) The problem of improving the precision of tumor marker assays in the low dose range must be urgently addressed to the manufacturers of tumor markers by the scientific community in order to apply individually tailored decision criteria for patients in whom the serum level of biological markers is low.

A novel method for monitoring high-risk breast cancer with tumor markers: CA 15.3 compared to CEA and TPA

BACKGROUND

An early and reliable diagnosis of metastatic spread has increased interest in serum tumor markers. This study investigated the ability of CA 15.3, CEA, and TPA to identify, predict, and exclude metastases in bone/viscera during adjuvant treatment and follow-up of high-risk breast cancer.

METHODS

Ninety females with high-risk breast cancer were included in the study. Response evaluation was based upon clinical examination, x-rays or histology and elaborated marker criteria.

RESULTS

During the marker monitoring period, metastases in four patients were confined to skin or lymph nodes, 21 developed metastases to bone/viscera, and 65 females had no evidence of metastases. CA 15.3, CEA, and TPA correctly classified 48%, 10%, and 19% of the patients with metastases in bone/viscera, and 100%, 94%, and 98% without. Following CA 15.3, CEA, and TPA recurrence, 100%, 33%, and 60% of the patients developed metastases in bone/viscera. Metastases in bone/viscera were excluded in 86%, 76%, and 79% of patients without CA 15.3, CEA, and TPA recurrence.

CONCLUSION

Only CA 15.3 gave reliable information about recurrence. Metastases in bone/viscera were identified in 10 of the 21 patients with CA 15.3. There was no false-positive CA 15.3 information on the 65 patients without clinical recurrence. The PVneg (86%) indicated that when CA 15.3 did not signal recurrence, metastases to bone/viscera were not likely.

Placental isoferritin (PLF) in comparison with MCA and CEA in advanced breast cancer--first data from a pilot study

The development of new and effective marker substances has optimized tumor-marker-guided follow-up programs to monitor generalization of disease and to assess the therapeutic outcome. Isoferritins of placental origin were first determined in the serum of patients with lymphoproliferative disease by way of the recently developed monoclonal antibody CMH-9. We have set up an Austro-Israeli working group and analysed 64 patients in terms of the sensitivity of placental ferritin (PLF) compared with the standard markers carcinoembryonic antigen (CEA) and mucinous-like cancer-associated antigen (MCA) in patients with metastatic breast cancer. We have additionally evaluated the importance of combined marker determination. Analysis of the data in view of site of metastatic spread yielded satisfying results both for PLF (sensitivity 70.4%) as well as MCA (sensitivity 76.9%) for visceral metastases; a combination of these two markers revealed a striking sensitivity of 88.4%, which, however, could not be improved by adding the third marker (CEA). With regard to non-visceral metastases, CEA and MCA were clearly superior.

The role of serum CEA as a prognostic indicator in stage II and III breast cancer patients treated with adjuvant chemotherapy

Carcinoembryonic antigen (CEA) values in 529 patients treated in two consecutive adjuvant chemotherapy protocols were analyzed to determine if CEA values correlated with disease-free status or prognostic utility. CEA values were evaluated preoperatively, before chemotherapy, at the conclusion of chemotherapy, and during postchemotherapy followup. The sensitivity of CEA for predicting disease recurrence was low; however, any abnormal CEA at the conclusion of chemotherapy and during followup significantly correlated with reduced disease-free and overall survival. A CEA value greater than or equal to 20 ng/ml at the end of chemotherapy or during followup was highly specific and a strongly positive predictor for the presence of metastases. Abnormal CEA values before chemotherapy that became normal at the conclusion of chemotherapy were associated with a significantly reduced recurrence rate. An abnormal CEA value obtained before or after adjuvant chemotherapy is clinically useful and can provide prognostic information.

Carcinoembryonic antigen in breast cancer. Clinical review

Carcinoembryonic antigen is widely used as a tumor marker for gastrointestinal neoplasms. Its role in the management of other tumors is poorly defined. This review considers the place of carcinoembryonic antigen measurement in the management of breast cancer and concludes that sufficient data exist to support its use in clinical practice. Of the many potential uses, the major role for carcinoembryonic antigen measurement in breast cancer is in following patients with advanced disease, especially patients with bone metastases.

Monitoring serum CEA in women with primary breast tumours positive for oestrogen receptor and with spread to lymph nodes

Serum carcinoembryonic antigen concentrations (serum CEA) in 80 patients with primary breast cancer were measured preoperatively, one month after operation, and thereafter serially every third month. These data were related to histological and morphometric features of the primary breast carcinoma and the lymph node metastases and to clinical follow up data. Analysis of the serum CEA values showed significant correlations with size of tumour, the presence of lymph node metastases, oestrogen receptor, and occurrence of distant metastases. Furthermore, the results indicated that serial determination of serum CEA in the first two years after operation may be useful in monitoring for the occurrence of distant metastases in patients with metastatic spread to lymph nodes and with large (greater than or equal to 2 cm) primary breast tumours positive for oestrogen receptor. In agreement with other studies, however, it was found that the predictive value of serum CEA concentrations in general is weak and costs may prohibit the implementation of the routine assessment of CEA concentrations.

Monoclonal antibodies to breast cancer-associated antigens as potential reagents in the management of breast cancer

Monoclonal antibodies reactive with the surface of human breast carcinoma cells have been generated and characterized. The immunogens used were membrane-enriched fractions of metastatic carcinoma lesions. The various monoclonals were shown to react with previously known as well as with novel tumor-associated antigens (TAAs). The most specific of the latter group is monoclonal B72.3, which is reactive with a 220,000 to 400,000 high-molecular-weight glycoprotein complex found in 50% of human mammary carcinomas and 80% of human colon carcinomas. Monoclonal antibody B6.2, which recognizes a 90,000-d glycoprotein, was radiolabeled and shown to efficiently localize human carcinoma transplants in athymic mice via gamma imaging without the use of second antibody or background subtraction manipulations. F(ab')2 and Fab' fragments were shown to be more efficient for tumor localization than intact immunoglobulin. Whereas the phenomenon of antigenic heterogeneity of tumor cell populations has long been known to exist, this phenomenon was also shown to manifest itself as antigenic modulation, in which specific TAAs can modulate their expression on the cell surface concurrent with different phases of the cell cycle. A phenomenon known as antigen evolution, in which a specific cloned tumor cell population can gradually drift in antigenic phenotype, has also been demonstrated. Recombinant interferon has been employed to (1) enhance the expression of specific TAAs on the surface of tumor cells already expressing the antigen; and (2) induce the expression of specific TAAs on the surface of carcinoma cells not previously expressing the antigen. The clinical implications of such phenomena in gamma scanning for the detection of tumor masses and for tumor immunotherapy are discussed. Methods for circumvention of problems inherent in the clinical use of monoclonal antibodies are also addressed.

Differential binding to human mammary and nonmammary tumors of monoclonal antibodies reactive with carcinoembryonic antigen

Splenic lymphocytes of mice immunized with membrane enriched fractions of human mammary carcinomas were fused with the NS-1 nonsecretory++ myeloma cell line. The resulting hybridomas were screened for the synthesis of immunoglobulins reactive with human mammary tumor associated antigens, and two IgG monoclonal antibodies (B1.1 and F5.5) were identified as being reactive with purified carcinoembryonic antigen (CEA). These antibodies were shown to bind to different epitopes on CEA based on their differential reactivities to five different purified CEA preparations, and their differential binding to the surface of tumor cells derived from various organ sites. Monoclonal B1.1 bound equally to the surface of human breast, colon, and melanoma cell lines. Monoclonal F5.5, on the other hand, did not react with the surface of melanoma cell lines, and showed a differential binding to breast carcinoma versus colon carcinoma cells. Monoclonals F5.5 and B1.1 were both used in immunoperoxidase studies with fixed tissue sections of a variety of histologic types of human mammary carcinomas and were shown to be reactive with 55% and 66%, respectively, of tumor masses.