Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups

Purpose

Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created.

Methods

Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS.

Results

30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]).

Conclusion

DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06082-y.

Clinical Profile of a New Monoclonal Antibody-Based Immunoassay for Tissue Polypeptide Antigen

Our preliminary evaluation of a new monoclonal antibody-based assay for tissue polypeptide antigen (TPA) has shown it to be clinically equivalent to the polyclonal antibody-based assay for TPA. The new assay (TPA-M) employs three monoclonal antibodies to epitopes on cytokeratins 8, 18 and 19. This multicenter, multinational study included 266 patients with newly diagnosed carcinomas of the lung, breast, large bowel and urinary bladder. TPA values from the two assays were compared with three other cytokeratin markers (TPS, CYFRA 21–1 and TPACyk) and with the established reference markers for these malignancies (CEA and NSE for lung, CA 15–3 for breast, CEA and CA 19–9 for colorectal tumors). Analysis of receiver operating characteristic (ROC) curves in lung, colorectal and bladder cancer showed similar sensitivities for the two assays, ranging from 50% to 80% with a specificity of 95%. In breast cancer all the markers studied showed poor sensitivity. However, TPA determination by either method could discriminate advanced stage (stages III and IV) from early stage disease (stages 0 to II). TPA showed similar discriminating ability in bladder cancer. On the basis of the results obtained in our patient series, it seems that of the cytokeratin markers studied, TPA and TPA-M are the most sensitive and offer a wide range of clinical applications.

An International Proficiency Study with the Tumor Marker CA 125

A strict and adequate quality assurance program is the only real guarantee of the reliability of laboratory test results. Such proficiency testing was carried out for the CA 125 test system in five university laboratories over a period of three years (1984 - 1987) using five different reference materials (BIOREF, FRG). A concentration-dependent performance profile could thus be established evaluating a total of 301 assays. Intra-assay precision of the test ranged between 4.8 and 11.5%, and interassay precision between 13.6 and 19.1%. Laboratory specific average values of the individual reference materials ranged between 26 and 32 U/ml for reference 1, 51 and 59 U/ml for reference 2, 109 and 121 U/ml and 193 to 240 U/ml for references 3 and 4, respectively. Mean values for reference 5 ranged between 401 and 458 U/ml. There was no significant difference between mean values for the laboratories. Considerable batch-dependent variations of values became evident during the study but these were not indicated by the kit control supplied by the manufacturer. During the whole investigation period no systematic drift in values could be observed using trend analysis, indicating excellent stability of the reference material if stored frozen (–20°C).

Radioimmunbehandlung solitärer Lebermetastasen mittels intratumoraler Instillation 131J-markierter monoklonaler Antikörper - Erste Ergebnisse einer klinischen Studie

Solitary liver metastases (carcinoembryogenic antigen positive) in two patients suffering from colon carcinoma were multifocally injected with 131I- labelled monoclonal antibodies (131I-MAb) against the carcinoembryogenic antigen (CEA). The 131I activity in the metastases decreased biexponentially. The131I serum concentration declined triexponentially in patient 1 and mono- exponentially in patient 2. The radiation dose to the whole tumor volume amounted to 358 Sv and 762 Sv, respectively; the whole-body radiation dose was 87.5 mSv for patient 1 and 39.0 mSv for patient 2. Complications did not occur. Before treatment there had been a volume doubling time of the metastases of 1.5 and 0.9 months, respectively; this contrasts with a constant tumor volume after treatment as observed over the follow-up period of 3.5 and 2 months, respectively. The CEA serum concentration decreased after131I-MAb instillation within 1.5 and 2.5 months to 66% and 58%, respectively, when compared with values immediately before treatment. On the basis of these results the intratumoral application of 131I-MAb appears in selected cases to be a suitable method of slowing down growth of liver metastases from gastrointestinal tumors.

Immunoscintigraphy and Radioimmunotherapy in Patients with Pancreatic Carcinoma

A new monoclonal antibody (BW 494/32) labeled with 131I or 111ln was used for planar and tomographic immunoscintigraphy (IS) in patients with pancreatic carcinoma. It appears that a) IS for pancreatic carcinoma and its metastases remains a hopeful but still difficult procedure and b) labeling with 111In is of advantage and results in more convincing images in the case of tumor lesions distant from liver and spleen. Attempts at radioimmunotherapy with 131l-anti- CA19-9 and with 131l-494/32 in a patient with local recurrence of a pancreatic cancer and with large liver metastases were without success because of extremely poor blood supply to the metastatic tumor masses. Intraarterial infusion of the tracer without or with blockade and perfusion of the common hepatic artery with saline solution could not enhance the tracer uptake compared to that after intravenous infusion. High intratumoral concentrations, however, as achieved e. g. by intratumoral instillation in animal studies, represent a necessary precondition for effective β-irradiation of tumor lesions.

Radioimmunotherapy of Xenografts of Human Pancreatic Carcinomas - Intravenous and Intratumoral Application of 131l-Labelled Monoclonal Antibodies

The effects of radioimmunotherapy were tested in xenografts of 2 different human pancreatic carcinomas comparing the intravenous and intratumoral application. On principle, intravenous injections of high doses of 131l-anti- Ca 19-9 or -BW 494/32 may inhibit tumor growth. In view of the low direct radiation dose (360-2100 rad), however, other factors than direct toxic effects have to be discussed, e. g. systemic effects due to the high whole-body irradiation. Intratumoral application, however, may induce tumor regression or growth inhibition due to the high local irradiation dose. Consequently, this treatment modality might be of clinical value at least in some patients.

Immunoscintigraphy and SPECT in Patients with Pancreatic Carcinom

Auf der Basis ermutigender Veröffentlichungen über die Immunszintigraphie bei kolorektalen Karzinomen sowie eigener immunhistochemischer und immunszintigraphischer Befunde an Pankreaskarzinom-Transplantaten auf der Nacktmaus untersuchten wir die diagnostischen Möglichkeiten mit 131J-markierten Antikörpern gegen die Tumor-Marker CA 19-9 und CEA bei 21 Patienten mit Pankreaskarzinom. Zum Vergleich dienten die Untersuchungsergebnisse von weiteren 10 Patienten mit kolorektalem Karzinom, 2 Patienten mit Gallengangs- und 1 mit Magen-Karzinom. Planare Szintigramme der Verdachtsregionen in 2-4 Sichten wurden mehrfach bis 6 Tage nach i.v. Infusion von 2 mCi eines Cocktails aus 131J-anti-CA 19-9 und -anti-CEA aufgenommen. SPECT wurde außerdem 3-4 Tage p.i., zuletzt auch früher, durchgeführt. Primäre Tumoren und Metastasen im Oberbauch waren wegen geringerer Tumor/Umgebungs-Relation der Traceraktivität schwieriger nachzuweisen und zu lokalisieren als kolorektale Karzinome im Unterbauch. Die Tumorabgrenzung wurde in planaren Szintigrammen meist erst 5-6 Tage p.i. oder später erkennbar. SPECT wies dieselben Befunde bereits 3 Tage p. i. oder früher nach. Die Lokalisation und die topographische Zuordnung gelang mit SPECT leichter und häufiger, somit der Nachweis sicherer und empfindlicher. Größere Tumoren stellten sich auch in Fällen ohne erhöhte Serumkonzentration der Tumormarker dar. Der Immunszintigraphie des Pankreaskarzinoms und anderer Karzinommanifestationen im Oberbauch kommt gegenwärtig eine eingeschränkte diagnostische Bedeutung zu; methodische Verbesserungen erscheinen notwendig und möglich.

Treatment of Giant Fibroadenoma in Young Women: Results after Tumor Excision without Reconstructive Surgery

Introduction: Giant fibroadenoma (GFA) of the breast is defined as fibroadenoma larger than 5 cm, usually presenting unilaterally and manifesting as breast asymmetry or deformity of the breast. Material and Methods: A retrospective database search was done of all patients with giant fibroadenoma who underwent surgery for GFA in the breast center of Hanover Medical School between 2007 and 2014; all patients with GFA were followed up. Data were analyzed with regard to tumor and patient characteristics and esthetic outcome. Results: A total of 13 patients with symptomatic GFA underwent surgery between 2007 and 2014. Mean patient age was 21.2 years (range 14-31 years). In 8 of 13 patients the tumor had resulted in breast deformity and/or breast asymmetry. Average size of the mass was 10.2 cm (range 8.5-12 cm) and average weight was 203.6 g (range 151.2-323.5 g). Initial clinical suspicion of GFA was confirmed by ultrasound examination. Preoperative core biopsy revealed fibroadenoma in 8/13 cases, cellular fibroepithelial lesions with a differential diagnosis of benign phyllodes tumor in 3 cases and unspecific histological findings in the remaining 2 cases. Conclusion: Excision was done using an inframammary or periareolar approach without reconstructive plasty. The cosmetic results were good, as were the outcomes on follow-up. We therefore favor this surgical technique to treat giant fibroadenoma of similar size to those described above.

SPECT/CT for SLN dissection in vulvar cancer: Improved SLN detection and dissection by preoperative three-dimensional anatomical localisation

OBJECTIVE

In this study, we assessed the feasibility and clinical advantages of single photon emission computed tomography with CT (SPECT/CT) for sentinel lymph node (SLN) detection in vulvar cancer.

METHODS

This is a unicentric prospective trial. Vulvar cancer patients underwent preoperative SLN marking (10MBq Technetium (TC)-99m-nanocolloid) and subsequent planar lymphoscintigraphy (LSG) and SPECT/CT for SLN visualization. Directly before surgery, a patent blue dye was injected. We assessed detection rates of SPECT/CT and those of planar LSG and intraoperative detection. We analyzed the sensitivity, negative predictive value and false negative rate.

RESULTS

At Hannover Medical School, 40 vulvar cancer patients underwent SLN dissection after preoperative LSG and SPECT/CT. The mean diameter of all tumors in final histology was 2.23 (0.1-10.5) cm with a mean tissue infiltration of 3.93 (0.25-11) mm. In preoperative imaging, SPECT/CT identified significantly more SLNs (mean 8.7 (1-35) LNs per patient) compared to LSG (mean 5.9 (0-22) LNs, p<0.01). In addition, SPECT/CT led to a high spatial resolution and anatomical localization of SLNs. Thus, SPECT/CT identified aberrant lymphatic drainage in 7/40 (17.5%) patients. There were no significant differences, but significant correlation was found between SPECT/CT and intraoperative SLN identification. Regarding inguino-femoral LNs, for all patients who underwent complete groin dissection, sensitivity was 100%, NPV was 100% and false negative rate was 0%.

CONCLUSION

SPECT/CT leads to higher SLN identification compared to LSG in vulvar cancer. Due to its higher spatial resolution and three-dimensional anatomical localisation of SLNs, SPECT/CT provides the surgeon with important additional information, facilitates intraoperative SLN detection and predicts aberrant lymphatic drainage.

Isthmocervical labelling and SPECT/CT for optimized sentinel detection in endometrial cancer: technique, experience and results

OBJECTIVE

We evaluated the clinical feasibility of a new injection technique for sentinel detection in endometrial carcinoma (EC), transcervical subepithelial injection into the isthmocervical region of the myometrium. We compared detection of sentinel lymph nodes (SLN) by single photon emission computed tomography with CT (SPECT/CT) with planar lymphoscintigraphy.

METHODS

This is a unicentric prospective study. In all patients, transcervical injection of 10 MBq Technetium-99m-nanocolloid was performed into the isthmocervical myometrium without anaesthesia. After 40 (30-60) min, lymphoscintigraphy and SPECT/CT were performed. Patent blue was administered before surgery. The number and localisation of SLN detected in SPECT/CT and lymphoscintigraphy were recorded and compared to the SLN and non-SLN dissected intra-operatively.

RESULTS

Between August 2008 and March 2012, 31 patients with EC were enrolled. The new transcervical injection of labelling substances led to high intra-operative (90.3%) detection rates, pelvic bilateral (57%), para-aortic (25%). SPECT/CT significantly identified more SLN than lymphoscintigraphy (mean 2.2 (1-8) to 1.3 (1-7)) in more patients (29/31 (93.5%) to 21/31 (68%), p<0.01). If SLN were identified in one hemi-pelvis, the histological evaluation of the SLN correctly predicted lymph node (LN) metastases for this basin which led to sensitivity 100%, negative predictive value (NPV) 100%, and false negative results 0%.

CONCLUSION

Transcervical SLN marking in combination with SPECT/CT is easily applicable and leads to high physiologic detection rates in pelvic and para-aortic lymphatic drainage areas. Non-affected SLN truly predicted a non-affected LN basin. Combining both methods SLN dissection may be a safe and feasible staging technique for clinical routine in EC.

European proficiency study with control serum for the tumor marker CA 19-9 measured on different test systems

BACKGROUND

Reliable and precise CA 19-9 testing is required for the long-term follow-up of patients with pancreatic carcinoma during therapy. The aim of this longitudinal proficiency study was to evaluate the comparability, linearity, and precision of CA 19-9 determinations performed in different laboratories using currently available test systems under routine conditions.

METHODS

During the one year study period, 15 laboratories applied 7 different tests and included a liquid BIOREF control serum with pancreatic carcinoma derived CA 19-9 in their routine testing and quality control procedures. The results were collected centrally and evaluated statistically.

RESULTS

The comparability of CA 19-9 results is limited especially when different tests are used, albeit, some tests show a good correlation: The CA 19-9 values obtained by different laboratories using different test systems vary up to a factor of 2. The precision of CA 19-9 determinations was acceptable in most laboratories with coefficients of variation ranging between very low 3.2% and high 17.8%. The imprecision was slightly increased when automatic dilution procedures of the analysers were used.

CONCLUSIONS

The comparability of CA 19-9 test results must be improved. The precision is acceptable in most cases. In order to monitor key performance parameters, every laboratory should participate in external quality assessment schemes and should perform a routine internal quality control with a control serum independent from the test kit manufacturer.

Vitamin D status and per-oral vitamin D supplementation in patients suffering from chronic pancreatitis and pancreatic cancer disease

Exocrine pancreatic insufficiency due to chronic pancreatitis may result--depending on the degree of insufficiency--, in a decrease in serum 25-hydroxyvitamin D (25(OH)D) level. However, the data in the literature concerning the rate and extent of vitamin D deficiency in pancreatic cancer with or without previous pancreas resection, are very rare, in particular regarding the question how to supplement these patients with vitamin D. In recent years, vitamin D is increasingly being discussed as one factor involved not only in musculo-skeletal diseases but also in cardiovascular and autoimmune diseases, cancer development, diabetes mellitus and overall mortality.

PATIENTS AND METHODS

In all, 248 ambulatory patients (n=140 patients suffering from exocrine pancreatic insufficiency due to chronic pancreatitis, pancreatic cancer with/without previous resections of the pancreas n=108 patients without pancreatic disease), we measured the serum 25(OH)D concentrations by the chemoluminescence method. In addition, in 91 of these patients (n=65 pancreatic patients, n=26 controls), we started supplementation with oral vitamin D in combination with dietary advice and adequate substitution with pancreatic enzyme preparations, followed by subsequent serum 25(OH)D determinations. The oral vitamin D doses varied from 1000 IU per day over 1× 20,000 IU per week, or 2-3 times 20,000 IU per week up to 20,000 IU per day in single patients, depending on the underlying disease and the estimated degree of maldigestion/malassimilation. In addition, in a pilot trial vitamins A and E were measured in the serum from 121 and 105 of these patients respectively (resp.) (HPLC method).

RESULTS

Serum 25(OH)D concentrations were <30 ng/ml in 93% of the patients with pancreatic diseases,<20 ng/ml in 77.9%, <10 ng/ml in 32.1% and <4 ng/ml in 9.3%. The results were comparable to those in patients suffering from chronic pancreatitis and those with pancreatic tumor disease, with or without a previous tumor resection (n=51 Whipple procedure, n=11 left resection, n=9 total duodeno-pancreatectomy). Similar data were also found in the controls, only slightly higher. In contrast to the vitamin D data, however, determination of vitamins A and E in the serum resulted in values within the normal range for the majority of the patients of both groups, suggesting a diminished vitamin D uptake as being at least one reason to explain the low serum vitamin D concentrations in the patients with pancreatic diseases. Individual supplementation with oral vitamin D in all patients studied (n=91) resulted in an increase of the serum 25(OH)D concentrations into the normal range (14.2±5.8 up to 42.3±12 in controls, 11.9±7.4 up to 46.6±15.7 in patients with pancreatic diseases). The data of a subgroup of patients with continuous long-term supplementation, however, suggest that some patients with pancreatic diseases may need a significantly higher vitamin D supplementation, up to 20000 IU per day in single patients, compared to the controls.

CONCLUSION

The results demonstrate that vitamin D deficiency is a common problem in patients suffering from exocrine pancreatic insufficiency from various reasons as well as in our controls. Apart from insufficient sun exposure, exocrine pancreatic insufficiency, as well as a too low vitamin D uptake with food seem to represent the main causes of low serum 25(OH)D. In nearly all patients, the serum 25(OH)D concentrations could be normalized by oral supplementation of vitamin D in the case of individual therapy based on routine serum controls.

Combination therapy with gemcitabine (GEM) and erlotinib (E) in exocrine pancreatic cancer under special reference to RASH and the tumour marker CA19-9

We report on the results of a prospective treatment of 30 proven metastatic pancreatic cancer patients with the recently described combination of gemcitabine and erlotinib (GEM+E) (24× 1st line therapy, 8× 2nd line therapy). Eight of these patients received GEM+E for treatment of metastastic tumour recurrence after previous resective surgery, followed by adjuvant chemotherapy with gemcitabine. In 2 patients GEM+E was given as 1st line treatment and later, after complete response which was followed by a new recurrence, also as a second line therapy. The evaluation of RASH severity grades, the course of the serum tumour marker CA19-9 were determined every 14 days and the evaluation of the imaging methods CT or MRT, evaluated every 6-8 weeks, revealed the following results: there was a tendency for RASH grades to correlate with the tumour response, however, with observed exceptions. The decision for interruption or maintenance of GEM+E, therefore, should not be based on the RASH phenomenon, but on a detailed follow-up with imaging methods and the relevant tumour markers as in the follow-up before erlotinib introduction into pancreatic cancer therapy. As known from previous studies tumour markers represent more sensitive parameters compared to the imaging methods. GEM+E was active in the whole group of patients, mainly given as 1st line therapy (34% PD, 29% SD, 47% MR, PR, CR), but also in the 2 subgroups: in the patients with GEM+E as 2nd line therapy, as well as in patients after previous adjuvant gemcitabine therapy after tumour resection. In the 2 patients with transient-CR after 1st line therapy with GEM+E the 2nd line therapy also resulted in a CR with long lasting remission. These data should motivate clinicians to focus their interest not only to 1st line therapy regimens with erlotinib, but also to 2nd and 3rd line strategies within the previously published concept of an efficacy-orientated sequential polychemotherapy or multimodal-therapy for pancreatic cancer.

Alpha-1-Fetoprotein (AFP): international proficiency study with different test systems

BACKGROUND

The present proficiency study aimed to elucidate the comparability and reliability of test systems for the determination of AFP concentrations.

METHODS

25 laboratories using 8 different commercial test systems used liquid BIOREF-AFP control serum in their routine internal quality control over a period of one year. For statistical analysis the results were collected centrally.

RESULTS

The statistical analysis of the test results revealed considerable variation for the different laboratories. The deviations of the mean values of different laboratories from the overall mean value varied between 0.1 and 26.1%, and for most of the laboratories the deviation was round about 10%. The precision of measured values in the individual laboratories was in most cases acceptable: Nevertheless, the coefficients of variation of the individual laboratories ranged from 13 to 16.1%.

CONCLUSIONS

In conclusion, this study indicates that AFP results vary between different laboratories albeit an international standard for AFP is available. Therefore, every laboratory should participate in external ring studies and should use a quality control serum independent of the test kit manufacturer for the internal quality control.

CA19-9 serum concentrations--analysis of the serum kinetics during first-line therapy of pancreatic cancer in relation to overall survival

In order to investigate the use of CA19-9 serum concentration kinetics during first-line chemotherapy of pancreatic cancer as a potential predictive prognostic factor for overall survival, we retrospectively analysed the data of 47 patients suffering from proven exocrine pancreatic cancer. The patients were treated following our concept of efficacy-orientated sequential palliative chemotherapy (EOSPC), on the basis of a short-term follow-up including CA19-9 determinations at least monthly and imaging methods CT and/or MR every 2 months. The results are in agreement with our previous reports suggesting an increase of survival of pancreatic cancer patients in relation to the number of effective treatment regimens applied. However, apart from a weak correlation between the lowest CA19-9 levels induced by the first-line therapy (as a % of the initial pretherapeutical CA19-9 levels) and progression-free survival there was no correlation between the various parameters of serum kinetics of CA19-9 in the course of the first-line therapy and overall survival of the patients. A potential correlation as reported by others seems to be confirmed in our patient group by the potential antitumoral and life-prolonging effects of the second- and third-line therapies.

Tumor markers in pancreatic cancer: a European Group on Tumor Markers (EGTM) status report

Pancreatic ductal adenocarcinoma is one of the most difficult malignancies to diagnose and treat. The aim of this article is to review how tumor markers can aid the diagnosis and management of patients with this malignancy. The most widely used and best validated marker for pancreatic cancer is CA 19-9. Inadequate sensitivity and specificity limit the use of CA 19-9 in the early diagnosis of pancreatic cancer. In non-jaundiced patients, however, CA 19-9 may complement other diagnostic procedures. In patients with resectable pancreatic cancer, presurgical and postresection CA 19-9 levels correlate with overall survival. In advanced disease, elevated pretreatment levels of CA 19-9 are associated with adverse patient outcome and thus may be combined with other factors for risk stratification. Most, but not all, reports indicate that serial levels of CA 19-9 correlate with response to systemic therapy. Use of CA 19-9 kinetics in conjunction with imaging is therefore recommended in monitoring therapy. Although several potential serum and tissue markers for pancreatic cancer are currently undergoing evaluation, none are sufficiently validated for routine clinical use. CA 19-9 thus remains the serum pancreatic cancer marker against which new markers for this malignancy should be judged.

Reflections on treatment strategies for palliative chemotherapy of pancreatic cancer

Following our concept of efficacy-orientated sequential polychemotherapy, we report on the results of palliative chemotherapy in 69 patients suffering from exocrine pancreatic cancer, admitted to our unit in 2004. Evaluation of tumor response was mainly based on the serum courses of the tumor markers CA 19-9 and CEA; in addition, the modern imaging methods CT or MRT, including MRCP and MR-angiography, were performed bi-monthly. The median survival of the 69 patients (65% metastasized stages) was 16 months. The median survival increased with the number of effective treatment sequences, for the whole group from 5 to 10 and 23 months in relation to 0, 1 and > 1 effective sequences respectively. The results support our concept of EOSPC in pancreatic cancer patients, compared to clinical studies following protocols with only 1 treatment sequence and median survival rates of no more than 6-9 months. Compared to the efficacy-orientated sequential polychemotherapy (EOSPC) concept, which does not exclude but also allows the inclusion of clinical trials for further evaluation of new drugs or drug combinations, the common practice looking for survival in studies following protocols with only 1 treatment sequence might represent a negative predictive factor with respect to overall survival, as can be demonstrated by a comparison of our data with relevant recent literature. Our results further indicate that the interest of the clinicians and companies should not be focused only on first-line therapies, but also on 2nd- and 3rd-line strategies, as in our patients a second- and third-line therapy could be started in 73% and 68% of the patients respectively.

Tumour markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines for clinical use

The aim of this article is to present updated guidelines for the use of serum, tissue and faecal markers in colorectal cancer (CRC). Lack of specificity and sensitivity preclude the use of all existing serum markers for the early detection of CRC. For patients with stage II or stage III CRC who may be candidates for either liver resection or systemic treatment should recurrence develop, CEA should be measured every 2-3 months for at least 3 years after diagnosis. Insufficient evidence exists to recommend routine use of tissue factors such as thymidylate synthase, microsatellite instability (MSI), p53, K-ras and deleted in colon cancer (DCC) for either determining prognosis or predicting response to therapy in patients with CRC. Microsatellite instability, however, may be used as a pre-screen for patients with suspected hereditary non-polyposis colorectal cancer. Faecal occult blood testing but not faecal DNA markers may be used to screen asymptomatic subjects 50 years or older for early CRC.

Further evidence for prolongation of survival of pancreatic cancer patients by efficacy orientated sequential polychemotherapy (EOSPC) based on serial tumor marker determinations (CA 19-9/CEA)

The results of palliative chemotherapy in 55 patients suffering from exocrine pancreatic cancer are reported, following our concept of efficacy orientated sequential polychemotherapy (EOSPC). Tumor answer/regression was mainly analyzed on the basis of the serum courses of the tumor markers CA 19-9 and CEA. Up to four different treatment trials were tried in the individual patients. The results confirm previously published data: a prolongation of survival in relation to the number of effective treatments (CR/PR/MR/SD vs. PD). The median survival of the whole group of patients (n=55, including n=39 patients with distant metastasis) was 12 months. The results support our concept of EOSPC in pancreatic cancer patients in order to improve survival. Furthermore, the data should stimulate attention not only on new and potentially more effective 1st- line regimens, but also to effective 2nd- and/or 3rd-line treatments. Moreover, the results should encourage clinicians to rediscuss the actual concepts of prospective therapeutical trails mainly based on analyzing the effects of single agents or drug combinations on survival. Furthermore, a comparison of 1st-line treatments with gemcitabine as monotherapy, and in combination with mitomycin-C, confirms that the combination of gemcitabine + mitomycin-C seems to be more active than gemcitabine monotherapy and that this combination might also be of value as 2nd-line therapy after gemcitabine monotherapy.

Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines

In recent years, numerous serum and cell/tissue-based markers have been described for colorectal cancer (CRC). The aim of this article was to provide guidelines for the routine clinical use of some of these markers. Lack of sensitivity and specificity preclude the use of any available serum markers such as carcinoembryonic antigen (CEA), CA 19-9, CA 242, CA 72-4, tissue polypeptide antigen (TPA) or tissue polypeptide-specific antigen (TPS) for the early detection of CRC. However, preoperative measurement of CEA is desirable as this may give independent prognostic information, help with surgical management and provide a baseline level for subsequent determinations. For patients with stage 2 (Dukes' B) and 3 (Dukes' C) disease who may be candidates for liver resection, CEA levels should be measured every 2-3 months for at least 3 years after diagnosis. For monitoring treatment of advanced disease, CEA should also be tested every 2-3 months. Insufficient evidence is presently available to recommend the routine use of other serum markers for monitoring purposes. Similarly, the new cell and tissue-based markers (e.g, ras, P53) cannot yet be recommended for routine clinical use.

Atypical courses of serum tumor markers--4 case reports

We report on 4 cancer patients with transient unspecific elevations of the serum tumor markers CA 19-9, CEA, CA 125 and CA 72-4, respectively. In one patient cholangitis due to biliary obstruction induced a significant transient increase of CA 19-9, in another patient HUS, probably as a severe complication after Mitomycin-C + Gemcitabine therapy resulted in a significant increase of serum CA 125. One patient demonstrated an extensively elevated and inexplicable serum CA 19-9 concentration (9450 u/ml) during a period of abdominal pain with continuous decrease and finally normalization within the following 5 years. Also inexplicable is an unexpected remittent increase of serum CA 72-4 in the course of chemotherapy after gastrectomy for gastric carcinoma. The presented data underline the necessity of interpreting serum courses of tumor markers only in the light of all available clinical data, imaging data and other laboratory tests in order to avoid misinterpretations.

Sequential polychemotherapy in exocrine pancreatic cancer

The results of palliative chemotherapy in 162 patients suffering from exocrine pancreatic cancer are presented. They are mainly discussed with respect to the possibility of improving survival of exocrine pancreatic cancer patients by an efficacy-orientated sequential polychemotherapy (EOSP). In about 40% of the patients treated between 1998 and 2001, sequential chemotherapy induced more than one effective treatment in the case that SD after a progressive prephase as well as MR, PR and CR are considered as antitumoral efficacy. Sequential polychemotherapy seems to be able to prolong the survival of these patients. The whole group of patients showed a 1-year survival of 56% and a 2-year survival of 16%. Especially in the case of metastasized tumor disease (M1), sequential polychemotherapy seems to be able to prolong survival: 45% of the metastasized tumor patients survived more than 1 year, 12% more than 2 years. The median survival for the whole group of locally advanced tumors was 15 months and the median survival for the whole group of metastasized tumors was 8 months. The results should stimulate clinicians to try palliative chemotherapy for pancreatic cancer more actively than before and to rediscuss the actual concepts of prospective therapeutical trials mainly based on analysing the effects of single agents or drug combinations on survival.

Irinotecan(Campto R): efficacy as third/forth line therapy in advanced pancreatic cancer

Following the concept that the actual survival of pancreatic cancer patients can only be significantly improved by sequential poly-chemotherapy (EOSPC) in order to add one or two further progression free-survival times (PFST), in addition to the potential antitumoral effects of a first- or second-line therapy we studied the therapeutic efficacy of a third- or fourth-line chemotherapy with irinotecan alone, or in combination with oxaliplatin and high dose 5-FU/FA respectively, in a pilot study in 17 patients. Follow-up was performed on the basis of clinical investigations, imaging methods and the course of tumor markers, mainly CT and CA 19-9. The overall response rate in these cases of third/fourth-line therapies was 1 PR, 4 MR, 6 SD in the imaging methods compared to 5 PR, 2 MR and 5 SD on the basis of the tumor marker courses in the serum. The median PFST amounted to 4 months. Side effects could be seen as reported in the literature. Only in 1 patient did treatment have to be stopped due to irinotecan-induced gastrointestinal symptoms. Our data might suggest that combinations are more effective than irinotecan alone. However, further studies have to demonstrate whether irinotecan alone or in combination with e.g. oxaliplatin and 5-FU/FA will be more effective. The results suggested that irinotecan alone or in combination might also be used as third- and fourth-line therapeutical trials in exocrine pancreatic cancer in order to improve the survival time of these patients based on efficacy orientated sequential poly-chemotherapy (EOSPC).

Improved sensitivity of fuzzy logic based tumor marker profiles for diagnosis of pancreatic carcinoma versus benign pancreatic disease

BACKGROUND

The definite diagnosis of pancreatic tumors of unknown origin remains a clinical challenge. Imaging techniques may fail to differentiate malignant tumors from inflammation, especially in chronic pancreatitis. In a considerable number of cases, the definitive diagnosis needs laparotomy. Single tumor markers as CA 19-9 or CEA are of limited value in these cases because of their limited sensitivity and specificity. This study was performed to find out, whether a classification method based on fuzzy logic analysis of tumor marker profiles is feasible in patients with pancreatic carcinoma and benign pancreatic disease.

PATIENTS AND METHODS

Tumor markers and other clinical and laboratory parameters of 74 consecutive patients, either with histologically proved pancreatic carcinoma (n = 43) or presumed benign pancreatic disease (n = 31) assessed by ultrasound, endoscopic retrograde pancreatography, or computed tomography were analysed in order to detect their diagnostic value in the multi-dimensional approach of fuzzy logic analysis.

RESULTS

Given a specificity of 95%, sensitivity was considerably increased by the fuzzy logic method (83%) compared with the best single tumor marker CA 19-9 (65%). CA 19-9, CYFRA 21-1 and CA 15-3 gave the most considerable contributions to the classification system, whereas CEA, CA 125, CA 72-4, AFP, liver enzymes, lipase, amylase, bilirubin, and ferritin were of no or little value.

CONCLUSIONS

Tumor marker profiles analysed with the fuzzy logic method may have an improved sensitivity compared with single standard tumor markers. The diagnostic efficacy should be proved in patients with pancreatic tumors of unknown origin.

Improvement of survival by efficacy orientated sequential polychemotherapy of exocrine pancreatic cancer

Results of palliative chemotherapy in 104 patients suffering from exocrine pancreatic carcinomas are presented. First-line therapy included intraarterial approaches with gemcitabine + mitomycin-C and intravenous systemic treatments with gemcitabine, gemcitabine + mitomycin-C and oxaliplatin, respectively. In addition, it was the aim to improve survival by adding second- and third-line chemotherapies, mainly including high dose 5-FU/FA and irinotecan resp. alone or in combinations. Follow-up included clinical investigations, imaging methods and determination of tumor markers. Evaluation of efficacy followed the WHO guidelines. The results indicated the intraarterial locoregional treatment of exocrine pancreatic cancer with a combination of mitomycin-C + gemcitabine as a highly effective treatment modality with PR + CR of 40% measured by imaging methods and 81% analysed by tumor marker determinations. The survival analyses suggested relevant prolongation of survival in relation to the number of effective second- and/or third-line therapies (0/1/> 1) with median survival--based on the imaging data--of 7, 11 and 20 months for Mo tumors and 3, 8 and 14 months for tumor diseases with liver metastases at time of admission, respectively. Relevant preconditions for second- and/or third-line therapies of pancreatic carcinomas are given by more or less effective first-line treatment modalities of this cancer disease on the one hand and by the actual diagnostic aids allowing the beginning of first-line therapy as well as the detection of recurrence early enough to try a second- or third-line therapy before clinical/ethical aspects prevent further antitumoral treatment trials in the individual patient.

Tumor marker determination after orthotopic heart transplantation

BACKGROUND

Because the risk of developing malignant tumors after heart transplantation is approximately 100-fold higher, methods for rapid diagnosis must be developed to allow early and aggressive treatment in these patients. Although tumor markers have been used frequently for surveying already detected cancer, we studied their value in screening for tumors in heart transplant patients.

METHODS

The levels of the tumor markers CEA, CA19-9, CA125, CA72-4, TPA, TPS, and CYFRA 21-1 were determined prospectively in 3-month intervals in 91 heart transplant patients between 1993 and 1998.

RESULTS

In eight patients a definite diagnosis of cancer was made during the marker survey (mean observation time 2.85 +/- 1.3 years), including bronchogenic carcinoma in six, renal carcinoma in one, and colon cancer in one. All patients with bronchogenic carcinoma were smokers. The markers had a sensitivity below 60% to detect cancer. Given a 2-fold cutoff level (10 ng/mL), the CEA was the only marker with sufficient specificity (93.8%, only one false-positive result). Two patients were symptom-free even though they had elevated CEA levels. In one of those patients, disseminated intractable cancer was diagnosed at first evaluation, whereas no tumor was found in the other case at first evaluation. Subsequently, by means of fluorodeoxyglucose positron emission tomography, a hypermetabolic region was found in the right upper mediastinum. Control computed tomographic scan 4 weeks after the first investigation showed disseminated intractable disease also in this patient. Another heart transplant patient with colon cancer showed a normalization of the CEA after hemicolectomy and an increase in the CEA when liver dissemination developed. There was a relationship between cardiac death and CA125 and TPS in some heart transplant patients.

CONCLUSIONS

We conclude that the CEA is the only tumor marker with adequate sensitivity and specificity to detect subclinical malignancies in the follow-up of heart transplant patients. However, because of several limitations (limited diagnostic and therapeutic possibilities and enormous costs), we cannot recommend screening by tumor markers on a regular basis. Because of the elevated risk of cancer in patients who had organ transplantation, further prophylactic measures, especially smoking cessation programs, must be developed. Once a malignancy is diagnosed, tumor markers can help target clinical decisions. Additionally, nonspecific increases in CA125 and TPS levels might be related to nonmalignant circulatory disturbances and cardiac death.