Tzu-Chen Lin

Early postoperative CEA level is a better prognostic indicator than is preoperative CEA level in predicting prognosis of patients with curable colorectal cancer

PurposeCarcinoembryonic antigen (CEA) measurements performed preoperatively and during the early postoperative period were examined prospectively to assess their prognostic value for colorectal cancer (CRC) patients receiving curative surgery.MethodsBetween 2000 and 2004, 1,361 patients with CRC who underwent curative surgery at the Taipei Veterans General Hospital were enrolled prospectively. CEA was measured prior to surgery and during the third or fourth postoperative week. The endpoint was length of postoperative disease-free survival, and prognostic importance was determined using the log-rank test and Cox regression hazard model.ResultsSix hundred (44.1%) CRC patients had high CEA concentrations preoperatively, and 188 (13.8%) patients retained high values postoperatively. Within the median follow-up period of 61 (6–108) months, CRC recurred in 313 patients. By univariate analysis TNM staging, tumor differentiation, lymphovascular invasion, preoperative CEA concentration, and postoperative CEA concentration affected the outcome. By multivariate analysis, the prognostic importance of postoperative CEA was retained (95% CI, 1.73–3.01; HRu2009=u20092.28) but that of preoperative CEA was lost (95% CI, 0.82–1.33; HRu2009=u20091.05). CRC recurred earlier in patients with high postoperative CEA concentrations; metastasis to the liver was common (72.3%) among patients in this group.ConclusionsEarly postoperative CEA concentration is an independent prognostic factor for CRC. Patients with high postoperative CEA values should receive aggressive follow-up examinations for early relapse of CRC, with special attention paid to recurrence at the liver.

Risk and patterns of brain metastases in colorectal cancer

PURPOSE: In patients with colorectal cancer, brain metastasis is infrequent. This study aims to elucidate the risk, pattern of occurrence, and survival time after different treatment modalities. METHODS: A retrospective review of all patients with colorectal cancer admitted to the Veterans General Hospital-Taipei between 1970 and 1996 from our hospital was performed. Univariate analysis for survival determination was performed. RESULTS: Brain metastases developed subsequent to surgery for colorectal cancer in 53 well-documented patients, at a median of 36 months after surgery. Brain metastases were more commonly seen in rectal cancer and often occurred concurrently with lung metastases. Forty of these patients received active intervention in terms of surgery, chemotherapy, or radiotherapy, with surgical intervention achieving a significantly increased mean survival time (± standard deviation) compared with chemotherapy or radiotherapy or both of 86.6±17.35vs. 2.9±0.59 months (P<0.05). CONCLUSION: Increased awareness of the possibility of brain metastases, early diagnosis, and aggressive therapy can provide increased survival time for patients with colorectal cancer with brain metastases.

Metachronous colorectal cancer: necessity of post-operative colonoscopic surveillance

Background and aimsThe aim of this study was to identify the occurrence and analyze the characteristics of metachronous colorectal cancers, and to compare the characteristics of these cases (index tumor) with the control group to find any predicting factor that may influence the occurrence of metachronous cancer.Patients and methodsThe database of colorectal cancer in the Veterans General Hospital-Taipei, from January 1981 to September 2001 was reviewed. In total, 3,846 cases of adenocarcinoma of the colon and rectum, which received curative resection during this period, were found. The criteria of metachronous cancer were: occurrence more than 12xa0months after curative surgery; with pre-operative complete colonoscopy or one negative post-operative colonoscopic follow-up to rule out synchronous tumor; tumor arising from mucosa at a site other than anastomosis. The age, gender of the patients, the location, pathological characteristics of the metachronous tumors, occurrence of associated adenomas, the number of lesions, and the tumor stage were analyzed and compared with the control group.ResultsIn total, 43 cases of metachronous cancer were identified, giving an annual incidence of 0.18%. The distribution of the location of the index tumor of metachronous cases was predominantly left-sided, which was not different from that of the control group. The mean duration of occurrence of metachronous cancer after the primary operation was 71±46.6xa0months. The association of adenomas had no relationship with the occurrence of the metachronous cancer. No significant predicting factors for the development of metachronous tumors were found.ConclusionLifelong regular post-operative colonoscopic surveillance is essential for colorectal cancer patients.

Carbohydrate antigen 19-9 is a valuable prognostic factor in colorectal cancer patients with normal levels of carcinoembryonic antigen and may help predict lung metastasis

PurposeWe retrospectively analyzed preoperative levels of carbohydrate antigen (CA) 19-9 in colorectal cancer (CRC) patients to determine the prognostic value of CA19-9 in CRC patients with normal carcinoembryonic antigen (CEA) levels.MethodsA total of 639 patients who underwent curative surgery at Taipei Veterans General Hospital between 2002 and 2006 were enrolled. We excluded 254 patients (39.7xa0%) with high preoperative CEA levels and analyzed 385 patients with normal CEA levels. The measured endpoint was the postoperative disease-free survival (DFS). The prognostic value of CA19-9 was determined using log-rank test and Cox regression analysis.ResultsHigh CA19-9 levels were significantly associated with advanced disease and were detected in 5.8xa0% of patients with stage I disease, 11.7xa0% of those with stage II disease, and 22.5xa0% of those with stage III disease (Pu2009<u20090.001). The 5-year DFS in patients with normal CA19-9 levels was 82.0xa0%, which was significantly higher than that in patients with high CA19-9 levels (68xa0%; Pu2009<u20090.001). In a multivariate analysis, the most important independent factor affecting the 5-year DFS was tumor–node–metastasis stage (95xa0% CI, 1.26–2.36; HRu2009=u20091.72). After stratification by other factors, high CA19-9 level remained an independent prognostic factor for patients with normal CEA levels. Patients with high CA19-9 levels also showed a higher incidence of lung metastasis (23.1xa0%) than those with normal CA19-9 levels (7.2xa0%).ConclusionsCA19-9 may be a prognostic factor for CRC patients with normal CEA levels. An aggressive follow-up protocol for lung metastasis should be used for these patients.

Carcinoembryonic antigen in monitoring of response to systemic chemotherapy in patients with metastatic colorectal cancer

The response to chemotherapy of solid tumors is generally assessed by measuring tumors visualized by imaging. However, the response assessment based on imaging is not always feasible because patients often have disease not measurable by imaging, such as diffuse peritoneal dissemination. We evaluated the correlation between the change on imaging and change in CEA levels for assessing chemotherapeutic response of patients with metastatic colorectal cancer. Between July 1993 and August 1999 we retrospectively examined 136 patients with metastatic colorectal carcinoma, all of whom had measurable lesions. Forty patients received oral tegafur-uracil (300xa0mg/m2/day) plus folinic acid (60xa0mg/day) for 4xa0weeks, repeated every 5xa0weeks, as the first-line treatment. Another 96 patients received either a weekly intravenous bolus injection of 5-fluorouracil (400xa0mg/m2) plus folinic acid (20xa0mg/m2), or an intravenous bolus injection of 5-fluorouracil (425xa0mg/m2) plus folinic acid (20xa0mg/m2) for 5 consecutive days every month. Responders, based on CEA assessment, were defined as those with a greater than 50% drop in CEA level for more than 4xa0weeks. The pretreatment CEA levels were elevated beyond the normal cutoff value in 110 (81%) patients. A response rate of 18.4% (95% CI, 11.9–24.9%), including 8 complete remissions and 17 partial remissions, was achieved according to imaging studies. The response rate assessed by CEA was 25% (34/136). Sixteen responders (47%) based on CEA had no remission on imaging. The sensitivity of change in CEA levels in the prediction of true responders and progressive diseases on imaging were 72% and 81%, respectively. In terms of the positive predictive value, change in CEA levels in the prediction of true responders and progressive disease on imaging were 53% and 85%, respectively. Patients with remarkable falls on CEA levels survived significantly longer than nonresponders (P<0.001, log-rank test). At follow-up of 48xa0months the median survival for responders and nonresponders assessed by CEA was 28xa0months and 13xa0months, respectively. These data suggest that measurement of CEA levels might be helpful in monitoring chemotherapeutic response when imaging study is unsuitable for assessing the response in clinical practice. Furthermore, measurement of CEA levels may be helpful in determining the prognosis of patients with metastatic colorectal cancer receiving chemotherapy.

The Impact of the Lymph Node Ratio is Greater than Traditional Lymph Node Status in Stage III Colorectal Cancer Patients

BackgroundThe prognostic value of nodal status in colorectal cancer (CRC) patients may be influenced by the total number of lymph nodes (LNs) harvested. This study evaluates the impact of LN ratio (LNR) on CRC patients’ outcome.MethodsA total of 612 stage III CRC patients who underwent curative-intent surgery between 2004 and 2008 were enrolled. The measured end point was postoperative disease-free survival (DFS) and overall survival (OS).ResultsThe metastatic LN numbers were significantly higher in patients with more than 12 LN harvested (4.6xa0±xa05.81 vs. 2.7xa0±xa01.97, Pxa0<xa00.001). The mean LNR was 22.9xa0±xa020xa0% (rangexa0=xa02–100xa0%, medianxa0=xa016.7xa0%). As the cutoff value of LNR was set above 17xa0%, the impact of the LNR on 5-year DFS became statistically significant. In univariate analysis, the 5-year DFS and OS for patients with high-LNR tumors was 54.4 and 57.3xa0%, respectively, significantly lower than those for patients with low-LNR tumors (72.8 and 76.4xa0%; Pxa0<xa00.001). In multivariate analysis, the independent factors affecting the 5-year DFS and OS were tumor depth, carcinoembryonic antigen level, and LNR.ConclusionThe LNR, set at the median value or 17xa0%, could be an independent prognostic factor for stage III CRC patients.

The impact of family history on the outcome of patients with colorectal cancer in a veterans’ hospital

AbstractPurposeThe purpose of the study was to investigate the impact of a family history (FH) of colorectal cancer (CRC) in first-degree relatives on the outcome of patients with CRC in a veterans’ hospital in Taiwan.MethodsPatients (Nu2009n =u20093,383) with colorectal adenocarcinoma were studied; pedigrees were collected prospectively. Associations between FH and clinicopathologic variables were analyzed using linear-by-linear association. Survival was examined with Kaplan–Meier curves and the log-rank test.ResultsTwo hundred ninety-seven patients (8.78%) had a first-degree relative with CRC. The average age of onset of CRC was 68.3xa0years in patients without a FH. This was significantly higher than the age of onset in patients with a FH (66.4xa0years—one first-degree relative with CRC; 48.8xa0years—two or more first-degree relatives, Pu2009<u20090.001). Patients with more affected family members had a higher incidence of right-sided tumor (Pu2009=u20090.004), metachronous cancer (Pu2009=u20090.034), and less-advanced disease (Pu2009=u20090.044). The 5-year overall survival was 83% for patients with two or more first-degree relatives with CRC, 57% for those with one first-degree relative, and 55% for those without a FH (Pu2009=u20090.001). The 5-year DFS was 91% for patients with two or more first-degree relatives, 66% for those with one first-degree relative, and 64% for those without a FH of CRC (Pu2009=u20090.002). In the multivariate analysis, TNM stage played the most independent prognostic factor, followed by FH (Pu2009<u20090.001, hazard ratiou2009=u20091.52; 95% confidence interval, 1.24–1.85).ConclusionsCRC patients with a family history of CRC had better survival than did those without a family history of CRC.

Neoadjuvant chemotherapy can improve outcome of colorectal cancer patients with unresectable metastasis

BackgroundThe prognosis for colorectal cancer (CRC) patients with unresectable metastases is dismal. This study compared outcomes of different metastatic treatments.Patients and methodsWe collected 653 CRC cases with unresectable metastases including 490 cases receiving primary tumor resection then chemotherapy (surgery group) and 163 patients receiving neoadjuvant chemotherapy then did or did not receive operations (chemotherapy (C/T) group) from 2004 to 2010. The statistical endpoint was overall survival from the date of diagnosis.ResultsIn the C/T group, 124 (76xa0%) patients received an operation after 9.0u2009±u20096.2xa0months of chemotherapy, including 57 (34.9xa0%) patients with curative surgery. The C/T group had a higher proportion of T4 lesions (37.4xa0%) than the surgery group (26.9xa0%). Survival of the C/T group was longer than that of the surgery group (28.8u2009±u20098.8 vs. 24.3u2009±u20097.5xa0months; pu2009=u20090.043). Survival of 57 patients receiving curative surgery was 36.0u2009±u20096.3xa0months, which was significantly better than that of the 67 patients receiving palliative resection (25.2u2009±u20095.6, pu2009<u20090.001). In the surgery group, 42 (8.6xa0%) patients received curative metastasectomy after 8.5u2009±u20097.1xa0months of postoperative chemotherapy; survival was 30.8u2009±u20097.8xa0months, which was significantly better than that of patients who did not receive metastasectomy (22.4u2009±u20096.3xa0months). In multivariate analysis, poor differentiation, lymphovascular invasion, isolated cancer nodules, clinical risk score, and curative surgery were independent prognostic factors of overall patient survival.ConclusionsNeoadjuvant chemotherapy can improve outcome of CRC patients with unresectable metastases.