Clinical factors in prediction of prognosis after anterior resection with total mesorectal excision for carcinoma of the rectum

Abstract

Abstract. The aim of the study was to estimate the long-term results and the prognostic value of clinical and pathological factors following R0 anterior resection with total mesorectal excision (TME). Ninety-eight consecutive patients with histologically confirmed rectal cancer were studied prospectively with five-year follow-up. Survival was calculated using the Kaplan-Meier method and differences between curves were tested by the log-rank test. Multivariate analysis was performed using the Cox regression model. Recurrence-free survival (RFS) was 63.6%. Mean time of recurrence was 13.8 months (range 3-38). Local recurrence rate was 7.8% with the mean time of 12.7 months (range 3-25). In univariate analysis Dukes' stage (RFS for stage: A=93.2%; B=53.8%; C=26.3%) and preoperative CEA serum level (s-CEA) (for s-CEA ≤5 ng/ml RFS=93.8%; for s-CEA >5 ng/ml RFS = 5.9%) significantly influenced survival (P<0.005 and P<0.00001). These parameters were also found to be independent prognostic factors in multivariate analysis (P<0.05 and P<0.00001). Survival was worse in older female patients with low-localised poorly differentiated tumors; however, those variables had not significant impact on prognosis. Neither symptom duration nor mucinous histology was significantly related to survival. Using TME technique a low local recurrence rate resulting in improved survival can be achieved. Apart from clinicopathological staging, elevated s-CEA can identify patients with poor prognosis. In addition to TME adjuvant therapy for this high-risk group should be considered.

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

“…It does, however, seem to be most useful when selectively applied to patients with worse prognoses. 34 In this field, 8,10,11,20,24 some authors add a further element reporting conflicting information in the literature with regard to the increase in p-CEA levels which could forecast a worse prognosis in more advanced stages (Dukes' C or TNM stage III), according to some authors, or in less advanced ones (Dukes' B or TNM stage II) according to others. Oddly despite a correlation between p-CEA and staging, and T and N parameters of the cancer such correlation was not recorded for the grading.…”

“…This approach finds its biological basis in the fact that the carcinoembryonic antigen appears to have a role both in fostering the uncontrolled growth of the tumor and in facilitating its invasion and metastasis. 10,20,31 However, not all seem to agree with such an approach nor have they become aware of one, if it is true that the determination of p-CEA in a patient with colorectal neoplasia varies in literature between 45 and 88%. 22,31 In our sample, only 27.34% of the patients with colorectal cancer showed high p-CEA levels.…”

“…11 These observations, which were made as recently as 2013 and which still seem surprising after 30 years, are certainly not due to the lack of testing new molecular, genetic, or humoral markers, but to the fact that these are not reliable, simple, nor cost effective as the CEA could be. In recent years, we are not the only ones 1,3,4,6,7,10,11,16,18,19,[27][28][29] who believe that the determination of the p-CEA has a prognostic value in identifying, preoperatively, the group of patients who most likely will show recurrences. In fact, p-CEA is able to identify both patients whose understaging results from occult metastasis and those who are carriers of histologically advanced or more aggressive neoplasms.…”

“…The cutoff value was 5 ng/mL, in agreement with what had been reported in other experiences. 10,24 The samples used to determine the p-CEA levels were obtained from peripheral venous blood drawn in the days immediately prior to surgery after obtaining consent from the patient.…”

“…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. 1,3,4,9,10 With 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 marker 11 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 Herrera 14 and Wanebo 15 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.…”