Is carcino-embryonic antigen useful in the follow-up management of patients with colorectal liver metastases?

BACKGROUND: The role of carcino-embryonic antigen (CEA) in monitoring early detection of recurrent or metastatic colorectal cancer, and its impact on resectability rate and patient survival remains controversial. Our objective was to determine any association between the preoperative level of CEA and prognosis, and the resectability and survival by method of diagnosis of colorectal hepatic metastases. METHODS: We analyzed patients who underwent exploration for hepatic resection for metastatic colorectal cancer over a 15-year period. The patient population consisted of those patients who had undergone primary colon or rectal resection and were followed up with serial CEA levels and of patients who were followed up with physical examination, liver function tests (LFTs) or computed tomography (CT) of the abdomen and pelvis that led to the diagnosis of liver metastases. Also included in the study were patients who were diagnosed with liver metastases at the time of the primary colon or rectal resection and underwent planned hepatic resection at a later time. RESULTS: Three hundred and one (301) patients who underwent a total of 345 planned hepatic resections for metastatic colorectal cancer between January 1978 and December 1993 were included in this analysis. The median preoperative CEA level was 24.8 ng/mL in the resected group, 53.0 ng/mL in the incomplete resection group, and 49.1 ng/mL in the nonresected group (P = 0.02). More of the patients who had a preoperative CEA < or =30 ng/mL were in the resected group, while those who had a preoperative CEA >30 ng/mL were likely to be in the nonresected group (P = 0.002). The median survival was 25 months for patients with a preoperative CEA level < or =30 ng/mL and 17 months for patients with a preoperative CEA >30 ng/mL (P = 0.0005). The resectability rate and the survival of patients by method of diagnosing liver metastases-rising CEA versus history and physical, elevated LFTs, CT scan versus diagnosis at the time of primary resection-was not significant (P = 0.06 and P = 0.19, respectively). Given the nonstandardized retrospective nature of the study cohort and relative small groups of patients, the power to detect small differences in survival by method of diagnosis is limited. In the complete resection group of patients with unilobar liver disease (5-year survival of 28.8%) there was no difference in survival between those patients who had normal preoperative CEA and those who had elevated preoperative CEA, and approximately 90% of them had an abnormal preoperative serum CEA level. CONCLUSIONS: CEA is useful in the preoperative evaluation of patients with hepatic colorectal metastases for assessing prognosis and is complimentary to history and physical examination in the diagnosis of liver metastases. Patients with colorectal liver metastases and preoperative CEA < or =30 ng/mL are more likely to be resectable, and they have the longest survival.

The radioimmunoguided surgery (RIGS) system as a diagnostic tool.

Radioimmunoguided surgery (RIGS) was developed to improve on the intraoperative detection of malignancy. The RIGS system uses a hand-held gamma radiation detection probe to identify radioactive tissues targeted by a preadministered tumor-associated radiolabeled targeting antibody or peptide. Clinical experience with RIGS in colorectal cancer has been favorable; better intraoperative staging has provided the surgeon more information regarding the pattern of disease and individual patients. Pancreatic, breast, ovarian, and prostate cancer have also been studied in clinical trials using RIGS and early results are encouraging. In the future, marked improvements with the RIGS system will be realized with the development of better targeting agents.

Radioimmunoguided surgery for patients with liver metastases secondary to colorectal cancer.

BACKGROUND: Hepatic resection for metastatic colorectal cancer offers a 5-year survival rate of 30%. Selection of patients who are most likely to benefit from excision is challenging. The judgment is made by radiographic techniques preoperatively and by sight and touch and the instinct of the surgeon intraoperatively. Confirmation that all tumor tissue has been excised relies on the appearance and texture of the tissue and is verified by routine histology. The authors' objective was to evaluate (1) the ability of radioimmunoguided surgery (RIGS) to improve the intraoperative detection of metastatic disease, and (2) any change in the operative plan originating from the information gained in patients with colorectal liver metastases. METHODS: Charts and tumor registry data for patients who underwent planned liver resection for colorectal cancer using the RIGS method from January 1985 to December 1993 were reviewed. This group of patients was compared to a similar group that underwent traditional liver resection for metastatic colorectal cancer during the same period. Patients who had the RIGS procedure during the earlier part of the period (1985-1990), were injected with tumor-associated glycoprotein (TAG) antibody B72.3; those in the later period (1990-1993) were injected with the second-generation anti-TAG monoclonal antibody CC49. Both monoclonal antibodies were labeled with sodium iodide I 125. Both traditional and RIGS exploration were used to determine the extent of the malignant process and any change in operative plan. RESULTS: Seventy-four cases of planned liver resection were performed with the RIGS method (group I), and 215 cases were performed with the traditional method (group II). Age and sex distribution were similar in both groups, as were morbidity and mortality, with an overall perioperative mortality of 1%. The distribution and number of metastatic lesions to the liver were the same, although group I included more cases with smaller metastatic lesions and more patients with anatomic resections. No extrahepatic tumor was found in 140 patients (65%) in group II, whereas there were only 21 patients (28%) in group I in whom no extrahepatic disease was detected (P < .001). RIGS exploration identified additional tumor in 12 (16%) of 74 cases: in the gastrohepatic ligament lymph nodes (LN) in five patients, in the celiac axis LN in one patient, and in the periaortic LN in six patients. These discoveries changed the operative plan for all of these patients, avoiding excision in the latter six patients and extending the resection in the other six. CONCLUSIONS: RIGS surgery provides an immediate and more accurate intraoperative staging system of patients with colorectal liver metastases than does traditional exploration by identifying additional metastatic disease, mainly to the lymph nodes, thus changing the plan of resection in a significant number of patients. More studies are needed to evaluate any significant survival advantage of patients who undergo removal of all RIGS-positive tissue.

Determinants of survival following hepatic resection for metastatic colorectal cancer.

Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer. This retrospective review study was undertaken in an attempt to identify factors that influence patient survival following hepatic resection for metastatic colorectal cancer. From January 1978 to December 1993, a total of 301 patients underwent a total of 345 planned hepatic resections for metastatic colorectal cancer. Of those, 245 patients had one resection, 44 had two resections, and 12 had three resections. For all patients the overall median survival was 20.6 months, operative mortality was 1.1%, and overall morbidity was 17.2%. Average hospital stay was 9 days. Statistical analysis included univariate analysis using log rank comparisons, Kaplan-Meier survival curves, and multivariate analysis using Cox proportional hazards regression. The statistically significant factors that influenced survival were distribution of liver metastases, unilobar versus bilobar (p = 0.0001), resected versus nonresected (p < 0.0001), and tumor-free surgical margins versus positive margins (p = 0.001). Surprisingly, the disease-free interval and the original stage of the primary tumor did not predict survival (p = not significant). Other factors that had no influence on survival were type of resection, size and number of liver metastases, ABO blood group, and the number of perioperative blood transfusions. For those patients who underwent resection of unilobar metastases with tumor-free margins, the 5-year survival rate was 29% with a median survival of 35 months and eight survivors > 7 years. In addition, one patient with bilobar disease had survival > 7 years and five patients who had resection of hepatic metastases and extrahepatic cancer simultaneously had survival > 3 years. Our data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.

Localization of ectopic corticotropin-producing carcinoid tumor with use of indium-111 pentetreotide scintigraphy.

OBJECTIVE: To report on the diagnosis of ectopic corticotropin (adrenocorticotropic hormone [ACTH])-producing bronchial carcinoid tumor by indium-111 pentetreotide (octreotide scan) scintigraphy. METHODS: We present a case of ectopic ACTH syndrome caused by an occult bronchial carcinoid tumor arising in a lymph node and review the pertinent literature. RESULTS: Biochemical diagnosis of ACTH syndrome can be difficult, and conventional imaging modalities often do not demonstrate these small carcinoid tumors. After biochemical proof of the presence of ectopic ACTH syndrome in our patient, conventional radiographic studies did not demonstrate any lesions. An octreotide scan showed a lesion in the lung, which was confirmed surgically. ACTH values returned to normal after resection of the lesion, and octreotide scans confirmed the completeness of surgical resection. The carcinoid tumor originated in a lymph node outside the bronchus. The differential diagnosis of ACTH syndrome, the localization of ectopic ACTH-producing tumors, the bronchial carcinoids, and the uniqueness of the carcinoid tumor arising in a lymph node are briefly discussed. CONCLUSION: Octreotide scintigraphy is useful in localizing occult carcinoid tumors and can be used in the follow-up of patients after successful removal of these tumors.

Liver abscess secondary to intrahepatic perforation of the gallbladder, presenting as a liver mass.

We present an unusual case of a large pyogenic liver abscess containing multiple stones caused by perforation of a necrotic gallbladder and spread of the infection into the liver. It manifested by weakness, weight loss, and a palpable liver mass, pointing toward a neoplastic process. Workup for metastatic disease was negative, and tumor markers also were negative. Ultrasound and computerized tomography were inconclusive, and the diagnosis was established by laparoscopy. Open drainage and cholecystectomy were performed, with good outcome. In the literature, there have been very few reports of intrahepatic perforation of the gallbladder resulting in formation of hepatic abscess. The presentation, diagnosis, and management of liver abscesses, as well as the complications of acute cholecystitis, are discussed.