Purpose: Recently, totally laparoscopic gastrectomy has been gradually accepted by surgeons worldwide for gastric cancer treatment. Complete dissection of the lymph nodes and the establishment of the surgical margin are the most important considerations for curative gastric cancer surgery. Previous studies have demonstrated that indocyanine green (ICG)-traced laparoscopic gastrectomy significantly improves the completeness of lymph node dissection. However, it remains difficult to identify the tumor location intraoperatively for gastric cancers that are staged ≤T3. Here, we investigated the feasibility of ICG fluorescence for lymph node mapping and tumor localization during totally laparoscopic distal gastrectomy. Materials and Methods: Preoperative and perioperative data from consecutive patients with gastric cancer who underwent a totally laparoscopic distal gastrectomy were collected and analyzed. The patients were categorized into the ICG (n=61) or the non-ICG (n=75) group based on whether preoperative endoscopic mucosal ICG injection was performed. Results: The ICG group had a shorter operation time and less intraoperative blood loss.Moreover, significantly more lymph nodes were harvested in the ICG group than the non-ICG group. No pathologically positive margin was found and there was no significant difference in either the proximal or distal surgical margins between the 2 groups. Conclusions Near-infrared fluorescence imaging with ICG can be successfully used in totally laparoscopic distal gastrectomy, and it contributes to both the completeness of D2 lymph node dissection and confirmation of the gastric transection line. Well-designed prospective randomized studies are needed in the future to fully validate our findings.

OBJECTIVE: To investigate the risk factors of postoperative pulmonary infection (PPI) in patients over 60 years of age with gastric cancer after radical gastrectomy. METHODS: Clinicopathological data of 373 patients over 60 years of age who underwent radical gastrectomy at Department IV of Gastrointestinal Cancer Center, Peking University Cancer Hospital, from April 2009 to December 2016 were retrospectively collected in this case-control study. The clinicopathological characteristics of patients with postoperative pulmonary infection (including postoperative atelectasis) and those without pulmonary infection were compared. A Student t-test (reported as Mean±SD if data matching normal distribution) or Mann-Whitney U test [reported as median (quartile) if data did not conform to normal distribution] was used to analyze continuous variables. A χ² test or Fisher exact tests (reported as number and percentage) was used for categorical variables. Multivariable logistic regression was used to analyze the risk factors for pulmonary infection after operation of gastric cancer.PPI was defined as postoperative patients with elevated body temperature (>38.0 degrees centigrade) for more than 24 hours; cough and expectoration; positive sputum bacteria culture;recent infiltration, consolidation or atelectasis confirmed by chest imaging examination. RESULTS: Among 373 patients, 50 cases had PPI(13.4%, PPI group), 323 cases had no PPI(86.6%, non-PPI group). There were 39 (78.0%) and 178(55.1%) patients with comorbidities (including hypertension, diabetes and cardiopulmonary disease) preoperatively in PPI and non-PPI group, respectively. The difference between two groups was statistically significant (χ²=9.325,P=0.002). The incidence of preoperative hypoalbuminemia in PPI group was also significantly higher than that in non-PPI group [10.0%(5/50) vs. 3.1% (10/323),χ²=4.098, P=0.048]. Compared to non-PPI group, the rate of total gastrectomy [54.0%(27/50) vs. 34.4% (111/323), χ²=12.501, P=0.002], postoperative wound pain [34.0%(17/50) vs. 11.8% (38/323),χ²=16.928, P<0.001], secondary operation [6.0%(3/50) vs. 0.6% (2/323), χ²=6.032, P=0.014] and the rate of gastric tube removal later than 7 days postoperatively [96.0%(48/50) vs. 84.5%(273/323),χ²=4.811, P=0.028] were significantly higher in PPI group, respectively. The postoperative hospital stay was also prolonged in PPI group [16.0(9.5) days vs. 12.0(5.0) days, U=4 275.0, P<0.001]. Multivariate logistic regression analysis showed that preoperative comorbidities (OR=4.008, 95%CI:1.768-9.086, P=0.001), abdominal infection (OR=3.164, 95%CI:1.075-9.313, P=0.037), and wound pain (OR=3.428, 95%CI:1.557-7.548, P=0.002) were independent risk factors for PPI in patients over 60 years of age with gastric cancer. Furthermore, 50 patients with pulmonary infection were classified according to the length of latency and the type of infection. The patients with PPI latency ≤ 3 days were classified as early onset (34 cases, 68.0%), and those with latency ≥ 4 days as delayed onset (16 cases, 32.0%); PPI combined with surgical infection (including anastomotic leakage, abdominal infection, duodenal stump leakage, wound infection, etc.) was classified into mixed infection group (13 cases, 26.0%), with non-surgical infection as simple infection group (37 cases, 74.0%). The results showed that the pulmonary infection occurred 0 to 12 days (median 3 days) before surgical infection in mix infection group. The incidence of previous chronic obstructive pulmonary disease (COPD) in patients with early onset was significantly higher than that in patients with delayed onset [17.6%(6/34) vs. 0, χ²=5.005, P=0.025], and the incidence of mixed infection in patients with delayed onset was significantly higher than that in patients with early onset [50%(8/16) vs. 14.7%(5/34), χ²=6.730, P=0.009],but there was no significant difference in postoperative hospital stay between the two groups[17.0(9.8) days vs. 14.0(9.5) days, U=224.0, P=0.317]. CONCLUSIONS Postoperative pulmonary infection is common in gastric cancer patients over 60 years of age. Preoperative comorbidities, abdominal infection and wound pain are independent risk factors for postoperative pulmonary infection. Pulmonary infection within 3 days after operation is associated with preoperative COPD. For patients suffering from PPI after the 4th day,attentions should be paid to abdominal infection and anastomotic leakage.
Age Factors ; Anastomotic Leak ; etiology ; Case-Control Studies ; Gastrectomy ; adverse effects ; methods ; Humans ; Intraabdominal Infections ; etiology ; Middle Aged ; Pneumonia ; etiology ; Pulmonary Atelectasis ; etiology ; Pulmonary Disease, Chronic Obstructive ; complications ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; complications ; surgery

OBJECTIVE: To evaluate the safety and feasibility of laparoscopy-assisted total gastrectomy in gastric cancer patients over 65 years old. METHODS: Clinical, pathological and follow-up data of 188 gastric cancer patients who underwent laparoscopy-assisted total gastrectomy at Department IV of Gastrointestinal Cancer Center, Peking University Cancer Hospital, from April 2009 to December 2016 were collected for a retrospective cohort study. INCLUSION CRITERIA: ECOG performance score 0-1; preoperative gastroscopy discovered gastric masses, and pathological biopsy confirmed adenocarcinoma; distant metastases were excluded by image examination; preoperative cardiopulmonary function was normal; preoperative blood routine test, liver and renal function, and coagulation function were normal; laparoscopy-assisted total gastrectomy was performed. EXCLUSION CRITERIA: intraoperative laparoscopic exploration indicated abdominal and/or pelvic peritoneal metastasis; free cancer cells in peritoneal cavity; conversion to laparotomy during laparoscopic surgery. Patients were divided by age into 2 groups, ≥ 65 years old group(59 cases) and < 65 years old group (129 cases). The perioperative conditions and postoperative complications between two groups were compared, and the high risk factors of postoperative complications in patients over 65 years old were analyzed. RESULTS: All the patients were operated by the same operation team. The incidence of comorbidities was 44.1%(26/59) in the ≥ 65 years old group, which was significantly higher than 20.2% (26/129) in the < 65 years old group (χ²=11.570, P=0.001). The incidence of cardia/fundus cancer was 64.4%(38/59) in the ≥ 65 years old group, which was also significantly higher than 40.3% (52/129) in the < 65 years old group (χ²=16.625, P=0.001). The number of retrieved lymph nodes in the ≥65 years old group was significantly lower than that in the < 65 years old group (28.9±10.7 vs. 36.1±15.4, t=3.271, P=0.001). The total morbidity of complications was 13.8%(21/188) and the mortality within 30 days after operation was 1.6%(3/188). The morbidity of postoperative complications and the mortality within 30 days after operation were 20.3%(12/59) and 3.4%(2/59,respectively) in the ≥ 65 years old group, which were slightly higher than those in the <65 years old group [10.9%(14/129) and 0.8%(1/129)], without significant difference(both P>0.05). Multivariate logistic regression analysis showed that preoperative comorbidities(OR=0.223, 95%CI:0.053 to 0.944, P=0.041) was an independent risk factor for postoperative complications in patients aged ≥ 65 years old undergoing laparoscopy-assisted total gastrectomy. The median survival time was 21.3 months and the overall 5-year survival rate was 50.0%. The 5-year survival rate was 45.5% and 57.5% in patients aged ≥ 65 and < 65 years, respectively, and there was no significant difference(P=0.205). CONCLUSIONS Laparoscopy-assisted total gastrectomy is safe and effective in the treatment of gastric cancer patients ≥ 65 years old. Age is not a contraindication of laparoscopy-assisted total gastrectomy.
Aged ; Cohort Studies ; Gastrectomy ; instrumentation ; Humans ; Laparoscopy ; Postoperative Complications ; Retrospective Studies ; Stomach Neoplasms ; surgery ; Treatment Outcome

Objective: This study aimed to compare the short- and long-term outcomes of laparoscopy-assisted radical gastrectomy between elderly and non-elderly patients with gastric cancer. Methods: A total of 219 patients who underwent laparoscopy-assisted radical gastrectomy in the Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute from April 2009 to October 2013 were included in this retrospective study. All patients were divided into elderly (≥65 years) and non- elderly (<65 years)groups. We compared these groups based on clinicopathological characteristics, postoperative morbidities, and survival. Results:Theelderly group showed higher ASA scores and higher number of preoperative comorbidities (P<0.05). The operative time, blood loss,and conversion rate did not differ significantly between the groups (all P>0.05). The mean time to first ambulation in elderly group was 2.2±2.3d while first ambulation time in the non-elderly group was 1.4±1.3d,which showed significant difference between the two groups (P<0.05). No significant differences were observed between groups in terms of postoperativemorbidities (34.8％ vs. 28.5％, P> 0.05) as well as 3-year disease-free survival and overall survival (P>0.05). However, the elderly patients withpostoperative morbidities experienced significantly poorer overall survival rate than non-elderly patients (44.5％ vs. 70.5％, P<0.05). Conclusion: Laparoscopy-assisted gastrectomy can be safely and successfully performed in an elderly population with acceptable short- and long-term outcomes.Enhanced perioperative treatment is necessary to improve postoperative outcomes.

Objective To investigate the clinical efficacy of laparoscopy-assisted radical gastrectomy for gastric cancer.Methods The retrospective cohort study was adopted.The clinical data of 210 patients with gastric cancer who underwent laparoscopy-assisted radical gastrectomy at the Peking University Cancer Hospital between May 2009 and December 2012 were collected.Fifty-two,43 and 115 patients were respectively detected in stage Ⅰ,Ⅱ and Ⅲ of postoperative pathological stage.Laparoscopy-assisted radical distal,proximal and total gastrectomies were selectively performed according to the location and extent of tumors.(1) Overall treatment indicators were observed,including surgical procedure,with or without conversion to open surgery,operation time,volumes of intraoperative blood loss and transfusion,number of lymph node dissected,time to anal exsufflation,duration of hospital stay,occurrence of complications,radical degree of tumors of pathological examination.(2) Other indicators were observed,including pathological features of patients in stage Ⅰ,Ⅱ and Ⅲ [gender,age,body mass index (BMI),scores of American Society of Anesthesiologists (ASA),medicinal complication,location of tumors,degree of tumor differentiation and with or without vascular tumor thrombi],intraoperative and postoperative situations (surgical procedure,conversion to open surgery,operation time,volumes of intraoperative blood loss and transfusion,number of lymph node dissected,time to anal exsufflation,duration of hospital stay and radical degree of tumors),postoperative complications,reoperation,death within postoperative day 30 and during follow-up,3-and 5-year survival rates.(3) Evaluation criteria:stages and classification of tumors were evaluated according to the tumor node metastasis (TNM) classification of malignant tumours (Seventh Edition) published by American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC).Severity of complications was evaluated according to Clavien-Dindo classification.Patients were followed up by outpatient examination,telephone interview and correspondence once every half a year up to December 31,2015,abdominal / pelvic CT,chest X-ray and blood test were performed once every half a year within 2 years and once every year within 2-5 years postoperatively,and gastroscopy was performed once every year.Overall survival time was counted from operation date to end of follow-up or time of death.Measurement data with normal distribution were presented as x ± s and comparison between groups was analyzed using the ANOVA.Measurement data with skewed distribution were presented as M (range) and comparison between groups was analyzed using nonparametric test.Comparisons of count data were analyzed using the chisquare test.Survival curve was drawn by the Kaplan-Meier method,and survival analysis was done using the Logrank test.Results (1) Overall treatment:all the 210 patients underwent successful radical gastrectomy,including 100 undergoing distal gastrectomy,35 undergoing proximal gastrectomy and 75 undergoing total gastrectomy.There were 198 patients undergoing radical gastrectomy and 12 patients converted to open surgery.Operation time,volume of intraoperative blood loss,number of patients with blood transfusion and number of lymph node dissected were (258 ± 54) minutes,(103 ± 86) mL,19 and 29 ± 12,respectively.Postoperative recovery:time to anal exsufflation and duration of hospital stay were (3.8 ± 0.9) days and (17 ± 7) days.Fortyfive patients had postoperative complications and 2 were dead within 30 days postoperatively.R0 and R1 resections were respectively applied to 209 and 1 patients.(2) Comparisons among the patients with the different pathological stage:numbers of patients in stage Ⅰ,Ⅱ and Ⅲ were 9,17 and 36 with tumor located in the upper stomach,3,9 and 22 with tumor located in the middle stomach,40,16 and 47 with tumor located in the lower stomach,0,1 and 10 with tumor located in the cross-region stomach,30,23 and 23 in G1 and G2 of tumor differentiation,21,19 and 92 in G3 and G4 of tumor differentiation,7,13 and 69 with vascular tumor thrombi,respectively,with significant differences in above indicators among the patients in stage Ⅰ,Ⅱ and Ⅲ (x2 =25.990,32.928,35.027,P ＜ 0.05).(3) Intra-and post-operative comparisons among the patients with the different pathological stage:numbers of patients in stage Ⅰ,Ⅱ and Ⅲl were respectively 40,20 and 40 with distal gastrectomy,3,8 and 24 with proximal gastrectomy,9,15 and 51 with total gastrectomy,and number of lymph node dissected were 26 ± 9,29 ± 13 and 31 ± 12 in patients with stage Ⅰ,Ⅱ and Ⅲ,showing significant differences in above indicators among the patients in stage Ⅰ,Ⅱ and Ⅲ (x2 =25.730,F =4.336,P ＜ 0.05).(4) Numbers of patients with postoperative overall complications were 11,8 and 26 in stage Ⅰ,Ⅱ and Ⅲ,showing no significant difference (x2 =0.301,P ＞ 0.05).(5) Of 210 patients,203 were followed up for a median time of 43 months (range,1-80 months) with a follow-up rate of 96.67％ (203/210).Sixty-eight patients were dead till the end of follow-up,including 60 died of recurrence of tumor,2 died of surgical complications and 6 died of other causes.Postoperative 3-,5-year overall survival rates were 96.1％,87.8％,62.4％ and 92.9％,77.5％,52.7％ in patients with stage Ⅰ,Ⅱ and Ⅲ,respectively,with a significant difference (x2 =29.071,P ＜ 0.05).Conclusion Laparoscopy-assisted radical gastrectomy for advanced gastric cancer is at least equivalent to early gastric cancer in the safety,with the satisfactory long-term outcomes.

Objective:To explore the clinicopathological factors in node-negative colon cancer patients with synchronous liver metasta-ses and to improve the efficiency of follow-up and rate of early diagnosis for high-risk patients. Methods:Clinical data of 140 colon cancer patients who underwent operation from January 2008 to December 2012 in Beijing Cancer Hospital were analyzed. The high-risk variables associated with synchronous liver metastases were subjected to univariate and multivariate analyses. Results:Synchro-nous liver metastases developed in 13 out of the 140 node-negative colon cancer patients. Eight out of those 13 patients (61.5%) ex-hibited complications with incomplete colon obstruction, and 6 cases underwent surgical treatment for both primary tumor and liver metastases. Both univariate and multivariate analyses revealed that preoperative abnormal serum carcinoembryonic antigen levels (≥5 ng/mL) and vascular invasion were significant independent risk factors for synchronous liver metastases. Conclusion:The risk of syn-chronous liver metastases for colon cancer patients with negative lymph node is slightly high. Vascular invasion and abnormal preoper-ative CEA levels are significant independent risk factors for synchronous liver metastases. Specific examination of livers is necessary for the special cohort at the time of diagnosis or after operation to avoid misdiagnosis.

OBJECTIVETo investigate the predictive value of preoperative detection of CEA and CA199 for prognosis in patients with stage II-III colorectal cancer (CRC).

METHODSClinicopathological and follow-up data of 266 patients with stage II-III colorectal cancer confirmed by pathology and undergoing radical resection in our department from 2004 to 2006 were retrospectively analyzed. The 5-year overall survival (OS) and disease-free survival (DFS) between normal CEA patients and increased CEA ones, and normal CA199 patients and increased CA199 ones were compared respectively. Moreover, the risk factors of OS and DFS were examined.

RESULTSAmong these 266 patients, 119 (44.7%) had preoperative elevated CEA, and 74 (27.8%) had increased CA199. The median follow-up time was 63 months. Kaplan-Meier survival curves indicated that patients with elevated preoperative CEA had worse 5-year OS (54.6% vs. 72.8%, P=0.001) and DFS (75.2% vs. 83.3%, P=0.042) than those with normal CEA respectively. Meanwhile, patients with elevated CA199 had worse OS (45.9% vs. 71.9%, P=0.000) and DFS (74.2% vs. 81.8%, P=0.047) than those with normal CA199 respectively. Multivariate analysis revealed that male (HR=3.016, 95% CI: 1.536-5.919, P=0.001), lymph node metastasis (HR=2.278, 95% CI: 1.272-4.081, P=0.006), and preoperative elevated CEA (HR=1.794, 95%CI: 1.022-3.149, P=0.042) were independent prognostic factors of DFS. While vascular thrombosis (HR=2.041, 95% CI: 1.294-3.221, P=0.002), lymph node metastasis (HR=2.480, 95% CI:1.548-3.972, P=0.000), and preoperative elevated CA199 (HR=2.145, 95% CI:1.414-3.254, P=0.000) were independent prognostic factors of OS in patients with stage II-III CRC.

CONCLUSIONCombined detection of preoperative CEA and CA199 can be used in evaluating the prognosis of patients with stage II-III CRC.

Antigens, Tumor-Associated, Carbohydrate ; blood ; Carcinoembryonic Antigen ; blood ; Colorectal Neoplasms ; diagnosis ; Disease-Free Survival ; Female ; Humans ; Kaplan-Meier Estimate ; Lymphatic Metastasis ; Male ; Multivariate Analysis ; Neoplasm Staging ; Predictive Value of Tests ; Prognosis ; Retrospective Studies ; Risk Factors ; Survival Rate

OBJECTIVETo investigate the clinical efficacy of laparoscopy-assisted radical gastrectomy in elderly patients with gastric cancer.

METHODSClinical data of 214 patients with gastric cancer were analyzed retrospectively, who underwent laparoscopy-assisted radical gastrectomy in the Department of Minimally Invasive Gastrointestinal Surgery at Beijing Cancer Hospital between May 2009 and December 2012. The patients were divided into two groups, consisting of elderly group(age ≥70 years old, n=53) and non-elderly group(age <70 years old, n=161). The operative procedure and postoperative recovery were compared between the two groups.

RESULTSElderly group had a worse ASA score as compared to non-elderly group with significant difference(P<0.05). Among the elderly, the incidences of concomitant diseases, such as hypertension and diabetes, were significantly higher. No significant differences were observed in terms of duration of operation, blood loss, blood transfusion rate, conversion to laparotomy, time to first flatus and postoperative hospital stay between the two groups(P>0.05). The mean number of retrieved lymph nodes in elderly group was less than that of non-elderly group (26.4±9.7 vs. 30.0±12.4), but whose difference was not significant(P>0.05). There were no significant differences between two groups with respect to postoperative complications (30.2% vs. 19.9%, P>0.05) and surgery-related complications(18.9% vs. 18.0%, P>0.05), but the incidence of medical complications was higher in elderly group (11.3% vs. 1.9%, P<0.05). Furthermore, the perioperative mortality was 1.9% and 0.6% respectively in elderly and non-elderly groups without significant difference(P>0.05).

CONCLUSIONAssociated with more concomitant diseases, the elderly had higher risk of medical complications after operation, while laparoscopy-assisted radical gastrectomy does not increase the risk of surgery-related complications in elderly patients.

Aged ; Digestive System Surgical Procedures ; Gastrectomy ; Humans ; Hypertension ; Laparoscopy ; Lymph Nodes ; Postoperative Complications ; Postoperative Period ; Retrospective Studies ; Stomach Neoplasms ; Treatment Outcome

OBJECTIVETo assess the accuracy of POSSUM scoring system in predicting surgical risk in patients with gastric cancer, and provide a feasible reference to clinical decision.

METHODSClinical data of 310 patients suffered from gastric cancer were analyzed retrospectively, including 278 cases in laparoscopic group and 32 cases in open group, between April 2009 and April 2014 in the department of minimally invasive gastrointestinal surgery, Peking University Cancer Hospital. Preoperative physiology score(PS), operative score(OS) and predictive morbidity rate(R1) were calculated according to POSSUM scoring system, which were used to assess the accuracy of R1 in open group. Two different scoring systems (R1traditional and R1modified according to adjustment of operative excision area) were applied in the laparoscopic group, and were compared for predicting the accuracy of R1 in the laparoscopic group. Besides, postoperative morbidities were compared between the two groups of patients with different preoperative physiological status(low risk group: PS≤20, high risk group: PS≥21).

RESULTSThe predictive accuracy for open group patients were acceptable, and the ratio of expected and observed(E/O) was 1.2. In the laparoscopic group, the R1modified was 29.1%, and observed morbidity was 23.4% with an E/O of 1.2. The R1modified was more accurate than R1traditional(38.5%, E/O traditional was 1.6). Both modified and traditional POSSUM scoring system predicted well in low risk patients in the laparoscopic and open group, and E/O was 1.0. However, it overestimated morbidities in median and high risk patients for both laparoscopic and open group. E/O was 1.6, and 1.9 in laparoscopic group, as well as 1.2 and 1.3 in open group. For patients in poor preoperative physiological status(PS≥21), the morbidity in laparoscopic group was lower than that in open group(27.3% vs. 5/7, P=0.020).

CONCLUSIONSModified POSSUM scoring system predicted morbidity more accurately in the laparoscopic group than traditional system. As for patients in poor preoperative physiological status, laparoscopic assisted gastrectomy procedure might reduce postoperative morbidities.

Gastrectomy ; Humans ; Laparoscopy ; Morbidity ; Postoperative Period ; Retrospective Studies ; Stomach Neoplasms

Objective:To investigate whether increased levels of preoperative carcinoembryonic antigen (CEA) and CA199 were associated with the mortality of patients with advanced colorectal cancer and to determine whether CA199 can be used to discriminate patients with normal preoperative CEA level from good to poor prognosis. Methods:A total of 314 patients with advanced colorectal cancer cases who underwent primary tumor resection were collected from 2014 to 2016 at Peking University Cancer Hospital and Institute. Preoperative CEA and CA199 serum levels were examined using electrochemiluminescence immunoassay. The association of CEA and CA199 with clinicopathologic features and their possible prognostic values were analyzed. Results:In the tested patients, 5.4%of whom had increased CA199 level but not up-regulated CEA level, whereas 28.3%only had increased CEA level, and 21.3%had both CEA and CA199 levels increased. Kaplan-Meier survival curves indicated that patients with elevated preoperative CEA level had worse disease-free survival (DFS) and overall survival (OS) than those with normal CEA (P<0.001 and P<0.001, respectively). Meanwhile, patients with elevated CA199 level had worse DFS and OS than those with normal CA199 (P<0.001 and P<0.001, respectively). Preoperative CA199 level could be used in discriminating patients with normal CEA from good to poor prognosis (P=0.012). Multivariate analysis revealed that elevated CA199 level was an independent prognostic factor for OS in patients with advanced colorectal cancer (HR=2.025, 95%CI=1.331-3.082, P=0.001). Conclusion:Combined detection of preoperative CEA and CA199 can be used in evaluating the prognosis of patients with advanced colorectal cancer. Preoperative serum CA199 level can be used in evaluating the prognosis of patients with colorectal cancer without an increase in CEA level. Patients with increased CA199 level had worse 5-year survival than those with increased CEA level.