Sixty second-look procedures indicated primarily by rise in serial carcinoembryonic antigen

doi:10.1016/0022-4804(80)90100-6

Journal of Surgical Research

Volume 28, Issue 5, May 1980, Pages 389-394

https://doi.org/10.1016/0022-4804(80)90100-6 Get rights and content

Abstract

Recurrent tumor was present at second-look operations in 56 of 60 patients (93.3%) reoperated upon during the past 7 years solely because serial carcinoembryonic antigen (CEA) values rose. Recurrent tumor was later identified in three of the remaining four patients; the fourth had severe liver disease and was undergoing hepatotoxic chemotherapy. Twenty-two patients were evaluated retrospectively; 38 patients entered in a protocol are termed prospective patients (60.5%). Delay between rise in CEA and reoperation in retrospective patients with unresectable tumor was 7 months, in contrast to 3.5 months in those with resectable tumor; while delay in prospective patients with unresectable tumor was 4.5 months and in those with resectable tumor only 1.5 months. Groups were similar according to Dukes' classification: B-7, C-14, D-1 (retrospective); B-10, C-26, D-2 (prospective). Serial CEA determinations every 6 weeks for the first 24 months detected recurrent tumor in 93.3% of patients. Incidence of resectable tumors increased when delay between rise in CEA and reoperation was shortened. Twenty-one patients (35%) remain disease-free, the longest time more than 7 years. One additional negative second-look patient is apparently free of tumor. No operative death has occurred, and major operative morbidity remains low (<10%).

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Citation Excerpt :
This combination of CEA, ultrasound and CT scanning has been shown to detect the highest number of CRC recurrences [33]. If CEA levels were to be used alone as a screening tool, the best results, although inferior, were obtained in those studies where CEA measurements were performed at monthly intervals during the follow-up period [34]. The inability to attain a high sensitivity may be partly attributed to non-CEA producing tumours which commonly produce a false negative result.
The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer.
Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a ‘positive’ CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken.
The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61–0.67) and 0.90 (95% CI: 0.89–0.91), respectively. The area under the SROC curve was 0.75 (SE = 0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94–28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving ≥100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC.
Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.
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Citation Excerpt :
Despite widespread use in follow-up, the utility of serial CEA testing has been questioned. Studies have demonstrated a lead time between elevation of CEA levels and detection of recurrent disease by other testing of between 1.5 months and 6 months.34,38,40,41 However, whether this lead time improves long-term survival after salvage surgery remains controversial.
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Colorectal cancer continues to be a major cause of significant morbidity and mortality in the United States. Approximately 140,000 American men and women will be newly diagnosed with colorectal cancer this year, and approximately 45,000 will die of this disease. ¹⁷ An asymptomatic, average-risk individual's lifetime risk of developing colorectal cancer is about 6%.
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Sixty second-look procedures indicated primarily by rise in serial carcinoembryonic antigen

Abstract

Internal mammary lymphoscintigraphy

Radiology

Demonstration of tumor-specific antigens in human colonic carcinomas by immunological tolerance and absorption techniques

J. Exp. Med.

Use of radiolabeled antibodies to carcinoembryonic antigen for the detection and localization of diverse cancers by external photoscanning

N. Engl. J. Med.

Demonstration of an ion-sensitive antigenic site of carcinoembryonic antigen using zirconyl phosphate

Clin. Res.

Direct carcinoembryonic antigen assay in diagnosis and prognosis

Surgery

Disparity between CEA-Roche “indirect” and “direct” carcinoembryonic antigen values: Clinical relevance

N. Engl. J. Med.