Background: Testing for carcino-embryonic antigen (CEA) in the blood is a recommended part of follow-up to detect recurrence of colorectal cancer following primary curative treatment. There is substantial clinical variation in the cut-off level applied to trigger further investigation. Objectives: To determine the diagnostic performance of different blood CEA levels in identifying people with colorectal cancer recurrence in order to inform clinical practice. Search methods: We conducted all searches to January 29 2014. We applied no language limits to the searches, and translated non-English manuscripts. We searched for relevant reviews in the MEDLINE, EMBASE, MEDION and DARE databases. We searched for primary studies (including conference abstracts) in the Cochrane Central Register of Controlled Trials (CENTRAL), in MEDLINE, EMBASE, and the Science Citation Index & Conference Proceedings Citation Index - Science. We identified ongoing studies by searching WHO ICTRP and the ASCO meeting library. Selection criteria: We included cross-sectional diagnostic test accuracy studies, cohort studies, and randomised controlled trials (RCTs) of post-resection colorectal cancer follow-up that compared CEA to a reference standard. We included studies only if we could extract 2 x 2 accuracy data. We excluded case-control studies, as the ratio of cases to controls is determined by the study design, making the data unsuitable for assessing test accuracy. Data collection and analysis: Two review authors (BDN, IP) assessed the quality of all articles independently, discussing any disagreements. Where we could not reach consensus, a third author (BS) acted as moderator. We assessed methodological quality against QUADAS-2 criteria. We extracted binary diagnostic accuracy data from all included studies as 2 x 2 tables. We conducted a bivariate meta-analysis. We used the xtmelogit command in Stata to produce the pooled estimates of sensitivity and specificity and we also produced hierarchical summary ROC plots. Main results: In the 52 included studies, sensitivity ranged from 41% to 97% and specificity from 52% to 100%. In the seven studies reporting the impact of applying a threshold of 2.5 µg/L, pooled sensitivity was 82% (95% confidence interval (CI) 78% to 86%) and pooled specificity 80% (95% CI 59% to 92%). In the 23 studies reporting the impact of applying a threshold of 5 µg/L, pooled sensitivity was 71% (95% CI 64% to 76%) and pooled specificity 88% (95% CI 84% to 92%). In the seven studies reporting the impact of applying a threshold of 10 µg/L, pooled sensitivity was 68% (95% CI 53% to 79%) and pooled specificity 97% (95% CI 90% to 99%). Authors’ conclusions: CEA is insufficiently sensitive to be used alone, even with a low threshold. It is therefore essential to augment CEA monitoring with another diagnostic modality in order to avoid missed cases. Trying to improve sensitivity by adopting a low threshold is a poor strategy because of the high numbers of false alarms generated. We therefore recommend monitoring for colorectal cancer recurrence with more than one diagnostic modality but applying the highest CEA cut-off assessed (10 µg/L).

Blood CEA levels for detecting recurrent colorectal cancer (Review)

© 2014 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the accuracy of single-measurement blood CEA as a triage test to prompt further investigation for CRC recurrence after curative resection. To identify sources of between- and within-study heterogeneity to inform potential subsequent analyses.

Blood CEA levels for detecting recurrent colorectal cancer

BACKGROUND Conversion during laparoscopic cholecystectomy has adverse effects on operating time, postoperative morbidity and hospital costs. Identifying risk factors for conversion is thus important to help surgeons to plan and counsel the patient and arranging operating schedules accordingly. This study evaluated retrospectively preoperative and intraoperative risk factors for conversion in 906 laparoscopic cholecystectomies for gallbladder calculosis. METHODS Examined preoperative variables were: age, sex, obesity, arterial hypertension, diabetes, previous acute myocardial infarction, chronic obstructive pulmonary disease, non-ischemic heart disease, chronic hepatitis, hepatic cirrhosis, previous pancreatitis, biliary colics, endoscopic retrograde cholangiopancreatography (ERCP) and abdominal or cardiac surgery,as well as pain, fever, a high white blood cell count, ultrasound signs of cholecystitis at hospitalization. Intraoperative variables were: adhesiolysis, associated hepatic biopsy. RESULTS Twenty-five operations were converted (conversion rate: 2.76%). Factors significantly associated with conversion were: age over 60 years, diabetes, previous supramesocolic abdominal surgery, ultrasound signs of cholecystitis, white cell count over 9x10(3)/dl, previous acute myocardial infarction and preoperative ERCP, intraoperative adhesiolysis (0.001<p<0.05). CONCLUSION Systematic evaluation of these factors in patients scheduled for laparoscopic cholecystectomy may help predict difficulties of the procedure, allow patients to be better informed about possible conversion, and optimize the planning of interventions for cases at risk.

Risk factors for conversion of laparoscopic cholecystectomy.

The recent report on “CEA and CA19-9 for detecting a previously undiagnosed cancer in patients with acute ischemic stroke” is very interesting.1 Hiraga et al. concluded that “gastrointestinal cancer was frequent in ischemic stroke patients...among Japanese patients”, and “measurements of CEA and CA19-9 levels are easy and useful screening for the detection of occult malignancies”.1 The important concern of this report is on the very few subjects. There is also limitation of CEA and CA19-9, with or without acute ischemic stroke, where high rate of false positive result can be seen when using the test for detection of cancers such as pancreatic cancer2 and colon cancer.3 The laboratory technique used for determination of CEA and CA-19-9 is also crucial. Some techniques pose interference and can lead to the incorrect diagnosis.4 The technique using human anti-mouse antibodies appear to be superior.4

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CEA and CA19-9 for detecting a previously undiagnosed cancer in patients with acute ischemic stroke

After an overview of the various procedures best able to achieve early diagnosis of recurrence of colorectal cancer, two different follow-up plans were compared in 207 consecutive patients, who had undergone curative resections for primary untreated large bowel carcinoma, at Parma University’s Istituto di Clinica Chirurgica Generale e Terapia Chirurgica. The intense follow-up led to more frequent identification of local recurrences without distant metastases, and to the detection of local recurrences in a high percentage of cases with as yet no manifestation of symptoms clearly indicative of recurrence. The intense follow-up led to a greater number of re-resections for local recurrences than those performed in the control group submitted to conventional follow-up (17 versus 2; p<0.01), and we observed an improved 5-year survival in patients undergoing intense follow-up (73.1% versus 58.3%; p<0.02).

The follow-up in colorectal cancer

A valid program of follow-up has always been a crucial point in the overall therapy of the colon-cancer. In this retrospective study, the authors have used as specimen 74 patients put under observation between the years 1987 and 1992. The patient have been followed throughout the diagnostic period with various methods. It has been the will of the authors, who have presented their protocol of reference, to put under comparison the various controlling methods in order to visualize their reliability, specificity and the indication of each one of them. The CEA is the most sensible haemanalysis for lifting the doubt of recidivation. As for the TAC and ultrasound it has been reserved the job of formulating a correct diagnosis; the results of both diagnostics through imagery have been more or less the same. However, the ultrasound examination have shown more false positives than the TAC. The research of the blood occult in the stool is a rapid and economic detection in the case of intramural recidivations, even if we cannot disregard the share of false positives. A high specificity for the study of intramural recidivations has been offered by the endoscopic scan particularly when associated by a brushing and biopsy.

Follow up in carcinoma of the large intestine

In this report the authors have analysed the various risk factors of the laparoscopy cholecystectomy, proving that those are not different from the ones of standard open cholecystectomy. It has been underlined that laparoscopy cholecystectomy offers significant advantages over open cholecystectomy and moreover the possibility to convert laparoscopy cholecystectomy when it is necessary.

Cacciaguerra B

Papers

Follow up in carcinoma of the large intestine

Risk factors in laparoscopic cholecystectomy