Elevated CEA Research Articles

Prognostic impact of MSI in stage II colon cancers: An additional translational study of the SACURA trial.

e15155 Background: The SACURA trial is a phase III study to evaluate the superiority of 1-year adjuvant treatment with oral tegafur-uracil (UFT) to surgery alone for stage II colon cancer. Superiority of adjuvant treatment with UFT to surgery alone was not demonstrated (ASCO2016 abst#3617). In an additional translational study, we assessed microsatellite instability (MSI) status of cancer tissues and prospectively examined the association of MSI with prognosis in stage II colon cancer patients. Methods: Formalin-fixed, paraffin-embedded samples were prospectively collected from 1026 patients enrolled in the SACURA trial. MSI was evaluated using 5 markers; BAT25, BAT26, D2S123, D5S346, and D17S250. MSI-high (MSI-H) was defined as the presence of instability in more than 20% of the markers. Median follow-up time was 69.6 months. Results: MSI-H, MSI-low (MSI-L) and microsatellite-stable (MSS) was observed in 74 (7.2%), 24 (2.3%), and 928 (90.5%) samples, respectively. Patients with MSI-H was significantly frequent in female, right-sided colon cancers, > 5cm tumors, poor histological type, and elevated CEA. Relapse rate for MSI-H patients (4.1%) was significantly lower than that for MSI-L/MSS cancer (13.4%, p = 0.02). Relapse free survival (RFS) in MSI-H patients was significantly better than in MSI-L/MSS patients (hazard ratio: 0.40, 95%CI: 0.17-0.98, p = 0.045), as well as adjusted results by prognostic factors. The 5-year RFS rates in MSI-H and MSI-L/MSS patients were 92.9% and 84.1%, respectively. Although there was no statistical significance, the 5-year RFS rate in MSI-H patients was tended to be better than that in MSI-L/MSS patients in the surgery alone group (94.3% vs. 83.1%, p = 0.086) as well as in the UFT group (91.7% vs. 85.1%, p = 0.233). Conclusions: MSI was an independent prognostic factor in stage II colon cancers. By considering their favorable RFS, adjuvant chemotherapy for stage II colon cancer patients with MSI-H may be unnecessary. Clinical trial information: NCT00392899.

Monitoring response of PDL-1 directed immunotherapy in patients with advanced NSCLC using serum CEA levels.

e20509 Background: Immunotherapy (IT) response measurements in advanced NSCLC management are evolving. We describe here our retrospective single institutional experience in measuring serum CEA levels as an early response determinant and correlation with radiographic assesment. Methods: Retrospective chart review was performed after obtaining IRB approval. Demographic information, stage, histology, prior treatment, IT agent used, radiographic response assesment and serum CEA levels were recorded. Patients were evaluable if they had elevated baseline serum CEA levels (normal range non smokers: 0-3 ng/ml, smokers 0-5 ng/ml), had recieved at least two cycles of IT and had radiographic response assessment performed. Results: Six eligible patients were identified. Median age 60 yrs; M:F1:5, SCC n=1, Adeno: n=5; Smoking history positive n=4; Stage IV n=6, EGFR mut+ n=2; IT agent used: nivolumab: n=5; atezolizumab: n=1. IT as 1st line of Rx n=1; 2nd line n=3, 3rd line: n=2. On first radiographic assesment: three patients had progressive disease (PD), Two patients had PR, one patient (#1) had an intial PR and subsequently PD with subsequent rise in CEA level to 16.1 corelating with PD on radiographs. Conclusions: Serum CEA levels appear to correlate well with response assesment in patients with advanced NSCLC while being treated with immunotherapy. This small study is hypothesis generating and is currently being evaluated in a larger series. [Table: see text]

Potential Pathogenesis and Biomarkers of Kidney Cancer-Related Stroke.

BackgroundStroke risk and stroke recurrence are increased in cancer patients, but the pathogenesis and biomarkers of kidney cancer-related stroke (KCS) are generally unclear. The aim of the present research was to investigate the pathogenesis and plasma biomarkers of kidney cancer-related stroke.Material/MethodsA retrospective review was conducted on acute stroke patients with kidney cancer (KC) who were admitted to the hospital between January 2006 and December 2015. A total of 106 patients with KCS (active KC patients with acute stroke but without conventional vascular risks) were identified. In addition, 106 age- and sex-matched patients with KC alone were recruited.ResultsKCS patients had higher plasma D-dimer, cancer antigen (CA) 125, and CEA levels and greater proteinuria levels than did KC patients. Multiple logistic regression analysis showed that the risk of stroke in patients with KC increased independently by 0.8% (odds ratio [OR] 1.008; 95% confidence interval [CI] 1.002, 1.013; p=0.004) with a 1 ng/mL increase in D-dimer levels, by 1.2% (OR 1.012; 95% CI 1.007, 1.018; p=0.000) with a 1 U/mL increase in CA125, by 2.5% (OR 1.025; 95% CI 1.012, 1.038; p=0.000) with a 1 U/mL increase in CEA by 1.4% (OR 1.014; 95% CI 1.005, 1.024; p=0.004) with a 1 mg increase in urine protein in 24 hours.ConclusionsElevated plasma D-dimer, CA125 and CEA levels, and increased urine protein levels might lead to hypercoagulability and then KCS; however, they may also be biomarkers of KCS.

Peritoneal recurrence in gastric cancer following curative resection can be predicted by postoperative but not preoperative biomarkers: a single-institution study of 320 cases.

To determine the risk factors for peritoneal recurrence in gastric cancer patients after curative resection, we included 320 patients with stage I-III primary gastric cancer between January 2008 and June 2012. Data on each patient's surgical and pathological information, preoperative and postoperative tumor markers were collected and analyzed retrospectively. The risk factors for peritoneal recurrence were investigated by univariate and multivariate analysis. In patients with peritoneal recurrence, advanced T or N stage, low differentiation, vascular/lymphatic invasion, perineural invasion, and elevated postoperative CEA/CA19-9 were more common than in patients without peritoneal recurrence. Patients with peritoneal recurrence showed a worse overall survival (OS) compared to those without peritoneal recurrence. In addition, patients with peritoneal recurrence within the first year had a worse OS compared to those with recurrence after 1 year. The univariate and multivariate analyses revealed that elevated number of metastatic lymph nodes and elevated postoperative CEA and CA19-9 were three independent risk factors for peritoneal recurrence in gastric cancer patients. For patients with N3 stage and high postoperative CEA and CA19-9, we found an initial steep slope within approximately 1 year and a subsequent gentle slope in the risk curve. Combined receiver operating characteristic curve analysis using the three independent risk factors for peritoneal recurrence yielded an area under the curve value of 0.73 with 73.7% sensitivity and 64.2% specificity. Therefore, the risk factors may be associated with peritoneal recurrence after curative resection in selected gastric cancer patients.

Analysis of prognostic factors for patients with stageⅠb non-small cell lung cancer after operation

Objective: To study the prognostic factors for patients with stage ⅠB non-small cell lung cancer (NSCLC) after radical operation (R0). Methods: The clinical data of 458 patients who underwent radical resection for NSCLC and were pathologically diagnosed with stage ⅠB lung cancer from January 2009 to December 2010, were reviewed retrospectively. Those cases include 269 male patients and 189 female, aged between 28 and 88, with a median age of 61 years. The Kaplan-Meier method and Log rank test were used for univariate survival analysis and the Cox proportional hazards model for multivariate survival analysis. Results: Among these 458 cases, 66 patients were dead and the 5-year survival rate was 85.6%.The results of the univariate analysis showed that the age ≥65 years, elevated preoperative CEA, preoperative FEV1%pred<70%, vascular carcinoma embolus, and low tumor differentiation were associated with poor prognosis of patients(P<0.05). The results of the multivariate analysis showed that elevated preoperative CEA, preoperative FEV1%pred<70% and low tumor differentiation were connected with poor prognosis of patients (P<0.05). Conclusions: Elevated preoperative CEA, preoperative FEV1%pred<70% and low tumor differentiation are independent risk factors which influence prognosis and survival rate of patients with stage ⅠB NSCLC, among which those with poorly differentiated tumor could benefit from postoperative chemotherapy.

Role of systemic immune-inflammatory index, tumor infiltrating neutrophils and PD-1+ T cells to predict the postoperative recurrence after S-1 adjuvant chemotherapy for gastric cancer: A retrospective study.

74 Background: The adjuvant chemotherapy with S-1 is the standard treatment for Stage II/III gastric cancer in Japan. Immunological status of host is critical for treatment outcome. Several investigators showed that systemic immune-inflammaotry indexes including neutrophil lymphocyte ratio (NLR) and modified Glasgow Prognostic Score (mGPS) well reflected the tumor progression. Methods: We analyzed clinical data obtained from 170 patients with pathological stage II/III gastric cancer who underwent surgery followed by S-1 adjuvant chemotherapy at Osaka City University Hospital between 2006 and 2015. Tumor infiltrating cells were detected by immunohistochemistry. Results: We found recurrent diseases in 70 (41%) patients including 15 in stage II and 55 in stage III. In univariate analysis using Cox proportion model, 2 grade of mGPS, the increase value of post-operative CEA, CA19-9, number of lymphocytes and NLR were associated with recurrence. Post-operative elevation of CEA and NLR were identified as independent risk factors for recurrence in multivariate analysis. Increase value of pre-operative NLR and CEA was significantly associated with early recurrent within one year after surgery. Tumor infiltrating neutrophils and PD-1+ T cells had correlated with the increase of pre-operative NLR and CEA value, respectively. Patients with low PD-1+T cells and low neutrophils had better prognosis than those with high infiltration. Conclusions: Post-surgical elevation of CEA and NLR value were useful as a predictive marker for recurrence in patients treated with S-1 adjuvant chemotherapy after surgery for gastric cancer. Early recurrence had correlated with tumor infiltrating neutrophils and PD-1+T cells. Our results suggested that systemic and local immune suppression should be an important element to exacerbate prognosis after chemotherapy for resectable gastric cancer.

Primary tumor location and survival in general population with metastatic colorectal cancer (mCRC).

674 Background: Recent evidence from clinical trials suggests that location of the primary tumor in patients with mCRC correlates with differential outcomes and patients with tumors originating in the right side of colon have inferior survival. This large population-based cohort study using individual patient data was performed to confirm this findings in general population with mCRC. Methods: A cohort of 1947 patients who were diagnosed with synchronous mCRC from 1992-2010 was studied. Ascending and transverse colon cancers were defined as right-sided tumors (RT) and remainder tumors were define as left-sided tumors (LT). Cox proportional multivariate analyses were done to determine prognostic significance of primary tumor location and to adjust other prognostic variables including age, Charlson comorbid index (CCI) and WHO performance status (PS) in patients treated with chemotherapy. Results: Median age was 70 years (IQR: 60-78) and M:F was 1.3:1. Mean CCI was 9.7±1.4 and 29% had WHO PS of &gt; 1. 770 (39%) patients had RT and 37% had stage IVb disease. 908 (47%) received chemotherapy and of those 44% received modern chemotherapy. Significant differences were noted between the groups with RT and LT with respect to age, WHO PS, CCI, liver metastases, mucinous tumor, grade, smoking history, and primary tumor resection. Median overall survival of patients with RT was 14 (95%CI: 12.7-15.3) months compared with 20.5 (95%CI: 18.5-22.5) of patients with LT (p &lt; 0.001). On multivariate analysis following variables were correlated with inferior survival: Right-sided tumors, hazard ratio (HR) 1.40 (95%CI: 1.20-1.60); no primary tumor resection, HR 1.60 (95%CI: 1.32-1.90); no metastasectomy, HR 2.40 (95%CI: 1.90-2.90); not using modern chemotherapy, HR 1.52 (95%CI: 1.31-1.80); leukocytosis, HR 1.44 (95%CI: 1.28-1.73); elevated CEA, HR 1.54 (95%CI: 1.30-1.90); WHO PS &gt; 1, HR 1.30 (95%CI: 1.10-1.55); and stage IVb disease, HR 1.50 (95%CI: 1.17-1.86). Tests for interaction were negative. Conclusions: Our results confirm that patients with RT who received chemotherapy have inferior survival independent of other known prognostic variables. Future studies are required to understand underlying pathophysiology.

CA19-9 or CEA Decline after the First Cycle of Treatment Predicts Survival in Advanced Biliary Tract Cancer Patients Treated with S-1 and Cisplatin Chemotherapy.

PurposeWhile tumor markers (carbohydrate antigen 19-9 [CA 19-9] and carcinoembryonic antigen [CEA]) can aid in the diagnosis of biliary tract cancer, their prognostic role has not been clearly elucidated. Therefore, this study was conducted to evaluate the prognostic role of tumor markers and tumor marker change in patients with advanced biliary tract cancer.Materials and MethodsPatients with pathologically proven metastatic or relapsed biliary tract cancer who were treated in a phase II trial of first-line S-1 and cisplatin chemotherapy were enrolled. Serum tumor markers were measured at baseline and after the first cycle of chemotherapy.ResultsAmong a total of 104 patients, 80 (77%) had elevated baseline tumor markers (69 with CA 19-9 elevation and 40 with CEA). A decline ≥ 30% of the elevated tumor marker level after the first cycle of chemotherapy conferred an improved time to progression (TTP), overall survival (OS), and better chemotherapy response. Multivariate analysis revealed tumor marker decline as an independent positive prognostic factor of TTP (adjusted hazard ratio [HR], 0.44; p=0.003) and OS (adjusted HR, 0.37; p < 0.001). Subgroup analysis revealed similar results in each group of patients with CA 19-9 elevation and CEA elevation. In addition, elevated baseline CEA was associated with poor survival in both univariate and multivariate analysis.ConclusionTumor marker decline was associated with improved survival in biliary tract cancer. Measuring tumor marker after the first cycle of chemotherapy can be used as an early assessment of treatment outcome.

Port Site Metastasis Following Laparascopic Right Hemicolectomy

Case Presentation: A 67 year old patient underwent laprascopic right hemicolectomy for carcinoma caecum in the month of January 2014; he had a good postoperative recovery. Histopathology showed well- differentiated carcinoma caecum T3N1M0 and patient received 4 cycles of adjuvant chemotherapy and was on regular follow up. In 2015 October, in view of elevation of CEA from 2.3 to 9, PET scan was done that showed evidence of abdominal wall metastasis (Figure 1) with incisional hernia at specimen extraction site with no other evidence of recurrence. The patient underwent excision of abdominal wall metastasis along with incisional hernia repair. On follow up, patient is doing well with CEA below (Figures 2-4). Conclusion: Port site metastasis in laprascopic colorectal surgery is still a possibility; hence appropriate measure needs to be taken to prevent contact of tumour to the skin during its extraction.

182P Serum CEA directed PET-CECT scan strategy for followup of colorectal cancer post curative therapy

Background As per existing guidelines, during the follow-up of surgically resected colorectal cancer, PET-CT is indicated forasymptomatic elevation of CEA>5ng/mland no obvious site of recurrence on clinical examination and basic imaging. As an instituitionalpolicy,PET-CECTscanwasbeingperformedatourinstitutewhenever 1)CEAlevelsroseabove5ng/mland2)whenevertherewasdoublingofCEAvalue(even if CEA was <5 ng/ml). Our aim was to correlate range of CEA elevation with recurrence rates and to evaluate the diagnostic utility of PET/CT scan in this setting. Methods We retrospectively analysed all cases where a PET-CT scan was performed for elevated CEA during the post treatment period after complete resection of the primary tumour with adjuvant therapy. Study period was from January 1,2013 to July 31, 2015. Results Among104 patientswho underwentPET/CT scan forrisingCEA values, 59.6%patientswerefoundtohaverecurrentdisease.AtCEAlevel<5ng/ml,5.1-10ng/ml,10.1-15ng/ml,15.1-50ng/mland>50ng/ml,diseaserecurredin10%, 45%,70%,94% and 100% of patients, respectively. Sensitivity, specificity, positive predictive value and negative predictive value of PET/CT scan were 92.7%,95.2%,96.2% and90.9%,respectively.CEAelevationduringfollow-upwasindicativeofrecurrencein 68% of secretors and 45% of non-secretors (based on baseline CEA status). Conclusions Inthesettingof risingCEAlevelsduringfollow-up ofcolorectalcancer patients, PET/CT scan is a valuable tool to detect recurrence, irrespective of the baseline CEA secretor status. Legal entity responsible for the study Karthik Chandra Funding N/A Disclosure All authors have declared no conflicts of interest.

Primary liver sarcoma: diagnosis and surgical treatment

Objective To study the diagnosis and surgical treatment of primary sarcoma of liver in order to obtain a better understanding of this disease and to improve its clinical treatment. Methods The clinical data on the clinicopathological features, surgical treatments and prognosis of 17 patients with primary liver sarcoma who were treated from January 2001 to May 2016 were retrospectively analyzed. Results Of 17 patients with primary sarcoma of liver, elevation of preoperative serum AFP was detected in one patient (5.9%), HBsAg positivity in 3 patients (17.6%), elevation of CEA in 2 patients (11.8%) and abnormal liver function in 3 patients (17.6%). The main clinical symptoms included epigastric pain in 9 patients, epigastric distention in 7 patients, loss of appetite in 5 patients (including in one patient after resection of gastric carcinoma). Twelve of these 17 patients underwent resection (resection rate 64.7%). Five patients underwent laparotomy and biopsy. Among patients who were treated with surgical resection, 10 patients had R0 resection and 2 patients had R1 resection. Postoperatively, 5 of these patients underwent adjuvant selective hepatic arterial infusion chemotherapy (mitomycin+ fluorouracil+ epirubicin), and 4 patients were treated with adjuvant systemic chemotherapy (vincristin, cisplatin, cyclophosphamide and Doxorubicin). The postoperative 1, 3 and 5-year overall survival rates for all the patients were 58.8% (10/17), 29.4% (5/17) and 11.7% (2/17), respectively. In patients with liver resection, the survival rates were 83.3% (10/12), 41.6% (5/12) and 16.7% (2/12), and for R0 resection, 100.0% (10/10), 50.0% (5/10) and 20.0% (2/10), respectively. Conclusions The diagnosis of primary sarcoma of liver was difficult before operation. High survival rate could be achieved by radical resection and adjuvant chemotherapy. Key words: Primary liver sarcoma; Liver tumor; Hepatectomy; Chemotherapy

Evaluation of disease free survival after radical resection for primary duodenal adenocarcinoma

Objective: To investigate the risk factors associated with the disease free survival (DFS) for primary duodenal adenocarcinoma patients undergoing radical resection. Methods: The clinicopathological data of 101 primary duodenal adenocarcinoma patients who underwent radical resection from January 2001 to October 2014 were retrospectively reviewed. Using SPSS 13.0 software, the survival curve was drawn by Kaplan-Meier method, and the survival rates were analyzed by Log-rank test.COX regression model was used to identify independent risk factors. Results: Among 101 patients, the main clinical manifestation were upper abdomen discomfort, abdominal pain, jaundice, gastrointestinal obstruction, hemorrhage, emaciation and so on. A total of 87 patients had the tumor located at the descending part of the duodenum. All the 101 patients underwent radical resection, and 85 patients received pancreatoduodenectomy while 16 patients underwent segmental resection. The median disease free survival time was 26 months and the postoperative 1, 3, 5 year DFS rate were 79.7%, 60.3% and 53.6%, respectively. The univariate analyses identified elevated preoperative CEA and CA19-9 level, T stage, lymph node state, vascular invasion and perineural invasion predicting a worse DFS(P<0.05). On multivariate analysis, positive lymph node state was an independent risk factor for DFS (RR=5.394, 95% CI: 1.624-17.913). Conclusion: Radical resection is the best therapeutic method for primary duodenal adenocarcinoma; the positive lymph node state is the independent risk factor affecting the disease free survival of patients after radical resection.

Postoperative serum CEA and CA125 levels are supplementary to perioperative CA19-9 levels in predicting operative outcomes of pancreatic ductal adenocarcinoma

Carbohydrate antigen (CA19-9) is a well-established marker to monitor disease status after resection of pancreatic cancer. However, few serum markers have been reported to improve the prognostic ability of postoperative CA19-9, especially in patients with normal postoperative CA19-9. A total of 353 patients with pancreatic ductal adenocarcinoma treated by radical resection were reviewed retrospectively, and a prospective cohort including 142 patients with resectable pancreatic head carcinoma was analyzed as a validation cohort. Perioperative CA19-9 and postoperative serum markers (CEA, CA242, CA72-4, CA50, CA125, CA153, and AFP) were investigated. Patients with postoperative normalization of CA19-9 had improved survival times (recurrence-free survival: 11.9months; overall survival: 22.5months) compared with those with decreased but still elevated postoperative CA19-9 (recurrence-free survival: 6.8months, P<.001; overall survival: 13.5months, P<.001) or those with increased postoperative CA19-9 (recurrence-free survival: 3.5months, P<.001; overall survival: 7.9months, P<.001), which was similar to those with consistently normal CA19-9 during perioperative periods (recurrence-free survival: 10.6months, P=.799; overall survival: 24.1months, P=.756). Normal postoperative CA19-9 levels were an independent indicator for a positive outcome after operation, regardless of preoperative CA19-9 levels. Elevated postoperative CEA and CA125 were identified further as independent risk factors for patients with normal postoperative CA19-9, while elevated postoperative CA125 and nondecreased postoperative CA19-9 were independent prognostic markers for patients with elevated postoperative CA19-9. The postoperative monitoring of CEA and CA125 provided prognostic significance to the measurement of CA19-9 in pancreatic cancer after resection.

A large multicenter study of recurrence after surgical resection of branch-duct intraductal papillary mucinous neoplasm of the pancreas.

Surgery for pancreatic branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) is indicated for therapy of symptomatic patients and to prevent development of invasive cancer. There is currently no consensus on management of BD-IPMN patients after surgical resection. The aim of this retrospective multicenter study was to determine the recurrence and long-term survival after surgical resection of BD-IPMN and to determine the predictive factors of recurrence. All patients who underwent surgery for BD-IPMN from 2005 to 2011 at 2 centers were identified. The diagnosis of BD-IPMN was based upon imaging and endosonographic analysis, and was confirmed by pathological analysis. The lesions were classified into 4 categories according to the WHO classification. Data on cyst characteristics, operative procedure, recurrence, and follow-up were evaluated. Recurrence was defined as the presence of BD-IPMN or mass in the remnant pancreas after surgery as seen on follow-up imaging. Recurrence suspected on imaging was confirmed via histological analysis when possible. A number of 271 patients (67% female; mean age 63.4 yrs) with BD-IPMN underwent surgical resection. The mean size of the cyst was 24.2mm (range, 12-80). There were 34 (12.5%) patients with an associated mass. 82 (30.3%) patients had worrisome features in the cyst on pre-operative EUS, included mural nodules (N.=25), solid component (N.=27), debris (N.=25), and a dilated major pancreatic duct (N.=5). 144(53%) patients had a pancreaticoduodenectomy for head lesions, 125 (46%) had distal pancreatectomy for tail/body lesions, and 1 (1%) underwent a total pancreatectomy. Histology showed 86% with noninvasive IPMN (adenoma 31%, moderate dysplasia 24%, severe dysplasia or carcinoma in situ 31%) and 14% with invasive IPMN. The mean patient follow-up was 28 months (range, 10-180 months). Recurrence in the remnant pancreas occurred in 34 (12.5%) patients. Of the patients with recurrence, 3/34 had invasive carcinoma and 31/34 had noninvasive cystic lesions; all patients with invasive carcinoma recurrence were those with a previous invasive IPMN. On MVA, risk factors for cyst recurrence were severe dysplasia/intraductal carcinoma in situ and invasive IPMN even after adjusting for elevated CEA (>193 ng/mL), type of surgery, and cyst size (OR 2.8, 95% CI=1.1-7.3; P=0.028). 3 patients who had invasive IPMN and 1 who had severe dysplasia patient with recurrence died, all because of recurrent cancer, with the mean time from recurrence to death being 36 months. The risk of BD-IPMN recurrence after resection depends upon the histological type, with the highest-risk groups being those with severe dysplasia/intraductal carcinoma in situ and invasive IPMN. Even after negative resection margins, the pancreatic remnant still harbors a risk of recurrence which requires long-term surveillance.

Surveillance of primary sclerosing cholangitis with ERC and brush cytology: risk factors for cholangiocarcinoma

Objective: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease leading to bile duct strictures and fibrosis, and predisposing to cholangiocarcinoma (CCA). Biliary dysplasia is a known precursor of CCA. In our unit, PSC patients undergo regular surveillance with ERC and brush cytology (BC), and liver transplantation is an option in case with biliary dysplasia. We evaluated the risk factors for biliary dysplasia and CCA based on ERC imaging, BC and liver function tests.Patients and methods: Seven hundred and eighty-eight ERCs were performed with BC for 447 PSC patients. ERC images were evaluated using the modified Amsterdam score, neutrophilic inflammation was assessed in BC, and liver function tests were collected. Ploidy analysis with DNA flow cytometry was performed in cases with advanced PSC or previous suspicious BC/aneuploidy. The endpoint was either a benign disease course (follow-up for ≥2.4 years after the latest ERC), benign histology, biliary dysplasia or CCA.Results: Benign disease course was seen in 424/447 (including 23 cases with biliary dysplasia), and CCA in 17 (3.8%) patients. Gallbladder carcinoma/carcinoma in situ was diagnosed in three patients. Advanced ERC findings, male gender, suspicious BC, aneuploidy in flow cytometry, inflammation, and elevation of ALP, bilirubin, ALT, AST, GGT, CEA and CA19-9 represented significant risk factors for CCA in univariate analysis.Conclusions: PSC patients with advanced bile duct disease and elevated liver enzymes, CEA or CA19-9, inflammation or suspicious BC are most likely to develop CCA. These patients may benefit from surveillance with BC if early liver transplantation is possible.

Repeated adjuvant anti‐CEA radioimmunotherapy after resection of colorectal liver metastases: Safety, feasibility, and long‐term efficacy results of a prospective phase 2 study

In previous work, a single administration of anticarcinoembryonic antigen (anti-CEA) 131 I-labetuzumab radioimmunotherapy (RIT) after complete resection of colorectal liver metastases was well tolerated and significantly improved survival compared with controls. In the current phase 2 trial, the authors studied repeated RIT in the same setting, examining safety, feasibility, and efficacy. Sixty-three patients (median age, 64.5 years) received RIT at 40 to 50 millicuries/m2 per dose. Before the receipt of RIT, restaging was performed with computed tomography/magnetic resonance imaging and 18 F-fluorodeoxyglucose-positron emission to confirm that patients were "truly adjuvant." Patients who had elevated serum CEA levels or radiographically inconclusive new lesions were classified as "possibly nonadjuvant," but they also received RIT. Time to progression (TTP), overall survival (OS), and cause-specific survival (CSS) were calculated. The median follow-up was 54 months. After the first course of RIT, 14 of 63 patients experienced National Cancer Institute Common Toxicity Criteria grade 4 hematotoxicity; 19 patients did not receive the second course of RIT because of impaired performance status (N = 5) or relapse (N = 14). After the second course of RIT, 9 of 44 patients experienced National Cancer Institute Common Toxicity Criteria grade 4 hematotoxicity. Five patients developed myelodysplastic syndrome (MDS) from 22 to 55 months after their last RIT. The median TTP, OS, and CSS for all patients were 16, 55, and 60 months, respectively. The "truly adjuvant" patients (N = 39) had an improved median TTP (not reached vs 6.1 months; hazard ratio, 0.12; P < .001), OS (75.6 vs 33.4 months; hazard ratio, 0.44; P = .014), and CSS (not reached vs 41.4 months; hazard ratio,0.42; P = .014) compared with "possibly nonadjuvant" patients (N = 24). Repeated RIT with 131 I-labetuzumab is feasible but is associated with hematotoxicity. Survival is very encouraging, especially for "truly adjuvant" patients. However, the maximum safe dose of 131 I-labetuzumab is a single administration of 50 millicuries/m2 . Cancer 2017;123:638-649. © 2016 American Cancer Society.

Serum carcinoembryonic antigen as a tumour marker in patients with endometrial cancer.

No potential tumour markers have been validated for prognosis in endometrial cancer. However, carcinoembryonic antigen (cea) is one of the most widely used tumour markers in various types of cancer. Although cea expression in endometrial cancer has been investigated, its prognostic value remains controversial, and no studies have investigated serum cea levels in large case series. In the present study, we investigated diagnostic and prognostic applications of serum cea for endometrial cancer. This prospective study was approved by our Institutional Review Board. Between January 2006 and December 2012, serum cea was measured prospectively in 215 patients with endometrial cancer and was subsequently measured during treatment and at scheduled follow-up examinations in patients with elevated baseline serum cea. During the study period, 215 patients (142 stage i, 19 stage ii, 32 stage iii, 22 stage iv) were treated for endometrial cancer. By the time of last follow-up, 52 had relapsed (24.2%), and the median follow-up duration was 45 months (range: 1-95 months). Elevated serum cea was identified in 25 patients (11.6%) and was associated with histologic type (p = 0.04), histologic grade (p = 0.03), and myometrial invasion depth (p = 0.01). Elevated serum cea was not related to clinical stage, lymph node metastasis, distant metastasis, age, menopausal status, or body mass index. Relapse of disease was related to elevated serum cea (p = 0.006). Serum cea is a potential prognostic indicator for endometrial cancer.

An Unexpected Showing at Nineteen Weeks Pregnant

A 31-year-old Nigerian female in the 19th week of her 5th pregnancy with a past medical history of diabetes mellitus presented with one week of intermittent right upper quadrant and epigastric abdominal pain with radiation to her back. She also reported associated nausea, decreased appetite, bloating, and steatorrhea. She had similar pain three years ago during her last pregnancy, but had no known history of pancreatitis or gallstone disease, and denied alcohol abuse. Her physical exam was normal except for a gravid abdomen and tenderness to palpation in the right upper quadrant and epigastric regions. Liver enzymes, lipase and amylase were normal. MRI of the abdomen demonstrated a 20 x 12 x 13 cm thick-walled, lobular cyst arising from the proximal pancreatic body. EGD showed significant external compression of gastric antrum and duodenum. Endoscopic ultrasound guided diagnostic cyst fluid aspiration was performed with cyst fluid demonstrating elevated amylase (value >1300 U/L), low CEA (4.8 ng/mL), and cytology was negative for malignancy, consistent with a pancreatic pseudocyst. We performed endoscopic cystogastrostomy placing a fully covered metal biliary stent. This was followed by cyst re-expansion on MRI with extrinsic compression on the common bile duct and an infected pseudocyst which was managed with intravenous antibiotics and cystoduodenostomy with copious drainage of purulent material and resolution of abdominal pain. At 37 weeks of pregnancy, she presented with contractions and complete breech presentation. A cesarean section was performed and she delivered a viable male infant. A CT scan after delivery showed complete resolution of the pseudocyst. Pancreatic pseudocysts complicating pregnancy are rare with only 10 cases reported in the literature since 1980. Although pseudocysts may regress spontaneously, approximately 30%-40% are complicated by infection, rupture, hemorrhage, or obstruction of the stomach, small bowel, colon, or bile duct. The natural history of pancreatic pseudocysts in pregnant patients seems to be similar to non-gravid patients, however there is concern for increased risk of rupture during vaginal delivery. Symptomatic, enlarging, very large, or complicated pseudocysts require drainage. While the management of pancreatic pseudocysts is not standardized in pregnant patients, the second trimester is generally considered the safest time to intervene.Figure 1Figure 2Figure 3

Type 1 Autoimmune Pancreatitis Associated with Mucinous Cystic Neoplasm

The relationship between autoimmune pancreatitis and pancreatic neoplasia is poorly understood. We report a case of a 26-year-old woman who presented with a 2-month history of upper abdominal pain. Computed tomography scan revealed a 5.8 cm cyst within the pancreatic tail. Fine needle aspiration revealed mildly atypical mucinous cells. Fluid analysis revealed elevated CEA …

A Nomogram to Predict Lymph Node Positivity Following Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer.

Patients with locally advanced rectal cancer typically receive neoadjuvant chemoradiation followed by total mesorectal excision. Other treatment approaches, including transanal techniques and close surveillance, are becoming increasingly common following positive responses to chemoradiation. Lack of pathologic lymph node staging is one major disadvantage of these novel strategies. The purposes of this study were to determine clinicopathologic factors associated with positive lymph nodes following neoadjuvant chemoradiation for rectal cancer and to create a nomogram using these factors to predict rates of lymph node positivity. This is a retrospective cohort analysis. This study used the National Cancer Database. Patients aged 18 to 90 with clinical stage T3/T4, N0, M0 or Tany, N1-2, M0 adenocarcinoma of the rectum who underwent neoadjuvant chemoradiation before total mesorectal excision from 2010 to 2012 were identified. The primary outcome measure was lymph node positivity after neoadjuvant chemoradiation for locally advanced rectal cancer. Bivariate and multivariate analyses were used to determine the associations of clinicopathologic variables with lymph node positivity. Eight thousand nine hundred eighty-four patients were included. Young age, lower Charlson score, mucinous histology, poorly differentiated and undifferentiated tumors, the presence of lymphovascular invasion, elevated CEA level, and clinical lymph node positivity were significantly predictive of pathologic lymph node positivity following neoadjuvant chemoradiation. The predictive accuracy of the nomogram is 70.9%, with a c index of 0.71. There was minimal deviation between the predicted and observed outcomes. This study is retrospective, and it cannot be determined when in the course of treatment the data were collected. We created a nomogram to predict lymph node positivity following neoadjuvant chemoradiation for locally advanced rectal cancer that can serve as a valuable complement to imaging to aid clinicians and patients in determining the best treatment strategy.