Vol. 118, November Printed in U.SA.

THE JOURNAL OF UROLOGY

Copyright © 1977 by The Williams & Wilkins Co.

THE CLINICAL VALUE OF URINARY CARCINOEMBRYONIC ANTIGEN-LIKE SUBSTANCES IN UROTHELIAL CANCER WILLIAM M. MURPHY, JACQUES P. VANDEVOORDE, MOPARTI K. RAO

AND

MARKS. SOLOWAY

From the Departments of Pathology and Urology, University of Tennessee Center for the Health Sciences, Memphis, Tennessee and the Hoffman-LaRoche Cancer Diagnostic Research Laboratory, Nutley, New Jersey

ABSTRACT

Although there is a positive correlation between the concentration of urinary carcinoembryonic antigen-like substances and urothelial cancer the clinical value of this association is in doubt. Urinary carcinoembryonic antigen values have been determined in large numbers of specimens from patients with a variety of urologic diseases but most studies have recorded only single measurements at the time of diagnosis. We examined the role of carcinoembryonic antigen in urothelial malignancies by comparing serial carcinoembryonic antigen, and cytologic and histologic analyses done on simultaneously collected urine and tissue specimens. We were particularly interested in the value of carcinoembryonic antigen as a diagnostic adjunct to cytology in low grade carcinoma and dysplasia, and the role of serial measurements of this substance in followup. The results of 102 analyses in 48 patients during a 15-month period indicate that urinary carcinoembryonic antigen measurements have little value in the diagnosis of bladder cancer, are of limited usefulness in combination with cytologic studies and are poorly correlated with simultaneously determined cytologic and histologic findings. Although the initial results were not promising serial measurements may be useful in followup. Previous reports concerning the role of urin;:iry carcinoembryonic antigen-like substances (CEA) in urothelial cancer have varied from optimistic 1-s to discouraging.9- 12 While most investigators agree that patients with urothelial malignancies tend to have increased urinary CEA concentrations the clinical significance of this finding is in doubt. High percentages of falsely positive and negative results diminish the usefulness of the procedure as a diagnostic and/or screening test. The possible value of urinary CEA combined with other parameters, such as cytology, in the diagnosis and/or followup of patients with urothelial neoplasms has been studied6 • 10 but not elucidated fully. Such a test might be particularly helpful to evaluate urothelial dysplasia, a lesion for which the pathologic features have not yet been well defined. To understand more fully the role of urinary CEA in urothelial cancer a prospective study was undertaken. The purposes were 1) to determine normal values and to examine the effects of age, sex, method of collection, smoking and bacterial colonization, 2) to correlate CEA levels with the presence and cytologic grade of urothelial tumors, 3) to study the diagnostic value of CEA when combined with urinary cytology and 4) to document the role of CEA in the followup of patients with urothelial malignancy. The study on the normal values has been reported. 13 Herein we investigate the remaining topics. MATERIALS AND METHODS

From October 1975 to January 1977, 102 specimens were obtained from 48 men with urothelial neoplasms. The patients ranged in age from 48 to 89 years. The clinical status of patients at specimen collection is outlined in table 1. All patients underwent transurethral resection of the tumor. During followup 9 specimens were collected from 6 patients receiving triethylene thiophosphoramide (thio-tepa) and 1 specimen was obtained after irradiation therapy. There were 92 samples submitted from patients receiving no therapy at the time of collection. At each followup visit cystoscopic urine, Accepted for publication March 25, 1977. Supported in part by ACS Institutional Grant IN-85-J-1.

bladder washings and multiple mucosal biopsies were obtained. The urine was divided into aliquots for CEA, cytology and, in most instances, bacterial culture. Urine for CEA was frozen at minus 70C and transported to the Hoffman-LaRoche Cancer Diagnostic Laboratory, where determinations were done by the method of Hansen and associates. 14 Cytologic specimens were prepared using Millipore filters* and were stained according to the Papanicolaou technique. Cultures were performed by the calibrated loop method on blood agar and were considered positive if greater than 1,000 colonies of a single organism per milliliter urine were grown. Bladder biopsies were processed according to standard techniques. Cytologic and histologic specimens were coded as carcinoma, dysplasia or normal. Previous work had established the upper limits of normal for urinary CEA in men more than 40 years old as 1. 7 ng. per ml. 13 RESULTS

Correlations between urinary CEA concentrations and cytohistologic findings were determined for single samples and serial specimens from individual patients (tables 1 to 8). Apparent differences in the number of positive cytologic and histologic specimens reflect the multifocal nature ofurothelial neoplasms (tables 3 and 4). Occasionally, random biopsies do not sample lesions detected cytologically. Less often, positive tissue specimens are associated with negative cytology. During the study carcinoma was detected in 33 histologic specimens from 27 patients, while positive cytology occurred in 43 cell samples from 30 patients. The data can be viewed in a number of ways (tables 2 to 6). Although high concentrations of urinary CEA were associated strongly with urothelial cancer (table 2) moderate and slight elevations were unreliable indicators. Indeed, carcinoma was often present in urothelia producing normal levels of CEA. When findings in simultaneously obtained urine and tissue were compared to CEA concentration (tables 3 and 4) the correlations were relatively poor and did not improve significantly when only elevated CEA values were considered (table

* Millipore Corp., Bedford, Massachusetts 01730. 806

URINARY CARCINOEMBRYONIC ANTIGEN IN UROTHELIAL CANCER

L Clinical status at specimen collection

TABLE

Initia_l cEagnosis Followup: 31*

Ca:rcinorrm

46t 17

* Includes

patients with high grade malignant cells in urine but denuded urothelium at biopsy. t Includes patients with dysplasia in either the cytologic or histologic specirnen.

TABLE 2.

CEA concentration and urothelial cancer Patients

CEA

With Cancer >20 5.0-20.0 .l.8-4.9

9 18 9 12

sl.7

TABLE

-------

9 10

1 7

3. Correlation a/CEA and cytology CEA(ng./ml.)

Carcinoma

>l..7

sl.7

17

23

26 13

36

16

20

43

TABLE

10

4. Correlation o/CEA and histology CEA (ng. /ml.)

No. Specimens

Carcinoma

33 33

35

>1.7

sl.7

21 18 16

15

12

20

Correlation ol elevated CEA (>1.'7 ng. per ml.) with cytology and histology in 55 specimens

TABLE

Carcinom.a

TABLE

Cytology

Histology

26 13 16

21

18 16

CEA(ng./ml.) >1.7

:s 1. 7

11

7

4

9

4

9

0

5 3

2

2 2

-------------------~----------

The diagnostic value a/CEA combined with cytology

'TABLE

No. Specimens

Cytology

33 3cl

26 16

Carcinon1a Dysplasia

TABLE

Urine Colonized Sterile Totals

13

11

14

13

Cytology Plus CEA 29

24 11 14

8. Effect ol bacterial colonization on CEA

No. Specimens

30 59 89

5). Neither did rnr,ine>,,ru CEA concentration appear to have g direct relationship to tumor (table 6). Carcinoma in situ and adenocarcinoma may exceptions but numbers were too small for accurate evaluation. The value of urinary CEA determination in combination with cytology was examined for single and (table 7). Of the 102 single specimens carcinoma was preserit in the biopsies of 33. Malignant cells occurred in the simultaneously obtained urine of 26 (79 per cent). Of the eu.w.1.uu1c:. 5 0w.ul',co 3 had CEA values than 1.7 ml. but 3 samples the were (1.8 and ng. per ml.). Multiple specimens were obtained from 13 of whom had histologically confirmed cancer some time during the collection period. were positive in 11 of these 13 remaining 2 levels were not elevated in these 2 fJacn:uc0 . Dysplasia occurred in 33 of the 102 urine contained dysplastic or u~vp.moc,c ceHs in 16 instances (49 per cent). However, the addition of CEA au,uy,~·'" the diagnostic to 24 of 33 cases (73 patients with more than 1 sp,,cunen 14 the collection period. Dysplastic or 11euµ.,a..o tified in the urine of 13 of these (93 per cent). patient had an elevated CEA. The value of serial CEA in individual cases was examined. Twenty-seven "ac,c°'"'"' had 2 to 5 such minations at intervals measurements of urinary were in 9 cases but misleading in 11. Elevated concentrations were valuable in situations when uu,."'"H~" cells were found in urine but the corresponding v,c, 0,u,~u O': denuded. In contrast, there were instances CEA levels in with recurrences and a few cases 11; which recurrence was associated with CEA. Of the 102 specimens colony counts were done in 89 and were in 30. c::,am1::i1e,s with bacterial colonization were proportionally among all levels of CEA (table 8). Although this factor may have influenced the CEA concent,ra tion of individual -,-,·--"·"'"-"'" it had little effect on the over-all correlations. As noted there was no correlation between the number colonies per milliliter and the concen tration of CEA. DISCUSSION

6. CEA and tumor grade

No. Specimens Grade I Grade II Grade HI Ca in situ Adenoca.

807

CEA(ng./ml.) ::::;;1,7

1.8-4.9

14 27 41

4 16

13

20

21

5.0-20.0 8

>20 4 3 'I

The association of urinary CEA with urothelial well established. The clinical ,J•F,"""~u",~~ of this have been diminished not clear. of studies """'cc,,;coc, of results. 2 have been from 1.56 to 35 ng. per accuracy of the test has varied little, with rnost laboratori,c,s achieving a 50 to 70 cent positive correlation. The data presented herein are substantial mr,oo,-n,o,n with reports. Although other limits of normal the lower of selected out the range of anced a proportional in nations, so that the over-all correlation is In our the data were collected so that could be made among simultaneously obtained-,-,--""""-""" cytology and histology. It is evident from that urinary CEA levels alone correlated with analyses of simultaneously collected The correlation was not improved when levels were considered (table 5). As VUVHi.vc01, JO and Guinan 3 and little relationship to adenocarci-the possible Vvifo noma approximately 50 to 65

808

MURPHY AND ASSOCIATES

carcinoma had elevated CEA, regardless of cytologic grade of tumor. The value of CEA in combination with urinary cytology has been cited by other investigators. 6 • 10 The data here tend to confirm this observation for comparisons of single specimens. When multiple samples are available for cytologic studies the additive effect of CEA is minimal. The apparent value of CEA even in single analyses must be viewed with caution. Most of the elevations accounting for increased diagnostic accuracy are slight and would be difficult to interpret, especially if the urine also were colonized by micro-organisms. It has been stated that serial determinations of urinary CEA may have a significant role in the followup of patients with urothelial cancer. 15 In our study 27 of 48 patients had more than 1 CEA determination. Although the numbers are small and no patient has more than 5 reported values preliminary results are not promising. For an individual patient CEA values seem to have an erratic pattern when compared to simultaneously obtained cytologic and histologic findings. The data indicate that urinary CEA-like substances, as currently measured, have little clinical application in the screening or diagnosis of urothelial cancer. This is true regardless of which of the wide range of reported normal values is accepted. CEA measurement tends to improve the diagnostic accuracy of cytology for single specimens only but this effect is minimal when multiple urine specimens are available for cytologic evaluation. The role of serial determinations of urinary CEA in followup has not been fully elucidated but is probably limited to those patients with positive cytology, high CEA concentrations and non-diagnostic tissue specimens. REFERENCES

1. Reynoso, G., Chu, T. M., Guinan, P. and Murphy, G. P.: Carcinoembryonic antigen in patients with tumors of the urogenital tract. Cancer, 30: 1, 1972. 2. Hall, R.R., Laurence, D. J. R., Neville, A. M. and Wallace, D. M.: Carcinoembryonic antigen and urothelial carcinoma. Brit. J. Urol., 45: 88, 1973. 3. Guinan, P., John, T., Sadoughi, N., Ablin, R. J. and Bush, I.: Urinary carcinoembryonic-like antigen levels in patients with

bladder carcinoma. J. Urol., 111: 350, 1974. 4. Guinan, P., Ablin, R. J., Sadoughi, N. and Bush, I. M.: Carcinoembryonic-like antigen in the urine of patients with carcinoma of the bladder and normal controls. J. Surg. Oncol., 6: 127, 1974. 5. Wahren, B., Edsmyr, F. and Zimmerman, R.: Measurement of urinary CEA-like substance. An aid in management of patients with bladder carcinoma. Cancer, 36: 1490, 1975. 6. Fraser, R. A., Ravry, M. J., Segura, J. W. and Go, V. L. W.: Clinical evaluation of urinary and serum carcinoembryonic antigen in bladder cancer. J. Urol., 114: 226, 1975. 7. Korsten, C. B., Persijn, J.-P., Renaud, J. and Houtzager-Boelens, C. A. M.: Carcino-embryonic antigen activity in urine of patients with bladder carcinoma. Clinical evaluation of carcino-embryonic antigen, II. J. Clin. Chem., 14: 389, 1976. 8. Ionescu, G., Romas, N. A., Ionascu, L., Bennett, S., Tannenbaum, M., Veenema, R. J. and Lattimer, J. K.: Carcinoembryonic antigen and bladder carcinoma. J. Urol., 115: 46, 1976. 9. Wajsman, Z., Merrin, C. E., Chu, T. M., Moore, R. H. and Murphy, G. P.: Evaluation of biological markers in bladder cancer. J. Urol., 114: 879, 1975. 10. Coombes, G. B., Hall, R.R., Laurence, D. J. R. and Neville, A. M.: Urinary carcinoembryonic antigen (CEA)-like molecules and urothelial malignancy: a clinical appraisal. Brit. J. Cancer, 31: 135, 1975. 11. Guinan, P., Dubin, A., Bush, I., Alsheik, H. and Ablin, R. J.: The CEA test in urologic cancer: an evaluation and a review. Oncology, 32: 158, 1975. 12. Ornellas, E. P., Bullock, G. B., Daly, J. J., Thompson, J. T. and Prout, G. R., Jr.: CEA in urogenital carcinomas (abstract). Read at National Bladder Cancer Conference, Miami, Florida, 1976. 13. Murphy, W. M. and Vandevoorde, J. P.: Determination of baseline values for urinary carcinoembryonic antigen-like substances (CEA). Amer. J. Clin. Path., 67: 455, 1977. 14. Hansen, H. J., Hainsselin, L., Donahue, D., Davis, R., Miller, 0. N. and Vandevoorde, J.P.: Z-gel assay method for carcinoembryonic antigen (CEA) in plasma as used in a multiclinic study. In: Methods in Cancer Research. Edited by H. Busch. New York: Academic Press, vol. 11, p. 355, 1975. 15. Persijn, J.-P., Korsten, C. B., Batterman, J. J., Tierie, A. H. and Renaud, J.: Clinical significance of urinary carcino-embryonic antigen estimations during the follow-up of patients with bladder carcinoma or previous bladder carcinoma. Clinical evaluation of carcino-embryonic antigen, III. J. Clin. Chem., 14: 395, 1976.