Pathologic N0 status in pulmonary adenocarcinoma is predictable by combining serum carcinoembryonic antigen level and computed tomographic findings

OBJECTIVES: It is not clear whether lymphadenectomy has therapeutic benefit in non-small cell lung cancer management. To avoid unnecessary lymphadenectomy, we attempted to identify clinical or radiologic predictors of pathologic N0 disease in patients with peripheral adenocarcinoma. METHODS: From August 1992 through April 1997, 269 consecutive patients with peripheral adenocarcinoma who underwent major lung resection and systematic lymph node dissection were enrolled in this study. We reviewed their contrast-enhancement computed tomographic scans and recorded the maximum dimension of tumors both on pulmonary (pDmax) and on mediastinal (mDmax) window setting images, the largest dimension perpendicular to the maximum axis on both pulmonary (pDperp) and mediastinal (mDperp) window setting images, and the size of all detectable hilar-mediastinal lymph nodes. We defined a new radiologic parameter, tumor shadow disappearance rate (TDR), which is calculated with the following formula: TDR = 1 - (mDmax x mDperp)/(pDmax x pDperp). RESULTS: In multivariable analysis a lower serum carcinoembryonic antigen level and a higher tumor shadow disappearance rate were significant predictors of pathologic N0 disease. Lymph node size on computed tomographic scanning was not a significant predictor. Among 59 patients with a normal preoperative carcinoembryonic antigen level and a tumor shadow disappearance rate of 0.8 or more, 58 (98%) patients had pathologic N0 disease, and the other patient had pathologic N1 disease. CONCLUSIONS: Mediastinal lymph node involvement was not found in patients with a normal preoperative serum carcinoembryonic antigen level and a tumor shadow disappearance rate 0.8 or more. The patients who meet these criteria may be successfully managed with major lung resection without systematic mediastinal lymphadenectomy.     

High resolution computed tomographic findings in pulmonary tuberculosis.

BACKGROUND: Although chest radiographs usually provide adequate information for the diagnosis of active pulmonary tuberculosis, minimal exudative tuberculosis can be overlooked on standard chest radiographs. The aim of the present study was to assess the findings of active pulmonary tuberculosis on high resolution computed tomographic (HRCT) scans, and to evaluate their possible use in determining disease activity. METHODS: Thirty two patients with newly diagnosed active pulmonary tuberculosis and 34 patients with inactive pulmonary tuberculosis were examined. The diagnosis of active pulmonary tuberculosis was based on positive acid fast bacilli in sputum and bronchial washing smears or cultures and/or changes on serial radiographs obtained during treatment. RESULTS: With HRCT scanning centrilobular lesions (n = 29), "tree-in-bud" appearance (n = 23), and macronodules 5-8 mm in diameter (n = 22) were most commonly seen in cases of active pulmonary tuberculosis. HRCT scans showed fibrotic lesions (n = 34), distortion of bronchovascular structures (n = 32), emphysema (n = 28), and bronchiectasis (n = 24) in patients with inactive tuberculosis. CONCLUSIONS: Centrilobular densities in and around the small airways and "tree-in-bud" appearances were the most characteristic CT features of disease activity. HRCT scanning clearly differentiated old fibrotic lesions from new active lesions and demonstrated early bronchogenic spread. These findings may be of value in decisions on treatment.     

Pre- and post-operative serum carcinoembryonic antigen in primary lung adenocarcinoma.

The clinical value of pre- and post-operative serum carcinoembryonic antigen (CEA) concentration (mean +/- SEM, ng/ml) in surgically treated primary lung cancer patients with adenocarcinoma (n=97) was studied. Preoperative CEA in pT2 patients (18.3+/-8.0) was higher than in pT1 (10.5+/-6.4, p<0.05) but was not different from pT3 patients (19.7+/-6.7). Preoperative CEA in pN1 patients (5.9+/-1.6) was lower than in pN2 (28.2+/-13.2, p<0.05) but not different from pN0 patients (8.8+/-3.8); p-stage II patients (8.2+/-4.7) had lower values than p-stage III patients (26.7+/-10.5, p<0.05), but not p-stage I patients (7.9+/-3.9). The CEA was not different between p-stages IA and IIA (3.5+/-0.6, 6.1+/-3.2) and IB and IIB (17.0+/-11.8, 11.7+/-7.8), but was different between IA and IB (p<0.05) and IIA and IIB (p<0.05). Preoperative CEA did not differ between patients who received complete (12.7+/-4.7) versus incomplete (9.5+/-6.0) resections, nor between patients who developed recurrence after surgery (21.9+/-10.4) versus those who were disease-free (30.9+/-21.7). CEA obtained 2 months after surgery in patients who recurred or metastasized after surgery (63.1+/-47.0) was higher than in disease-free patients (4.8+/-1.6, p<0.05). The post-/pre-operative CEA ratio in patients who recurred or metastasized after surgery (146.6+/-53.3%) was also higher than in disease-free patients (91.0+/-10.9%, p=0.05). In conclusion, CEA reflected tumor size but not the tumor invasion nor hilar lymph node disease; patients with mediastinal lymph node involvement had higher CEA values. Preoperative CEA did not reflect the likelihood of complete resection nor postoperative metastasis, but postoperative CEA obtained 2 months after surgery did reflect postoperative metastasis.     

Secretory meningioma with elevated serum carcinoembryonic antigen level.

We recently encountered a 68-year-old woman with right sphenoid wing meningioma of the secretory type accompanied by an elevated serum carcinoembryonic antigen level. This case was neuroradiologically characterized by marked brain edema. Histologically, the lesion was rated as having meningothelial components and was rich in blood vessels and pseudopsammoma bodies. Carcinoembryonic antigen, epithelial membrane antigen, keratin, and cytokeratin were immunohistochemically detected in the pseudopsammoma bodies and the cells producing these bodies.     

Prognosis of surgically resected lung cancer with extremely high preoperative serum carcinoembryonic antigen level

Purpose  

The aim of this study was to investigate the prognosis of resected lung cancer patients with extremely high carcinoembryonic antigen (CEA) levels. Several reports have indicated that increased preoperative serum CEA levels are associated with a dismal outcome after surgery, whereas others have reported long-term survival among patients with extremely high preoperative CEA levels. We investigated whether preoperative serum CEA levels, especially extremely high levels, were related to the prognosis of non-small-cell lung cancer (NSCLC) after surgery.     

Prognostic significance of preoperative serum carcinoembryonic antigen level in lung adenocarcinoma but not squamous cell carcinoma.

OBJECTIVES: Clinical significance of measurement of preoperative serum carcinoembryonic antigen (CEA) level in patients with non-small cell lung cancer was investigated. METHODS: Consecutive 271 adenocarcinoma and 112 squamous cell carcinoma patients of non-small cell lung cancer referred to our institute were included in this study. There were 214 men and 169 women, ages ranged from 19 to 90 years, with an average of 64.46 years. Curative resection was performed for 220 adenocarcinoma and 93 squamous cell carcinoma patients. Serum level of CEA was measured before staging or resection of cancer. RESULTS: There is a trend toward a correlation between serum CEA level and stage of the diseases, however, serum CEA level was not always related to tumor node metastasis (TNM) status. In patients with adenocarcinoma, survival rate of patients with an elevated serum CEA level was significantly lower than that with a normal serum CEA level. Multivariate analysis showed that prognostic significance of serum CEA level was TNM staging independent in patients with adenocarcinoma. On the other hand, serum CEA level was not related to patients' survival in patients with squamous cell carcinoma. CONCLUSIONS: Elevated preoperative serum CEA level is a TNM staging independent prognostic factor for patients with adenocarcinoma but not for those with squamous cell carcinoma.     

Intention tremor after head injury. Clinical features and computed tomographic findings

Eight cases of intention tremor as a late complication of head injury were investigated. The patients ranged in age from 3 to 24 years. All received severe head injuries and lapsed into coma immediately afterward (Glasgow Coma Scale scores less than or equal to 8). Six patients exhibited decerebration or decortication. Hemiparesis was present in six cases and oculomotor nerve palsy in four. In the chronic stage, all patients displayed some degree of impairment of higher cortical function and five had dysarthria and/or ataxia. Initial computed tomography (CT) scans within 3 hours after the injury were obtained in five cases, of which four showed a hemorrhagic lesion in the midbrain or its surroundings. Other CT findings were diffuse cerebral swelling (four cases), intraventricular hemorrhage (three), and multiple hemorrhagic lesions (two). In the chronic stage, generalized cortical atrophy or ventricular enlargement was noted in five cases. These clinical features and CT findings indicate diffuse brain damage as well as midbrain damage and may reflect shearing injury.     

Correlation between dynamic computed tomographic and histopathological findings in the diagnosis of small hepatocellular carcinoma

BACKGROUND/AIMS: To determine the characteristic image findings on dynamic computed tomography (CT) for small hepatocellular carcinoma (HCC), we evaluated the correlation of histopathological and radiological findings with respect to the angioarchitecture in small HCCs. METHODS: CT and early- and late-phase dynamic CT findings of 80 small HCCs (< or =3 cm) were divided into iso-, high, low, and mixed density. We studied the correlation between the imaging findings and the histopathological findings as follows: differentiation grade; presence of fibrous capsule; presence of Glisson's sheath, and growth pattern. RESULTS: High-density early-phase CT and low-density late-phase CT correlated significantly with moderately/poorly differentiated HCCs, which have a fibrous capsule, no Glisson's sheath, and an expansive growth pattern. In contrast, well-differentiated HCCs with a Glisson's sheath and a replacing pattern (early HCC) appeared as iso-dense lesions in the early and late phases. Well-differentiated HCCs (non-early wHCC) demonstrated various density images in the early phase and low-density images in the late phase. CONCLUSIONS: Dynamic CT is an economic and simple diagnostic tool for planning treatment of small HCC lesions because of the multistep nature of HCC carcinogenesis and the hemodynamic changes of tumor blood flow.     

Effect of histologic type and smoking status on interpretation of serum carcinoembryonic antigen value in non-small cell lung carcinoma

Background

Serum carcinoembryonic antigen (CEA) has all of the properties desired for a biologic measure to be used as a prognostic indicator in the clinical evaluation of lung cancer. Carcinoembryonic antigen value appears to be related to tumor histologic type and patients' smoking status, which has yet to be intensively analyzed as reports available thus far have consisted of a limited number of patients. This study was undertaken to determine whether the prognostic value of CEA differs according to histologic type in a large group of patients with clinical early-stage lung cancer, and how smoking influences its value.

Methods

Two series of 694 and 260 consecutive patients who underwent resection for clinical stage I lung adenocarcinoma and squamous cell carcinoma, respectively, were evaluated. We measured serum CEA before and after surgery, and analyzed its prognostic significance in relation to histologic type and its correlation with smoking status.

Results

We found significantly higher CEA levels in patients with adenocarcinomas than in those with squamous cell carcinomas (7.8 versus 5.5 ng/mL; p = 0.0018), but a higher percentage of CEA-positive patients among those with squamous cell carcinoma (109 of 260, 41.9%) than those with adenocarcinoma (245 of 694, 35.3%). Clinical stage I patients with a high preoperative CEA level had a poor prognosis, and for pathologically confirmed stage I patients with a high postoperative CEA level the prognosis was worse. The prognostic value of serum CEA level was thus significantly greater for adenocarcinoma than for squamous cell carcinoma. This was probably because of a much higher proportion of smokers among patients with squamous cell carcinoma. In adenocarcinoma, the growth of which was generally less influenced by smoking, the proportion of CEA-positive smokers (49.3%, 170 of 345) was greater than that of CEA-positive nonsmokers (21.5%, 75 of 349, p < 0.0001). Additionally, in patients with adenocarcinoma, survival of nonsmokers was more greatly influenced by CEA level than that of smokers.

Conclusions

Although serum CEA values measured before and after surgery are important in identifying patients at high risk of poor survival, its specificity is higher for adenocarcinoma than for squamous cell carcinoma. When serum CEA levels are checked, smoking status of patients, particularly of those with squamous cell carcinoma, should be taken into account.     

Chronic sputum production: correlations between clinical features and findings on high resolution computed tomographic scanning of the chest.

BACKGROUND: There are few published data on the correlation between the clinical findings in subjects with chronic sputum production and the appearances on high resolution computed tomographic (HRCT) scans of the chest. METHODS: HRCT scanning of the chest was performed on 40 subjects with chronic sputum production. Three readers independently reported the scans for the presence or absence of bronchiectasis and the extent of bronchiectasis on the basis of the percentage of involved bronchi in each lobe. Relationships were sought between these findings and the clinical history, physical examination, and laboratory investigations. RESULTS: HRCT scanning showed that 27 subjects had bronchiectasis. Of the clinical features only the continual production of purulent sputum and childhood pertussis were associated with bronchiectasis. There was a positive correlation between the extent of bronchiectasis and dyspnoea, and a negative correlation with forced expiratory volume in one second but not with forced vital capacity. CONCLUSIONS: These results indicate that, in subjects with chronic sputum production, only a few clinical features show any correlation with the presence or extent of bronchiectasis as visualised on HRCT scans.     

Effect of cigarette smoking, pulmonary inflammation, and lung disease on concentrations of carcinoembryonic antigen in serum and secretions.

A specific radioimmunoassay for carcinoembryonic antigen was used to investigate aspects of its measurement in lung disease. The results confirm that serum carcinoembryonic antigen concentrations are higher in healthy smokers and patients with chronic obstructive bronchitis than in healthy non smokers (p less than 0.01). Corticosteroid treatment reduced the concentration in nine patients with bronchitis (p less than 0.05). Other inflammatory lung diseases (bronchiectasis, pneumonia, fibrosing alveolitis) are not associated with a raised serum carcinoembryonic antigen concentration. The sputum concentrations were about 100 times those found in serum and there was a positive correlation (r = 0.611 2p less than 0.01) between the concentrations in sputum and serum in patients with bronchitis. No preferential rise in sputum concentration was found in current smokers or patients with lung carcinoma (n = 16). A higher ratio of carcinoembryonic antigen to albumin concentration (p less than 0.05) was, however, found in lavage fluid obtained from the tumour site than in fluid from "normal" lung in the same patients, suggesting an increase in carcinoembryonic antigen secretion in the vicinity of the tumour. Despite this "local" effect the sputum concentration does not, however, appear to be a useful marker of lung carcinoma and the measurement could not be used as a screening test.     

Cerebral gliosarcomas: correlation of computed tomographic findings, surgical aspect, pathological features, and prognosis

The cases of 5 patients with cerebral gliosarcomas examined by computed tomography are reported and the correlations among the computed tomographic (CT) findings, the surgical and histological aspects, and the prognosis are discussed. In some patients, these tumors appear on CT scan as intracerebral lesions, with large necrotic areas and peripheral contrast enhancement; this CT aspect, similar to that of glioblastomas, corresponds to a diffusely infiltrating growth of the tumor and the prevalence of a gliomatous component. In other patients, the tumor appears on the CT scan as a hyperdense mass with well-defined margins and homogenous contrast enhancement; this CT finding, which may mimic that of a meningioma, corresponds to a rather well-demarcated surgical aspect and the prevalence of sarcomatous component. In our series, we have also noticed a more prolonged survival in a patient with a CT aspect that suggested a meningioma and prevalence of the sarcomatous component.     

Clinical evaluation of urinary and serum carcinoembryonic antigen in bladder cancer.

Urinary carcinoembryonic antigen-like activity was increased (more than 1.5 ng. per ml.) in 61 per cent of patients with transitional cell carcinoma of the bladder. The frequency of abnormal carcinoembryonic antigen values correlated with the extent and the grade of the tumor. However, urinary tract infection can produce abnormal carcinoembryonic antigen values in non-cancer patients. The use of urinary carcinoembryonic antigen measurement and urine cytologic examination for diagnosis of transitional cell carcinoma gave a better diagnostic yield than did use of either test alone. In transitional cell carcinoma patients with abnormal preoperative urinary carcinoembryonic antigen values, postoperative urinary carcinoembryonic antigen values were useful for determining completeness of tumor resection. However, with total cystectomy and creation of an ileal conduit or ureterosigmoidostomy, urinary carcinoembryonic antigen values increased markedly postoperatively. Serum carcinoembryonic antigen values were of little value in the diagnosis of transitional cell carcinoma.     

血清癌胚抗原水平对于预测非小细胞肺癌术后早期复发的意义

目的　探讨影响非小细胞肺癌术后早期复发的临床病理因素 ,了解血清癌胚抗原(CEA)检测对预测非小细胞肺癌患者术后早期复发的作用。方法　对 2 0 0 0年 9月～ 2 0 0 2年 8月收治的 93例非小细胞肺癌患者行手术治疗 ,术前行血清CEA测定 ,术后随访 1年以上 ,记录第 1次复发的时间。应用Logistic回归分析观察影响非小细胞肺癌术后早期复发的临床病理因素 ,应用受试者工作特征 (ROC)曲线进行数据分析 ,比较各危险因素预测非小细胞肺癌术后早期复发的能力。结果血清CEA水平、临床分期和肿瘤分化与非小细胞肺癌术后早期复发有关。其中CEA >10 μg/L是预测非小细胞肺癌术后早期复发较好的指标 (ROC曲线下面积 :0 84 3,95 %CI :0 72 3～ 0 96 3,P =0 0 0 0 )。结论　对于可以手术切除的非小细胞肺癌患者 ,术前应行血清CEA水平测定 ,术前血清CEA >10 μg/L提示 ,术后复发的可能性较大     

Large-cell carcinoma of the lung with a remarkable preoperative elevation of serum carcinoembryonic antigen level

Carcinoembryonic antigen, a serum tumor marker, is useful for diagnosing cancer and for following the response to therapy in cancer cases. Serum carcinoembryonic antigen levels are also important as a predictive tool in evaluating prognosis. A 56-year-old man presented with an abnormal shadow on a chest X-ray. His preoperative serum carcinoembryonic antigen was at an elevated level of 1274.0 ng/ml. Chest computed tomography revealed a tumor in the posterior segment of the right lung and a swollen right interlobar lymph node. Right lung pneumonectomy and node dissection were performed. A histological diagnosis determined that the tumor was a large-cell carcinoma at clinical stage IIA. Immunohistochemical analysis detected the production of carcinoembryonic antigen by the tumor cells. Following surgery, the patient's carcinoembryonic antigen levels were maintained within the normal range. This is a rare case of lung cancer with no evidence of recurrence and metastasis for 8 years despite markedly elevated preoperative carcinoembryonic antigen levels.     

Primary thymic adenocarcinoma with production of carbohydrate antigen 19-9 and carcinoembryonic antigen

A 59-year-old male, whose chest X-ray showed an abnormal shadow, visited us for further study. Laboratory examination showed the elevated level for both carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) in serum, and the chest X-ray and computed tomography showed an anterior mediastinal mass. Under a diagnosis of thymic malignancy, extended thymectomy with combined resection of the pleura and pericardium was performed. Histopathological findings showed a well-differentiated adenocarcinoma of the thymus, in which CA19-9 and CEA were positive immuno-histochemically. The level of serum CA19-9 and CEA returned to normal ranges postoperatively, however, the tumor recurred in local site with re-elevation of these tumor markers at the 20th month after surgery. He died at 4th month after the first recurrence despite the intensive chemotherapy. We report an extremely rare case of primary thymic adenocarcinoma with the production of CA19-9 and CEA.