Early Diagnosis Of Recurrence Research Articles

Early detection of recurrence after endoscopic treatment for early gastric cancer

Objective. Although there have been many reports regarding clinical outcomes of endoscopic treatment for early gastric cancer (EGC), little is known about detection of recurrence after endoscopic submucosal dissection (ESD). This study aims to clarify the clinical value of serological marker or imaging tools, including conventional CT and PET-CT scans, in detecting recurrent gastric cancer after ESD in Korea. Material and methods. From July 2004 to March 2008, 212 patients who had received ESD for EGC were enrolled in the study. For preoperative staging, conventional CT and PET-CT scans were performed in 141 patients, and for detection of recurrence of cancer, conventional CT, PET-CT scans and tumour marker; CEA, CA19-9, AFP were checked in 165 patients. Results. The local recurrence rate was 4.7% (10/212) during the study period. At 9 months after endoscopic treatment, 3 cases recurred. Four showed recurrence at 12 months, 2 at 18 months and 1 at 24 months. The positive rate was 7.1% (10/141) in conventional CT and 0% (0/24) in PET-CT scans for preoperative staging. Conventional CT and PET-CT scans could not detect local recurrence of cancer during the follow-up period. Tumour markers did not show any significant correlation with recurrence of cancer. Conclusions. The study suggests that conventional CT, PET-CT scans and tumour marker have no role in the primary surveillance of early gastric cancer and/or in detecting recurrence after endoscopic treatment. For early diagnosis of recurrence after endoscopic treatment, a biopsy specimen from the endoscopic examination has to be obtained at regular intervals.

The use of silicone expander and cecal transposition after pelvic exenteration

Aims Describe a new approach for pelvic floor treatment employing a temporary mechanical support device with silicone expander, with or without association to cecal transposition. Methods From January 2000 to June 2006, 106 patients were submitted to pelvic exenteration. A retrospective evaluation was done of the last 30 patients previously submitted to total pelvic exenteration without neither urinary nor faecal sphincter preservation who latter were submitted to a pelvic floor treatment with silicone expander with or without association to cecal rotation. Results Twenty-six patients were female and four male. The most common primary neoplasm site were of gynecological origin (20 cases). The median follow-up period was 12 months (0.36–38). Only one patient presented small intestine loops slipping after expander removal. No other patient had small intestine loops slippage into the pelvis, probably because of cecal transposition. All patients were submitted to a post-operative CT scan to confirm that intestinal loops remained out of the pelvis. Six patients presented pelvic hollow infection after device removal. All cases had complete resolution with local cleaning using physiological solution associated with systemic antibiotic therapy, except one who needed a trans-abdominal surgical approach. Conclusions Pelvic floor treatment employing a temporary mechanical support device with silicone expander, associated or not to cecal transposition is a low-morbidity procedure. The most common complication is pelvic floor infection, but maintaining a cutaneous perineal hole allows easy access and treatment of possible pelvic abscesses as well as early recurrence diagnosis.

The Actual Five-year Survival Rate of Hepatocellular Carcinoma Patients after Curative Resection

The five-year survival rate of patients after curative resection of hepatocellular carcinoma (HCC) has been reported to be 30 to 50%, however the actual survival rate may be different. We analyzed the actual 5-year survival rate and prognostic factors after curative resection of HCC. Retrospective analysis was performed on 63 HCC patients who underwent curative resection from 1998 to 1999. A total of 63 cases were reviewed, consisting of 53 men and 10 women, with a median age of 49 years. These cases included all four pathologic T stages (pT stage) and had the following representation: stage 1 (1 case), stage 2 (17 cases), stage 3 (38 cases), and stage 4 (7 cases). In our study, the actual 5-year survival rate was 57.0% and the median survival time was 60 months. In addition, the patients in our study had an actual 5-year disease-free survival rate of 50.2% and a median disease-free survival time of 46 months. Thirty-one patients had recurrences, with a majority occurring within one year (65%). These patients with early recurrences had a poor actual 5-year survival rate of 5%. A univariate analysis showed that the prognostic factors influencing survival rate were the presence of satellite nodules, increased pT stage, HCC recurrence, and the time to recurrence (within one year). Interestingly, microvascular invasion made a difference in survival rate but was not statistically significant (p = 0.08). Furthermore, factors influencing the disease free survival rate include the presence of satellite nodules, microvascular invasion, and pT stage. Multivariate analysis identified pT stage as the only statistically related factor in determining the disease-free survival rate. The most important prognostic factor of HCC is recurrence. Moreover, the major risk factor for recurrence is an advanced pT stage. Therefore, performing prospective studies of postoperative adjuvant therapy is necessary to prevent recurrences after hepatic resection. Furthermore, active preventative treatment and early diagnosis of recurrences should be of the highest priority in the care of high-risk patient groups that have an advanced pT stage.

Review of Fluorine-18-2-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography (FDG-PET) in the Follow-Up of Medullary and Anaplastic Thyroid Carcinomas

The goal of posttreatment follow-up for medullary and anaplastic thyroid cancer (MTC and ATC) is the early diagnosis of recurrence or metastases. However, routine follow-up protocols, including physical examination and clinically oriented investigations, are not standardized, and their sensitivity in accurately detecting recurrent or metastatic disease is often suboptimal. A valuable addition to posttreatment follow-up of oncology patients is positron emission tomography using fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG-PET). We review the role of FDG-PET imaging in the follow-up of patients previously treated for MTC and ATC. Based on the encouraging literature data, FDG-PET appears to be useful in detecting recurrent or metastatic disease in patients with MTC and ATC, providing a higher sensitivity (66% to 100%) and specificity (79% to 90%) than conventional imaging methods. However, the PET technique is limited by less accurate spatial assignment of small lesions, especially in the lung and liver. Supporting evidence indicates that FDG-PET has a significant role in the follow-up of patients with MTC and ATC.

Apport de l’imagerie au 18FDG dans la prise en charge du cancer du testicule

The key to prognosis. Initial staging and early recurrence diagnosis are key parameters in the treatment and outcome of testicular cancer. Initial staging. It is difficult using conventional modalities, which can miss node involvement and are non-specific since enlargement does not rhyme with involvement. 18FDG PET improves the accuracy of initial staging. Residual mass and recurrences. Existence of residual mass or enhancement of its Volume in the presence of an otherwise beneficial chemotherapy is difficult to manage. Several studies have demonstrated the value of 18FDG imaging in such cases. As for follow-up whole body 18FDG can prevent multiple diagnostic imaging and can diagnose recurrences with greater diagnostic accuracy than with other imaging modalities.

Gallium-67 scintigraphy: a cornerstone in functional imaging of lymphoma.

Until recently, gallium-67 scintigraphy (GS) has been the best available functional imaging modality for evaluating patients with non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD). The diagnostic accuracy of GS in detecting lymphoma is based on optimisation of the imaging protocol, knowledge of potential physiological and benign sites of (67)Ga uptake, and the Ga avidity characteristics of the individual lymphoma. As (67)Ga is a tumour viability agent, the role of GS is primarily at follow-up. A residual mass persisting on CT after treatment poses a common clinical dilemma: it may indicate the presence of viable lymphoma, which requires further treatment, or it can be benign, consisting of only fibrotic and necrotic tissues. GS can successfully differentiate between these conditions. Routine follow-up with GS may allow early diagnosis of recurrence and early institution of treatment. Reversion of a positive GS to a negative test, and the rapidity with which this occurs has a high predictive value for the outcome of the individual patient. Lymphoma showing a normal GS early during treatment has a better prognosis than lymphoma with persistence of pathological findings. Other tumour-seeking single-photon emitting agents, such as thallium-201, technetium-99m methoxyisobutylisonitrile and indium-111 octreotide, have been investigated in lymphoma, primarily as an alternative to GS in specific clinical settings, but are of limited value. The role of radioimmunoscintigraphy is gaining importance in conjunction with radioimmunotherapy. Fluorine-18 fluorodeoxyglucose (FDG) imaging of lymphoma using either dedicated or camera-based PET systems is gradually replacing GS for assessment of lymphoma. FDG overcomes some of the limitations of GS while sharing its tumour viability characteristics. The extensive clinical knowledge and experience accumulated over three decades with GS in lymphoma provides a solid background as well as a model for the assessment of new functional imaging techniques.

October 17, 2000 8:30—8:45: The New Technology of Combined Transmission and Emission F-18 FDG Tomography (FDG-TET) in the Diagnosis and Management of Cancer Patients

The purpose of the study was to evaluate a new technology of simultaneous transmission and F-18 FDG emission tomography (FDG-TET) in tumor imaging and its impact on patient management.Emission and transmission devices were installed on the same gantry. 167 patients with histologically proven malignancy were evaluated at diagnosis or during follow up. Eight mCi of FDG were injected for PET and a low dose X-ray tube was used for CT. The FDG and CT were first interpreted independently, without knowledge of findings in other imaging modality. Subsequently fusion images were analyzed.FDG-TET changed the interpretation of PET or CT in 75 patients (45%). In 60 patients TET allowed for correct localization of lesions on the PET studies. In 15 patients, FDG uptake was found in sites of physiologic activity. In 12 patients lesions previously missed on CT were retrospectively identified. In 21 patients, TET detected 34 previously unknown sites of disease.FDG-TET changed the clinical management of 29 patients (17%). The stage of disease was changed in 9 patients. Early diagnosis of recurrence was made in 8 patients. Seven patients were referred for previously unplanned surgery. In 6 patients surgery was cancelled. Fifteen patients received additional chemo- or radiotherapy.Diagnosis of cancer on CT is based on a change in size or attenuation of a mass. PET shows the metabolic status of a lesion but lacks anatomical landmarks. FDG-TET improves the diagnostic accuracy in cancer and may have a significant impact on patient management.

TREATMENTS AND THEIR OUTCOMES FOR RECURRENCE OF THORACIC ESOPHAGEAL CARCINOMA AFTER CURATIVE RESECTION

In this study, clinical outcomes of treatments for recurrence of throacic esophageal carcinoma after curative resection were analyzed. Fifty six out of 120 patients, who received curative resection for squamous cell carcinoma of thoracic esophagus between March 1983 and December 1995, experienced a recurrence. These 56 cases were subjected to the study. The sites of recurrence were cervical lymph noden (8 cases), upper mediastinal region (25 cases), a distant organ (16 cases) and others. One-and 2-year recurrence rates were 54% and 86% respectively. The median disease-free survilal period was 11 monhs and median survival period after recurrence was 6 months. The incidence of cervical lymph node recurrence of patients with postoperative irradiation of the T-fields was significantly lower than those without radiation therapy (p<0.05). Patients with cervical lymph node dissection for cervical recurrence and patients with irradiation for upper mediastinal recurrence had relatively good prognosis. Although patients with distant organ metastasis had poor prognosis, active therapies such as transcatheter arterial chemotherapy for liver metastasis or resection of brain metastasis brought some better prognosis. To improve the prognosis of patients with recurred esophageal cancer after curative surgery, not only early diagnosis of recurrence but also vigorous treatment appropriate for the recurred site it would be mandatory.

Monitoring carcinoembryonic antigen in colorectal cancer: is it still useful?

The results of a study conducted to determine the usefulness of carcinoembryonic antigen (CEA) monitoring in the follow-up of patients with resected colorectal cancer are reported herein. The subjects of this study were 125 patients in whom CEA had been determined preoperatively and 239 patients in whom CEA had been monitored postoperatively. The results revealed increased preoperative CEA in only 24% of the subjects, and that this increment was correlated with subsequent more advanced tumor stage and a higher recurrence rate (P < 0.01). The postoperative CEA level exceeded the threshold in 71% of the patients affected by recurrence, 94.4% of whom developed liver metastases and 50%, nonhepatic recurrence. This marker showed elevated sensitivity for liver metastases (99%), whereas the sensitivity was lower for nonhepatic recurrence of the disease (94%). Thus, we concluded that CEA monitoring can be useful for preoperative colorectal tumor grading, even if its validity in the early diagnosis of recurrence is problematic, especially in terms of radical repeated surgery and survival.

Bronchial carcinoid tumours: a study on clinicopathological features and role of octreotide scintigraphy

Several authors proposed the stage at diagnosis and some histopathological features as prognostic factors of bronchial carcinoids. However, since large tumour diameters or nodal metastases are frequently associated to aggressive histology, their prognostic role is unclear. To investigate the relationships between the clinicopathological parameters at diagnosis and outcome, 21 patients were analysed. Overall 26% of the radically resected patients recurred. Recurrences and disease-specific mortality were related to atypical histology and, only in cases with typical histology, to the presence of hilar or mediastinal lymph node metastases. These prognostic factors were valuable independently of the size of the primary tumour, that was remarkably homogeneous, always less than 3 cm, thus not predictive of recurrence. Moreover we evaluated the role of somatostatin receptor scintigraphy, a diagnostic tool only preliminary studied in this field. Scintigraphy with 111In-octreotide revealed the primary tumours at diagnosis (8/8), the increase in tumour size in two unresected patients, and all the cases of recurrent or metastatic disease (5/11), sometimes before the appearance of symptoms. These results suggest the usefulness of histology and nodal status as prognostic factors in clinical practice. Somatostatin receptor scintigraphy turns out to be a powerful diagnostic tool, for an accurate staging and an early diagnosis of recurrence in bronchial carcinoids.

Use of blood tumour markers in the detection of recurrent breast cancer

Breast cancer remains the most common malignancy in women in Western countries. The search for specific tumour markers which might aid the diagnosis and monitoring of treatment has increased over the last decade owing to the continuing high mortality rate from this disease. Today a large number of markers have been proposed for breast cancer, including mucins, CEA, oncoproteins, milk proteins, cytokeratins, etc. Of these CEA and CA153 are the most commonly used in clinical practice. Other MUC1-gen family tests (e.g. MCA, CA549, B27.29, BRMA) have been reported to have a similar sensitivity and specificity as CA15-3. The use of several mucins simultaneously does not improve the efficacy obtained compared with using only one of them. For this reason CEA and one mucin have been recommended where serial assay of blood markers is indicated. Certain tumour markers look promising but are still under evaluation (e.g. cytokeratins, TPS, TPA, CYFRA 21.1) and soluble oncoproteins (c-erbB2). The main clinical applications of tumour markers are in disease monitoring, prognosis and early detection of recurrence. Tumour marker sensitivity in patients with locoregional breast cancer is low (15-35%) and they are not useful for diagnostic purposes. However, patients with local recurrence with elevation of CA15-3 have a shorter time to symptomatic metastases compared to patients with local recurrence and a normal CA 15-3 level. Tumour marker sensitivity and specificity increase significantly in patients with metastatic recurrence. CEA and CA15-3 (or other MUC-1 related antigen) levels are abnormal in more than 80% of patients with advanced disease. These results suggest that serial determinations of tumour markers may be useful in the early diagnosis of recurrence. To use tumour markers in early diagnosis we have to know their sensitivity and specificity and to compare their

The continuing clinical role of gallium 67 scintigraphy in the age of receptor imaging

Gallium 67 scintigraphy is useful clinically for assessment of tumor viability after treatment of Hodgkin's and nonHodgkin's lymphoma. Because more than 50% of the patients with complete response have a residual mass after treatment, computed tomography is not a good test to determine if a patient has reached a complete response. 67Ga scintigraphy, on the other hand, has a sensitivity of 76% to 100% and specificity of 75% to 96% to determine if a residual mass is a residual cancer or made up only of fibrosis and necrosis. Early diagnosis of recurrence is important in order to start therapy when the tumor can, potentially, still be controlled. The sensitivity of 67Ga for diagnosis of recurrence is 95% and the specificity 89%. Scintigraphy has been shown to diagnose recurrence sometimes months before other tests. 67Ga scintigraphy also has the potential to separate rapid from slow responders during therapy. Even when it has been known for many years, 67Ga has proved recently to be a useful test in assessing lymphoma patients after treatment.

Carcinoembryonic Antigen in Staging and Follow-Up of Patients with Solid Tumors

The presence of a tumor antigen in human colonic carcinomas and their metastases was described about 25 years ago. This antigen, called carcinoembryonic antigen (CEA), is one of the first known tumor markers. Since then, many more have been described, but CEA, determined alone or in combination with others, is still one of the most used. CEA is not organ specific and abnormal values may be found in a wide range of carcinomas, especially those with gastrointestinal involvement. CEA assay should not be used for cancer diagnosis because its sensitivity in patients without cancer metastases is low. In addition, abnormal CEA values may be found in patients with benign diseases. However, the probability of malignancy increases directly with CEA concentration. Its main clinical applications are prognosis, early diagnosis of recurrence and follow-up of patients with carcinomas. In a wide range of malignancies, CEA serum levels are clearly related to tumor stage. Presurgical CEA serum levels are a well-established prognostic factor in colorectal, breast and lung cancer. Patients presenting with increased preoperative CEA serum levels have both a shorter disease-free interval and lower survival than those with normal CEA levels. In the early diagnosis of recurrence, CEA also plays an important role: in about 70-85% of patients with colorectal tumors and in 40-50% with breast cancer, CEA serial increase is the first sign of tumor recurrence. In patients with disseminated tumors, serial determinations are also a useful tool for therapy monitoring: CEA values decrease with effective treatment while stable or increasing values are observed when treatment is not effective.

Use of CA 19-9 in the early detection of recurrences in colorectal cancer: comparison with CEA.

The serum levels of CA 19-9 were determined in the follow-up of 370 patients with colorectal cancer and compared with CEA. An increase in CA 19-9 preceded clinical diagnosis of recurrence in 25% of 72 patients. The mean time between the rise in CA 19-9 and clinical diagnosis of relapse was 3.7 months (median 3). Sensitivity of CA 19-9 in the early diagnosis of recurrence was much lower than that obtained for CEA (75%). Only 1 patient had elevated CA 19-9 levels and normal CEA.

Surgery of supratentorial tumors

Neurosurgery may be the ultimate treatment of benign tumors, eg, certain meningiomas and acoustic neurinomas; however, for invasive and malignant tumors, it is just another part in a multimodality approach coupled with radiotherapy, chemotherapy, and possibly immunotherapy. Still heading for more efficiency, new surgical techniques and aids have been developed. Their multiplicity and precision should encourage the neurosurgeon to even more carefully plan the type of surgery by a thorough preoperative evaluation. Preoperative management now not only assesses the size and the extent of the tumor but tries to find hints of its degree of malignancy to understand the perilesional edema and to guide the surgeon's hand. Although surgical approaches have been improved over the past years by the introduction of microsurgery, the ultrasonic aspirator, laser, and perioperative ultrasound, computer-assisted stereotactic neuronavigation seems to be the major novelty, and its future developments may prove to be of great medical value. Finally, the postoperative evaluation of the patient also benefits from new standards in neuroimaging and radionuclide investigations, allowing better estimation of residual tumor and early diagnosis of recurrence.

Wertigkeit der Radioimmunszintigraphie im Vergleich zur Computertomographie in der Diagnostik und Rezidivdiagnostik kolorektaler Tumoren

Radioimmunoscintigraphy (= RIS, scintigraphic "specific" imaging of benign and malignant diseases by means of radioactively marked monoclonal antibodies) has been performed in Germany in clinical studies since 1985 in patients suffering from colorectal cancer. After having been successfully proven in primary studies, RIS is now being used in the early diagnosis of recurrences and metastases. In the prospective study presented here the clinical usefulness of RIS was assessed in comparison against well-tried diagnostic methods including computed tomography in patients suffering from colorectal cancer. It was shown that RIS in SPECT technique (= single photon emission computed tomography) with 99mTc-labelled monoclonal CEA antibodies can visualise local recurrences if diagnostic findings are doubtful, with a sensitivity of 78% versus 50% for CT findings.

Ultrasound, CT and MRI of ruptured and disseminated hydatid cysts

Three cases of echinococcus granulosus with rupture of hydatid cysts and widespread abdominal, pelvic or pleural dissemination are described. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) allowed recognition of ruptured hydatid cysts. This assisted to come to an appropriate therapy and exclusion or confirmation of hydatid cysts elsewhere in the body. Ultrasound, CT and MRI are also important for follow-up, evaluation of therapeutic response and/or early diagnosis of recurrence.

Ultrasonography of Testicular Tumors

The ultrasonograms obtained from 20 cases with testicular tumors were reviewed to correlate the ultrasonographic findings with the histologic features. Some seminomas and all metastatic tumors (leukemia, malignant lymphoma and prostatic cancer) showed homogeneous and hypoechoic findings ultrasonographically. All nonseminomatous germ cell tumors had heterogeneous findings on ultrasonography. In patients with leukemia or malignant lymphoma, ultrasonography can serve as a marker in assessing the efficacy of chemotherapy or in the early diagnosis of recurrence. Scrotal ultrasonography also seems to be useful in detecting the small tumor and seems to be convenient for the follow-up of the contralateral testis of a patient who has undergone extirpation of a testicular tumor.

The value of tumormarkers in early diagnosis of recurrence in colon carcinomas

The value of tumormarkers in early diagnosis of recurrence in colon carcinomas

Carcinoembryonales Antigen (CEA)

Serial determinations of CEA concentrations in serum were performed postoperatively in 303 patients with histologically confirmed adenocarcinoma of the gastrointestinal tract. The trend of the time course of computerised CEA curves made early diagnosis of recurrence or metastases possible. Diagnosis of recurrence by means of a rise in CEA concentration preceded positive clinical diagnosis by up to 10 months. In all 26 cases confirmation was obtained by second-look operation or other diagnostic means. Analysis of serial CEA measurements made it possible to distinguish between generalised metastasization and local recurrence of the tumour, on the one hand, and limited metastasization at the site of recurrence, on the other.