Radioimmune Localization of Occult Carcinoma Rosemary B. Duda, MD; A. Michael Zimmer, PhD; Steven T. Rosen, MD; Katherine A. Gilyon, RN; Denise Webber; Stewart Spies, MD; William Spies, MD; Bruce Merchant, MD, PhD \s=b\ Patients with a rising serum carcinoembryonic antigen level and no clinical or roentgenographic evidence of recurrent or metastatic cancer present a treatment dilemma. Eleven such patients, 10 with a previously treated colorectal carcinoma and 1 with a previously treated breast carcinoma, received an injection of the anticarcinoembryonic antigen monoclonal antibody ZCE\x=req-\ 025 labeled with the radioisotope indium 111. Nuclear scintigraphy was performed on days 3 and 5 through 7 to detect potential sites of tumor recurrence. The monoclonal antibody scan accurately predicted the presence or absence of occult malignancy in 7 (64%) patients. Second-look laparotomy confirmed the monoclonal antibody scan results in the patients with colorectal cancer, and magnetic resonance imaging confirmed metastatic breast cancer. This study demonstrates that In-ZCE-025 can localize occult carcinoma and may assist the surgeon in facilitating the operative exploration. In-ZCE-025 assisted in the initiation of adjuvant therapy for the patient with breast cancer.
(Arch Surg. 1990;125:866-870)
carcinoembryonic antigen (CEA) Serum malignancies, including gastrointestinal origin.
can serve as a
tumor marker for several those of and mammary A rise in the serum CEA level alone, in patients with a previously resected CEAproducing tumor, may indicate recurrent disease. Several studies have shown the value of CE A in predicting the clinical detection of recurrent disease in patients with colorectal can¬ cer1"5 and in predicting metastatic disease in patients with
breast cancer.6"7 The detection of human carcinoma with radiolabeled mono¬ clonal antibodies (MABs) has been successfully demonstrated for patients with primary and metastatic colon cancer.8'2 Advances of the technology that allow production of highly specific antibodies, improved conjugation methods, and the utilization of nuclear tomographic scintigraphy have per¬ mitted investigations that assist in the preoperative evalua¬ tions of patients with occult cancer. The present study describes the use of a radiolabeled MAB, ZCE-025, to facilitate the detection of occult carcinoma in patients with a rising serum CEA level. These patients had undergone a curative resection for their malignancy, devel¬ oped a rising serum CEA in the absence of clinically or roentgenographically detectable recurrent or metastatic disease, and had a second-look laparotomy performed if the primary malignancy was colorectal cancer.
Accepted for publication April 20,1990. From the Departments of Surgery (Dr Duda), and Medicine (Dr Rosen and Ms Gilyon) and the Division of Nuclear Medicine (Drs Zimmer, S. Spies, and W. Spies and Ms Webber), Northwestern University Medical School, Northwestern Memorial Hospital, Chicago, Illinois; and Hybritech Inc, San Diego, Calif
PATIENTS AND METHODS ZCE-025 is a murine IgGl MAB that has a high affinity for the CE A and does not cross-react with granulocyte glycoproteins.13,14 This antibody has been demonstrated to successfully localize colon cancer xenografts in nude mice15 and colorectal carcinoma in human pa¬ tients.8 The ZCE-025 was provided by Hybritech Ine, San Diego, Calif, in a kit that included the antibody, neutralizing buffer solution, and indium Ill-citrate in sterile, nonpyrogenic preparations. All patients received 40 mg of antibody labeled with 185 MBq of indium 111 in 48 mL of normal saline by slow intravenous infusion. The ZCE025 MAB is approved by the Food and Drug Administration (Wash¬ ington, DC) (BB-IND 2041), and this study was approved by the Institutional Review Boards of Northwestern University (Chicago, 111) and the Illinois Cancer Council, Chicago. Patients eligible for inclusion in this phase III multi-institutional clinical trial are those who have had a malignant tumor previously resected or treated for cure and subsequently developed a rising serum CEA level. A rising serum CEA level was defined as three successively increasing CEA values or one or more CEA values equal to twice the patient's baseline postoperative CEA level. These pa¬ tients had no definitive evidence of recurrent disease by clinical, laboratory, or roentgenographic evaluations including colonoscopy, computed tomography, and occasionally bone scan. A second-look laparotomy was scheduled for all patients with a colorectal primary cancer. Patients whose tumors were not of a gastrointestinal origin were followed up on an individual basis. Serum CEA was determined prior to the administration of the radiolabeled MAB. In-ZCE-025 was injected intravenously under close observation for adverse allergic reactions. Nuclear scintiscans were obtained on day 3 and again on days 5 through 7 following the lnZCE-025 injection, including tomographic scans when possible. Up¬ per and lower trunk scintiscans were obtained in the anterior and posterior views using either a large-field-of-view gamma camera (Raytheon, Rosemont, 111) or a planar and tomographic camera (Sie¬ mens Digitrack, Des Plaines, 111). Second-look laparotomy was per¬ formed 7 to 15 days after the ln-ZCE-025 injection. Tumor and normal tissues obtained at the time of surgery were immediately analyzed for radioactive uptake by an automatic multichannel analyz¬ er with sodium iodide detector (Nuclear Data, Schaumburg, 111) and the results are expressed as percent of injected dose per kilogram (%ID/kg) of tissue. An MAB scan was determined to have positive results if there were areas of increased uptake or if there were defects or cold nodules in the liver. Correlations were performed between the intraoperative surgical findings and the results of the nuclear MAB scans. A scan with negative findings had no areas of increased IN-MAB uptake and no cold defects in the liver. The results of the MAB scan were conveyed to the operating surgeon prior to the laparotomy, including a diagram of the MAB scan findings. The surgeon then indicated on this diagram which findings were examined and which were recur¬ rent or metastatic disease. Serum CEA values were compared for positive and negative results of MAB scans and for those patients with and without hepatic metastasis. Statistical evaluation was per¬ formed using Student's t test.
RESULTS
(Dr Merchant).
Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 13,1989. Reprint requests to Department of Surgery, Northwestern University Medical School, 250 E Superior St, Wesley 201, Chicago, IL 60611 (Dr Duda).
Eleven
patients rising serum CEA roentgenographically detectable evaluated from December 1988 to May 1989. clinically
with
or
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
a
level and
no cancer were
Ten of these
Fig 1.—Left, Nuclear scintiscan performed 48 hours after injection of ln-ZCE-025 demonstrating increased uptake in the lumbar spine on the posterior view. Right, Tomographic nuclear scintiscan from same time demonstrating tumor uptake in the lumbar spine in the anterior view. Tumor was confirmed by magnetic resonance imaging. indicates tumor; and L, liver.
patients had a previous colorectal cancer treated during the previous 2 years and one was treated for breast cancer 4 years prior to this study. The mean ( ± SEM) serum CEA level of all patients at the time of ln-ZCE-025 injection was 45.6 ±12 ng/mL, with a range from 11.7 ng/mL to 153 ng/mL. Following the intravenous injection of ln-ZCE-025, only one patient experienced an adverse reaction. This reaction was a minor delayed pruritus that resolved promptly with diphenhydramine hydrochloride (Benadryl). This particular patient has a skin sensitivity to several other drugs, including fluorouracil. Normal tissue
uptake was seen at 3 days in liver, spleen, kidneys, colon, bone, bladder, testes, and background blood pooling. The intensity of the normal tissues decreased for all tissues except the liver on the scans done at 5 to 7 days after the ln-ZCE-025 injection. Conversely, the images of the tu¬ mor tissue (except for cold nodules in the liver) were more
intense on the later scans. The radiolabeled MAB scan revealed evidence of recurrent cancer in 7 of the 11 patients. The MAB scan revealed no detectable sites of recurrence in 4 patients. Six of the 7 patients with a "positive" scan were found to have recurrent or metastatic disease and 3 of the 4 patients with a "negative" scan were found to have cancer at the time of second-look laparotomy. Standard measures of diagnostic efficacy were performed for patients. The sensitivity ofthe MAB scan (true positive/[true positive + false negative]) was 64%. The posi¬ tive predictive value (true positive/[true positive + false positive]) was 86%. The accuracy of the scan in identifying patients with recurrent or metastatic cancer ([true positive + true negative]/[true positive + true negative + false positive + false negative]) was 64%. The patient with the previously treated breast cancer had a serum CEA level of 27.2 ng/mL that had increased steadily from 5.5 ng/mL 4 months earlier. The radiolabeled MAB scan revealed an abnormal uptake in the lumbar spine on both anterior and posterior views. This area of increased uptake was also demonstrated by tomographic scans (Fig 1). Magnet¬ ic resonance imaging of the lumbar spine confirmed the In-
ZCE-025 detection of metastatic breast cancer. This patient is not included in the comparative analysis of the second-look laparotomy with the MAB scan results on a site-specific review. Eight of the 10 patients with colorectal carcinoma had recurrent or metastatic disease identified at the time of the second-look laparotomy; 2 patients had no disease and contin¬ ue to be observed. Six (75%) of the 8 patients had disease re¬ sected with curative intent. In-ZCE-025 nuclear scintigraphy identified potential re¬ current cancer in 6 of the 10 patients with colorectal cancer. One of these patients had no disease found at laparotomy. Three ofthe 4 patients with a negative MAB scan had 4 sites of cancer identified at laparotomy. The MAB scan identified 11 sites of disease in the operative field; 8 were confirmed to be sites of cancer. Second-look laparotomy identified a total of 15 sites of cancer. The standard measures of diagnostic efficacy for individual lesions detected revealed a sensitivity of 53%, positive predictive value of 73%, and overall accuracy of 62%. Three hepatic lesions were identified as cold nodules on the nuclear scintigraphy (Fig 2). All three lesions were confirmed to be metastatic carcinoma. One was 3 cm in diameter, anoth¬ er was 6 cm, and the third nearly completely replaced the left lateral lobe of the liver. In addition, four other hepatic metastases were identified in three patients at the second-look laparotomy. Intraoperative ultrasound study detected two lesions in one patient. The lesions ranged in size from 2 cm to 6 cm. One was located in the gallbladder fossa, two were adjacent to the right hepatic vein near the inferior vena cava, and the fourth was located in the posterolateral right hepatic lobe. Four patients had no evidence of hepatic metastasis found at the second-look laparotomy or by the MAB scan. Overall, the MAB scan detected 43% of hepatic métastases that were identified at surgery but had not been detected preoperatively by computed tomography of the abdomen. The MAB scan identified eight areas of increased uptake within the operative field, in addition to those identified in the liver (Figs 3 and 4). Five of these sites (63%) were confirmed to be metastatic disease. They included metastatic implants
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
analysis of radioactive antibody content. The average uptake in the normal liver tissue of these three patients was 14.18 ± 1.1 (%ID/kg). Only two patients had hepatic metasta¬ tion
sis available for tissue biodistribution studies. The average
2.—Nuclear scintiscan performed on a patient with colorectal 48 hours after ln-ZCE-025 injection. Tumor (T) is shown as a cold nodule and liver (L) is seen on the anterior view. Tumor was confirmed at second-look laparotomy.
Fig
cancer
3.—Nuclear scintiscan performed on a patient with colorectal 48 hours after ln-ZCE-025 injection. The anterior view demon¬ strates increased activity in the midabdomen, indicated by T, and confirmed at second-look laparotomy.
Fig
cancer
uptake of the rim of a hepatic metastasis was 10.20 ±1.2 %ID/kg and the average uptake of the core of the hepatic metastasis was 10.72 ± 4.0 %ID/kg(Table). The mean ± SE serum CEA level for all patients with a true-positive MAB scan was 53.4 ±20 ng/mL. The patient with a true-negative scan had a serum CEA level of 30.0 ng/mL at the time of the ln-ZCE-025 injection. The serum CEA values for those patients with false-positive or falsenegative scans were 12.4 ng/mL and 46.6 ± 20 ng/mL, respec¬ tively. The range of CE A for the positive scans was 12.4 to 153 ng/mL and for the negative scans was 11.7 to 81.6 ng/mL. The serum CEA level of those patients with hepatic metas¬ tasis was 65.2 ± 20 ng/mL compared with 22.1 ± 4 ng/mL for those without hepatic metastasis (P
(Arch Surg. 1990;125:866-870)
carcinoembryonic antigen (CEA) Serum malignancies, including gastrointestinal origin.
can serve as a
tumor marker for several those of and mammary A rise in the serum CEA level alone, in patients with a previously resected CEAproducing tumor, may indicate recurrent disease. Several studies have shown the value of CE A in predicting the clinical detection of recurrent disease in patients with colorectal can¬ cer1"5 and in predicting metastatic disease in patients with
breast cancer.6"7 The detection of human carcinoma with radiolabeled mono¬ clonal antibodies (MABs) has been successfully demonstrated for patients with primary and metastatic colon cancer.8'2 Advances of the technology that allow production of highly specific antibodies, improved conjugation methods, and the utilization of nuclear tomographic scintigraphy have per¬ mitted investigations that assist in the preoperative evalua¬ tions of patients with occult cancer. The present study describes the use of a radiolabeled MAB, ZCE-025, to facilitate the detection of occult carcinoma in patients with a rising serum CEA level. These patients had undergone a curative resection for their malignancy, devel¬ oped a rising serum CEA in the absence of clinically or roentgenographically detectable recurrent or metastatic disease, and had a second-look laparotomy performed if the primary malignancy was colorectal cancer.
Accepted for publication April 20,1990. From the Departments of Surgery (Dr Duda), and Medicine (Dr Rosen and Ms Gilyon) and the Division of Nuclear Medicine (Drs Zimmer, S. Spies, and W. Spies and Ms Webber), Northwestern University Medical School, Northwestern Memorial Hospital, Chicago, Illinois; and Hybritech Inc, San Diego, Calif
PATIENTS AND METHODS ZCE-025 is a murine IgGl MAB that has a high affinity for the CE A and does not cross-react with granulocyte glycoproteins.13,14 This antibody has been demonstrated to successfully localize colon cancer xenografts in nude mice15 and colorectal carcinoma in human pa¬ tients.8 The ZCE-025 was provided by Hybritech Ine, San Diego, Calif, in a kit that included the antibody, neutralizing buffer solution, and indium Ill-citrate in sterile, nonpyrogenic preparations. All patients received 40 mg of antibody labeled with 185 MBq of indium 111 in 48 mL of normal saline by slow intravenous infusion. The ZCE025 MAB is approved by the Food and Drug Administration (Wash¬ ington, DC) (BB-IND 2041), and this study was approved by the Institutional Review Boards of Northwestern University (Chicago, 111) and the Illinois Cancer Council, Chicago. Patients eligible for inclusion in this phase III multi-institutional clinical trial are those who have had a malignant tumor previously resected or treated for cure and subsequently developed a rising serum CEA level. A rising serum CEA level was defined as three successively increasing CEA values or one or more CEA values equal to twice the patient's baseline postoperative CEA level. These pa¬ tients had no definitive evidence of recurrent disease by clinical, laboratory, or roentgenographic evaluations including colonoscopy, computed tomography, and occasionally bone scan. A second-look laparotomy was scheduled for all patients with a colorectal primary cancer. Patients whose tumors were not of a gastrointestinal origin were followed up on an individual basis. Serum CEA was determined prior to the administration of the radiolabeled MAB. In-ZCE-025 was injected intravenously under close observation for adverse allergic reactions. Nuclear scintiscans were obtained on day 3 and again on days 5 through 7 following the lnZCE-025 injection, including tomographic scans when possible. Up¬ per and lower trunk scintiscans were obtained in the anterior and posterior views using either a large-field-of-view gamma camera (Raytheon, Rosemont, 111) or a planar and tomographic camera (Sie¬ mens Digitrack, Des Plaines, 111). Second-look laparotomy was per¬ formed 7 to 15 days after the ln-ZCE-025 injection. Tumor and normal tissues obtained at the time of surgery were immediately analyzed for radioactive uptake by an automatic multichannel analyz¬ er with sodium iodide detector (Nuclear Data, Schaumburg, 111) and the results are expressed as percent of injected dose per kilogram (%ID/kg) of tissue. An MAB scan was determined to have positive results if there were areas of increased uptake or if there were defects or cold nodules in the liver. Correlations were performed between the intraoperative surgical findings and the results of the nuclear MAB scans. A scan with negative findings had no areas of increased IN-MAB uptake and no cold defects in the liver. The results of the MAB scan were conveyed to the operating surgeon prior to the laparotomy, including a diagram of the MAB scan findings. The surgeon then indicated on this diagram which findings were examined and which were recur¬ rent or metastatic disease. Serum CEA values were compared for positive and negative results of MAB scans and for those patients with and without hepatic metastasis. Statistical evaluation was per¬ formed using Student's t test.
RESULTS
(Dr Merchant).
Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 13,1989. Reprint requests to Department of Surgery, Northwestern University Medical School, 250 E Superior St, Wesley 201, Chicago, IL 60611 (Dr Duda).
Eleven
patients rising serum CEA roentgenographically detectable evaluated from December 1988 to May 1989. clinically
with
or
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
a
level and
no cancer were
Ten of these
Fig 1.—Left, Nuclear scintiscan performed 48 hours after injection of ln-ZCE-025 demonstrating increased uptake in the lumbar spine on the posterior view. Right, Tomographic nuclear scintiscan from same time demonstrating tumor uptake in the lumbar spine in the anterior view. Tumor was confirmed by magnetic resonance imaging. indicates tumor; and L, liver.
patients had a previous colorectal cancer treated during the previous 2 years and one was treated for breast cancer 4 years prior to this study. The mean ( ± SEM) serum CEA level of all patients at the time of ln-ZCE-025 injection was 45.6 ±12 ng/mL, with a range from 11.7 ng/mL to 153 ng/mL. Following the intravenous injection of ln-ZCE-025, only one patient experienced an adverse reaction. This reaction was a minor delayed pruritus that resolved promptly with diphenhydramine hydrochloride (Benadryl). This particular patient has a skin sensitivity to several other drugs, including fluorouracil. Normal tissue
uptake was seen at 3 days in liver, spleen, kidneys, colon, bone, bladder, testes, and background blood pooling. The intensity of the normal tissues decreased for all tissues except the liver on the scans done at 5 to 7 days after the ln-ZCE-025 injection. Conversely, the images of the tu¬ mor tissue (except for cold nodules in the liver) were more
intense on the later scans. The radiolabeled MAB scan revealed evidence of recurrent cancer in 7 of the 11 patients. The MAB scan revealed no detectable sites of recurrence in 4 patients. Six of the 7 patients with a "positive" scan were found to have recurrent or metastatic disease and 3 of the 4 patients with a "negative" scan were found to have cancer at the time of second-look laparotomy. Standard measures of diagnostic efficacy were performed for patients. The sensitivity ofthe MAB scan (true positive/[true positive + false negative]) was 64%. The posi¬ tive predictive value (true positive/[true positive + false positive]) was 86%. The accuracy of the scan in identifying patients with recurrent or metastatic cancer ([true positive + true negative]/[true positive + true negative + false positive + false negative]) was 64%. The patient with the previously treated breast cancer had a serum CEA level of 27.2 ng/mL that had increased steadily from 5.5 ng/mL 4 months earlier. The radiolabeled MAB scan revealed an abnormal uptake in the lumbar spine on both anterior and posterior views. This area of increased uptake was also demonstrated by tomographic scans (Fig 1). Magnet¬ ic resonance imaging of the lumbar spine confirmed the In-
ZCE-025 detection of metastatic breast cancer. This patient is not included in the comparative analysis of the second-look laparotomy with the MAB scan results on a site-specific review. Eight of the 10 patients with colorectal carcinoma had recurrent or metastatic disease identified at the time of the second-look laparotomy; 2 patients had no disease and contin¬ ue to be observed. Six (75%) of the 8 patients had disease re¬ sected with curative intent. In-ZCE-025 nuclear scintigraphy identified potential re¬ current cancer in 6 of the 10 patients with colorectal cancer. One of these patients had no disease found at laparotomy. Three ofthe 4 patients with a negative MAB scan had 4 sites of cancer identified at laparotomy. The MAB scan identified 11 sites of disease in the operative field; 8 were confirmed to be sites of cancer. Second-look laparotomy identified a total of 15 sites of cancer. The standard measures of diagnostic efficacy for individual lesions detected revealed a sensitivity of 53%, positive predictive value of 73%, and overall accuracy of 62%. Three hepatic lesions were identified as cold nodules on the nuclear scintigraphy (Fig 2). All three lesions were confirmed to be metastatic carcinoma. One was 3 cm in diameter, anoth¬ er was 6 cm, and the third nearly completely replaced the left lateral lobe of the liver. In addition, four other hepatic metastases were identified in three patients at the second-look laparotomy. Intraoperative ultrasound study detected two lesions in one patient. The lesions ranged in size from 2 cm to 6 cm. One was located in the gallbladder fossa, two were adjacent to the right hepatic vein near the inferior vena cava, and the fourth was located in the posterolateral right hepatic lobe. Four patients had no evidence of hepatic metastasis found at the second-look laparotomy or by the MAB scan. Overall, the MAB scan detected 43% of hepatic métastases that were identified at surgery but had not been detected preoperatively by computed tomography of the abdomen. The MAB scan identified eight areas of increased uptake within the operative field, in addition to those identified in the liver (Figs 3 and 4). Five of these sites (63%) were confirmed to be metastatic disease. They included metastatic implants
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
analysis of radioactive antibody content. The average uptake in the normal liver tissue of these three patients was 14.18 ± 1.1 (%ID/kg). Only two patients had hepatic metasta¬ tion
sis available for tissue biodistribution studies. The average
2.—Nuclear scintiscan performed on a patient with colorectal 48 hours after ln-ZCE-025 injection. Tumor (T) is shown as a cold nodule and liver (L) is seen on the anterior view. Tumor was confirmed at second-look laparotomy.
Fig
cancer
3.—Nuclear scintiscan performed on a patient with colorectal 48 hours after ln-ZCE-025 injection. The anterior view demon¬ strates increased activity in the midabdomen, indicated by T, and confirmed at second-look laparotomy.
Fig
cancer
uptake of the rim of a hepatic metastasis was 10.20 ±1.2 %ID/kg and the average uptake of the core of the hepatic metastasis was 10.72 ± 4.0 %ID/kg(Table). The mean ± SE serum CEA level for all patients with a true-positive MAB scan was 53.4 ±20 ng/mL. The patient with a true-negative scan had a serum CEA level of 30.0 ng/mL at the time of the ln-ZCE-025 injection. The serum CEA values for those patients with false-positive or falsenegative scans were 12.4 ng/mL and 46.6 ± 20 ng/mL, respec¬ tively. The range of CE A for the positive scans was 12.4 to 153 ng/mL and for the negative scans was 11.7 to 81.6 ng/mL. The serum CEA level of those patients with hepatic metas¬ tasis was 65.2 ± 20 ng/mL compared with 22.1 ± 4 ng/mL for those without hepatic metastasis (P
