Preoperative Carcinoembryonic Antigen and Prognosis of Colorectal Cancer. An Independent Prognostic Factor Still Reliable

To evaluate whether, in a sample of patients radically treated for colorectal carcinoma, the preoperative determination of the carcinoembryonic antigen (p-CEA) may have a prognostic value and constitute an independent risk factor in relation to disease-free survival. The preoperative CEA seems to be related both to the staging of colorectal neoplasia and to the patient''s prognosis, although this—to date—has not been conclusively demonstrated and is still a matter of intense debate in the scientific community. This is a retrospective analysis of prospectively collected data. A total of 395 patients were radically treated for colorectal carcinoma. The preoperative CEA was statistically compared with the 2010 American Joint Committee on Cancer (AJCC) staging, the T and N parameters, and grading. All parameters recorded in our database were tested for an association with disease-free survival (DFS). Only factors significantly associated (P < 0.05) with the DFS were used to build multivariate stepwise forward logistic regression models to establish their independent predictors. A statistically significant relationship was found between p-CEA and tumor staging (P < 0.001), T (P < 0.001) and N parameters (P = 0.006). In a multivariate analysis, the independent prognostic factors found were: p-CEA, stages N1 and N2 according to AJCC, and G3 grading (grade). A statistically significant difference (P < 0.001) was evident between the DFS of patients with normal and high p-CEA levels. Preoperative CEA makes a pre-operative selection possible of those patients for whom it is likely to be able to predict a more advanced staging.Key words: Colorectal carcinoma, Preoperative carcinoembryonic antigen, Disease-free survival, Independent prognostic factorIn the world today, more than 1 million cases of patients with colorectal neoplasia are identified each year. Forty percent of these will have a poor prognosis for which targeted therapeutic strategies could most likely be more effective.^1–3 For this reason, finding prognostic factors that are early, reliable, and related to the extent of the tumor is of the utmost importance. Among these, the most that are considered even to this day are T and N parameters.^1,2,4,5 Less relied upon, however, is the M parameter, which is often understaged due to inadequate pretreatment diagnostic methods.⁶ However, these parameters, which are available to us only after surgery, do not represent the gold standard. In fact, the prognosis of patients with the same staging is often various and that the need to continually implement ever-changing variables in an already excessively fragmented staging is still present.^2,4,7–9Recently, in light of these needs, great attention has been paid to the study of molecular and genetic markers. At present, these markers still have not found a regular application due to the complexity of their determination, the difficulty of standardization and, last but not least, the low cost-benefit ratio.^1,3,4,9,10With this in mind, in our opinion, the carcinoembryonic antigen (CEA) maintains its position, as for over 30 years it has continued to be the most widely used marker¹¹ and whose validity, with regard to colorectal follow-up, has been sanctioned by leading organizations such as the American Society of Clinical Oncology (ASCO)¹² and the European Group on Tumor Markers.¹³ Moreover, as Herrera¹⁴ and Wanebo¹⁵ had already reported by the end of the ‘70s, the preoperative determination of the CEA (p-CEA) seems to be related both to the staging of colorectal neoplasia and to the patient''s prognosis. However, to date, none of this has been conclusively demonstrated and is still a matter of intense debate both in prestigious scientific journals^{4,7,11,16–21} as well as in different guidelines.²²The American Society of Clinical Oncology itself, if on the one hand suggests using the determination of the CEA in the preoperative staging thus justifying a worse prognosis when increased,¹² on the other, does not validate using the p-CEA in the determination of an adjuvant or neo-adjuvant therapeutic strategy.²³Regarding this issue, we believe it still pertinent to evaluate whether in a sample of patients radically treated for colorectal carcinoma, the determination of the p-CEA may have a prognostic value and constitute an independent risk factor in relation to disease-free survival (DFS).     

Role of Fusion of Prone FDG‐PET and Magnetic Resonance Imaging of the Breasts in the Evaluation of Breast Cancer

Abstract: The purpose of this study is to report further about the statistically significant results from a prospective study, which suggests that fusion of prone F‐18 Fluoro‐deoxy‐glucose (FDG) positron emission tomography (PET) and magnetic resonance (MR) breast scans increases the positive predictive value (PPV) and specificity for patients in whom the MR outcome alone would be nonspecific. Thirty‐six women (mean age, 43 years; range, 24–65 years) with 90 lesions detected on MR consented to undergo a FDG‐PET scan. Two blinded readers evaluated the MR and the computer tomography (CT) attenuation‐corrected prone FDG‐PET scans side‐by‐side, then after the volumes were superimposed (fused). A semiautomatic, landmark‐based program was used to perform nonrigid fusion. Pathology and radiologic follow‐up were used as the reference standard. The sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy (with 95% confidence intervals) for MR alone, FDG‐PET alone, and fused MR and FDG‐PET were calculated. The median lesion size measured from the MR was 2.5 cm (range, 0.5–10 cm). Histologically, 56 lesions were malignant, and 15 were benign. Nineteen lesions were benign after 20–47 months of clinical and radiologic surveillance. The sensitivity of MR alone was 95%, FDG‐PET alone was 57%, and fusion was 83%. The increase in PPV from 77% in MR alone to 98% when fused and the increase in specificity from 53% to 97% were statistically significant (p < 0.05). The false‐negative rate on FDG‐PET alone was 26.7%, and after fusion this number was reduced to 9%. FDG‐PET and MR fusions were helpful in selecting which lesion to biopsy, especially in women with multiple suspicious MR breast lesions.     

Disentangling the Roles of Mammographic Screening and HRT in Recent Breast Cancer Incidence Trends in Italy by Analyses Based on Calendar Time and Time Since Screening Activation

Abstract: The aim of the study was to evaluate the roles of screening activation and hormone replacement therapy discontinuation on the recent declining breast cancer incidence trends in Italy. We analyzed 41,358 invasive female breast cancers incident during 1991–2004 in six Italian population‐based cancer registries. Overall and age‐specific incidence trends were evaluated using Joinpoint analysis. In addition to calendar years, data were analyzed on a years‐since‐screening‐activation basis. Annual percentage change of standardized rates was computed. There were statistically significant increasing trends for women 40–44 and 45–49 years that did not change after screening activation. On the contrary, for women 50–69 years old and for those 70+ years, the increasing trends flattened around 2 years after screening activation. The prevalence of hormone replacement therapy use in Italy is and was rather low. In conclusion, the recent tendency toward stabilization observed in Italy for female breast cancer incidence rates in women aged 50 years or more follows the introduction of mammographic screening.     

MR cholangiography in orthotopic liver transplantation: sensitivity and specificity in detecting biliary complications

Boraschi P, Donati F, Gigoni R, Volpi A, Salemi S, Filipponi F, Falaschi F. MR cholangiography in orthotopic liver transplantation: sensitivity and specificity in detecting biliary complications.
Clin Transplant 2010: 24: E82–E87.
© 2009 John Wiley & Sons A/S. Abstract: Background: To assess the diagnostic value of magnetic resonance cholangiography (MRC) when evaluating biliary complications in a large series of liver transplants. Methods: One hundred and twenty‐nine patients prospectively underwent magnetic resonance (MR) imaging and MR cholangiography at 1.5‐T device after orthotopic liver transplantation (OLT). After the preliminary acquisition of axial T1‐ and T2‐weighted images, MRC involved respiratory‐triggered, thin‐slab (2 mm), heavily T2‐weighted fast spin‐echo and breath‐hold, thick‐slab (10–50 mm), single‐shot T2‐weighted sequences. MR images were blindly evaluated by two experienced readers in conference to determine the biliary anatomy and the presence of complications, whose final diagnosis was based on endoscopic retrograde cholangiography, percutaneous trans‐hepatic cholangiography, and by integrating clinical follow‐up with ultrasound and/or MR findings. Results: Biliary complications were found in 60 patients (46.5%) and were represented by ischemic‐type biliary lesions (n = 21); anastomotic strictures (n = 13); non‐anastomotic strictures (n = 5); anastomotic strictures associated to lithiasis (n = 6); lithiasis (n = 6); papillary dysfunctions (n = 9). The sensitivity, specificity, positive predictive value, and negative predictive value of the reviewers for the detection of all types of biliary complications in patients with OLT were 98%, 94%, 94%, and 98%, respectively. Conclusions: MRC is a reliable technique for detecting post‐OLT biliary complications and should be recommended before planning therapeutic interventions.     

Cerebral monitoring during cardiovascular surgery

PURPOSE OF REVIEW: Recent publications have reported on the neurologic complications in cardiovascular surgery. They are frequent, and have surpassed the mortality rate in cardiac surgery. Brain injury compromises surgical results and the patient's outcome. This review reports on the recent literature on neuromonitoring tools used to prevent and reduce brain injury in cardiovascular surgery. RECENT FINDINGS: In the past year a good correlation between cerebral oxymetry and flow velocity by transcranial Doppler ultrasonography during carotid endarterectomy has been demonstrated, but this technique did not detect reliable flow velocity in 35% of cases. Transcranial Doppler ultrasonography, near-infrared spectroscopy and stump-pressure measurement have emerged with similar levels of accuracy for detecting cerebral ischemia, but, owing to the high number of technical difficulties, transcranial Doppler ultrasonography seems less practical than the other monitoring methods. In cardiac surgery multimodal monitoring seems to be more effective than single tools. There is evidence for a lack of established monitoring. SUMMARY: Neuromonitoring tools may guide both intervention and treatment, and are aimed at reducing brain damage during cardiovascular surgery, especially when combined in multimodality monitoring. Further prospective, double-blind, randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities) in specific surgical settings.     

Systematic extended right posterior sectionectomy: a safe and effective alternative to right hepatectomy

BACKGROUND: A surgical approach based on ultrasound-guided hepatectomy might minimize the need for major resection, whose rates of morbidity and mortality are not negligible. Right hepatectomy (RH) is traditionally performed in cases of vascular invasion of the right hepatic vein with multiple tumors in the right posterior section, and/or of the right posterior portal branch (P6-7) with tumor in contact with right anterior portal branch (P5-8). We herein describe an alternative approach to RH consisting in ultrasound-guided systematic extended right posterior hepatic sectionectomy (SERPS). METHODS: Among 207 consecutive patients who underwent hepatectomies, 21 (10%) underwent SERPS. Median age was 67 years (range, 48-79). There were 13 men and 8 women. Ten (48%) patients had hepatocellular carcinoma; 11 (52%) had colorectal liver metastases. Median tumor number was 2 (range, 1-15); median tumor size was 4.5 cm (range, 2.5-20). Ten (48%) patients had cirrhosis, 8 (38%) had steatosis, and 3 (16%) had normal liver. Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS. RESULTS: In-hospital and 90-days mortality were nil. Major and minor morbidity occurred in 3 (14%) and 2 (9.5%) patients, respectively. No patients were reoperated because of complications. Blood transfusions were given to 2 (9.5%) patients. After a median follow-up of 21 months, no local recurrence was observed. CONCLUSIONS: IOUS-guided SERPS is feasible, safe, and effective. It should be applied whenever possible as alternative resection to RH to maximize liver parenchymal sparing.     

Neo-adjuvant chemotherapy in invasive bladder cancer

In patients with locally advanced muscle-invasive bladder cancer, neo-adjuvant chemotherapy was designed to treat micrometastatic disease present in up to 50% of patients at the time of diagnosis. Early chemotherapy has been combined with local therapy based on the reasoning that treatment of small volume disease would result in a better outcome. Another reason for giving neo-adjuvant chemotherapy is in an attempt to save the bladder. In selected patients, bladder preservation can be achieved with the use of chemotherapy plus radiotherapy, partial cystectomy, or transurethral resection of the bladder (TURB). Neo-adjuvant chemotherapy and bladder preservation remain controversial topics, as radical cystectomy is still considered to be the gold standard of treatment for muscle-invasive bladder cancer. The true success of bladder-preserving treatment by chemotherapy with or without RT will require validation in prospective randomized trials.     

Tension-free vaginal tape for the treatment of urodynamic stress incontinence with intrinsic sphincteric deficiency

The purpose of this study was to evaluate the outcome of tension-free vaginal tape (TVT) procedure in women with urodynamic stress incontinence diagnosed as having intrinsic sphincteric deficiency (ISD). The combination of a maximal urethral closure pressure <20 cm H₂O and a Valsalva leak point pressure <60 cm H₂O was considered as diagnostic of ISD. Subjects with detrusor overactivity on preoperative urodynamics were excluded. A total of 35 patients with both low closure pressure and leak point pressure were enrolled. Bladder perforation occurred in three (8.6%) cases. Postoperative urinary voiding difficulties occurred in nine (25.7%) women. Two patients underwent surgical detension of the tape, with complete resolution of urinary retention and no relapse of incontinence. Women with postoperative voiding dysfunction had a significantly lower detrusorial pressure at the peak flow on preoperative urodynamics compared to those who voided efficiently after TVT. The mean (range) follow-up time was 12.5 months (3–36). The objective cure rate for stress incontinence was 91.4%. Two of the three (66%) patients in whom the TVT procedure failed had a fixed urethra. De novo urge incontinence was found in five (14.3%) patients.     

State-of-the-art management of metastatic disease at initial presentation or recurrence

Carcinoma of the bladder is the second most prevalent genitourinay malignancy and the fifth most common solid tumor in the USA. On the basis of favorable response rates and survival data, cisplatin-based regimens can be considered the standard treatment for fit patients with metastatic urothelial cancer. Since cisplatin-containing regimens are contraindicated for patients with impaired renal function, gemcitabine plus either paclitaxel or docetaxel may be an effective and well-tolerated treatment option for these patients. Randomized trials are needed to determine the future role of these combinations in the management of advanced transitional cell carcinoma. The optimal regimens for the medically unfit patients and second-line chemotherapy remain undefined. Postchemotherapy surgical resection of residual cancer may result in a disease-free survival in highly selected patients who would otherwise die of the disease. Progresses in the understanding of the molecular biology of bladder cancer and identification of new targeted therapies will undoubtedly provide new opportunities but whether or not this approach to therapy will lead to better results must still be determined.