Validation of a new classification system for curatively resected colorectal adenocarcinoma

Does Adjuvant Chemotherapy Benefit Patients with T4 N0 Colon Cancer?

Background and Objectives: Colorectal cancer (CRC) poses a major global health challenge, with high incidence rates and ongoing treatment debates. Adjuvant chemotherapy benefits for high-risk subgroups, particularly stage II disease, remain controversial. This study seeks to clarify this issue by specifically examining the impact of adjuvant chemotherapy on disease-free survival (DFS) and overall survival (OS) in patients diagnosed with T4 colon cancer. Materials and Methods: This retrospective study analyzed patients undergoing radical surgery for T4 colon cancer between 2002 and 2023. Results: Our study of 184 pT4 pN0 colon cancer patients revealed that 79.3% received adjuvant chemotherapy. Multivariate analysis demonstrated significant DFS improvement: a 60% reduction in risk for those who received adjuvant therapy (0.40 95% CI: 0.25-0.62, p < 0.001). Lymphovascular invasion (LVI) and adjuvant treatment were also significantly associated with OS. Adjuvant treatment reduced mortality by 60% (HR: 0.40, 95% CI: 0.23-0.68, p = 0.001). Patients with LVI had a 1.9-fold increase in mortality (HR: 1.94, 95% CI: 1.17-3.20, p = 0.011). These findings underscore the potential value of adjuvant chemotherapy and highlight the importance of treatment completion in managing T4 colon cancer. Conclusions: Our study identifies LVI and adjuvant chemotherapy as key prognostic factors in T4 colon cancer patients. These results support the consideration of adjuvant chemotherapy in this patient population.

Adjuvant Therapy for High-Risk Stage II or III Colon Adenocarcinoma: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: To determine the optimal adjuvant chemotherapy regimen for patients with high-risk stage II or III colon adenocarcinoma, we conducted this propensity score-matched, nationwide, population-based cohort study to estimate the effects of adjuvant treatments in high-risk stage II or III colon adenocarcinoma. Patients and Methods: Using propensity score matching, we minimized the confounding effects of sex, age, pathologic stage, tumor location, total chemotherapy cycles, and Charlson comorbidity index scores on adjuvant treatment outcomes in patients with high-risk stage II or III resectable colon adenocarcinoma. We selected the patients from the Taiwan Cancer Registry database and divided them into four groups: Group 1, comprising patients who received surgery alone; group 2, comprising those who received adjuvant fluoropyrimidine alone; group 3, comprising those who received adjuvant oxaliplatin-fluoropyrimidine-leucovorin (FOLFOX); and group 4, comprising those who received adjuvant folinic acid-fluorouracil-irinotecan (FOLFIRI). Results: In both univariate and multivariate Cox regression analyses, the adjusted hazard ratios (aHRs, as well as the 95% confidence intervals (Cis)) for mortality observed for groups 1, 2, and 4 relative to group 3 were 1.55 (1.32 to 1.82), 1.22 (1.05 to 1.43), and 2.97 (2.43 to 3.63), respectively. After a stratified subgroup analysis for high-risk stage II colon adenocarcinoma, we noted that the aHR (95% CI) for mortality for group 2 relative to group 3 was 0.52 (0.30 to 0.89). Conclusions: Adjuvant fluoropyrimidine alone is the most optimal regimen for patients with high-risk stage II colon adenocarcinoma compared with the other adjuvant chemotherapy regimens. Adjuvant FOLFOX can serve as an optimal regimen for patients with pathologic stage III colon adenocarcinoma, regardless of age, sex, or tumor location.

Livin serves as a prognostic marker for mid-distal rectal cancer and a target of mid-distal rectal cancer treatment

Livin is a novel member of the inhibitor of apoptosis protein family, which has been identified to be expressed in various malignancies and is suggested to be associated with poor prognostic significance. However, no data are available concerning the significance of livin in mid-distal rectal cancer. In the present study, livin expression, and its association with clinicopathological characteristics and prognosis was examined in patients with mid-distal rectal cancer. Apoptotic susceptibility, invasion capacity and chemosensitivity of LoVo cells were investigated using small interfering RNA (siRNA)-mediated knockdown of livin. It was revealed that livin was highly expressed in mid-distal rectal cancer tissues compared with the normal rectal mucosal tissues. Livin expression was associated with pathological grade, extent of invasion (T stage) and extent of lymph node metastasis (N stage) of tumor, contributing to poor prognosis of mid-distal rectal cancer following surgery. The data suggest that aggressive surgery should be applied in patients with mid-distal rectal cancer with high expression of livin. It was also revealed that knockdown of livin by siRNA increased the apoptotic rate, suppressed invasion of LoVo cells, and decreased the half-maximal inhibitory concentration of oxaliplatin and 5-fluorouracil by ~50% in LoVo cells significantly compared with control groups. The data suggested that a combination of downregulation of livin and anticancer drugs may significantly decrease the toxicity of anticancer drugs. Taken together, the present study indicated that livin may be a promising target in clinical therapy of mid-distal rectal cancer.

Prognostic Value of Lymph Node Ratio in Locally Advanced Rectal Cancer Patients After Preoperative Chemoradiotherapy Followed by Total Mesorectal Excision

Although the absolute number of positive lymph nodes (LNs) has been established as 1 of the most important prognostic factors in rectal cancers, many researchers have proposed that the lymph node ratio (LNR) may have better predicted outcomes. We conducted a retrospective study to compare the predictive ability of LNR and ypN category in rectal cancer. A total of 264 locally advanced rectal cancer (LARC) patients who underwent preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME) between 2005 and 2012 were reviewed. All patients were categorized into 3 groups or patients with metastatic LNs were categorized into 2 groups according to the LNR. The prognostic effect on overall survival (OS) and disease-free survival (DFS) was evaluated. With a median follow-up of 45 months, the OS and DFS were 68.4% and 59.3% for the entire cohort, respectively. The respective 5-year OS and DFS rates for the 3 groups (LNR = 0, 0 < LNR ≤ 0.20, and 0.20 < LNR ≤ 1.0) were as follows: 83.2%, 72.6%, and 49.4% (P < 0.001) and 79.5%, 57.3%, and 33.5% (P < 0.001), respectively. Multivariate analysis revealed that LNR and differentiation, but not the number of positive LNs, had independent prognostic value for OS (hazard ratio [HR] = 2.328, 95% confidence interval [CI]: 1.850-4.526, P < 0.001) and DFS (HR = 3.004, 95% CI: 1.616-5.980, P < 0.001). As for patients with positive LNs, the respective 5-year OS and DFS rates for the 2 groups (0 < LNR ≤ 0.20, and 0.20 < LNR ≤ 1.0) were 72.6% and 49.4% (P < 0.001) and 57.3% and 33.5% (P < 0.001), respectively. Multivariate analysis revealed that only LNR was an independent factor for OS (HR = 3.214, 95% CI: 1.726-5.986, P < 0.001) and DFS (HR = 4.230, 95% CI: 1.825-6.458, P < 0.001). Subgroups analysis demonstrated that the ypN category had no impact on survival whereas increased LNR was a significantly prognostic indicator for worse survival in the LNs < 12 subgroup. LNR is an independent prognostic factor in LARC patients treated with preoperative CRT followed by TME. It may be a better independent staging method than the number of metastatic LNs when <12 LNs are harvested after preoperative CRT.

[Is body mass index a prognostic factor of survival in colonic cancer? A multivariate analysis]

INTRODUCTION

The long-term survival of patients operated on for colonic cancer depends on many factors. Obesity decreases the life expectancy of the general population who suffer from it, but it is not clear whether obesity, measured by the Body Mass Index (BMI), is a prognostic factor of survival for patients operated on for colonic cancer.

MATERIAL AND METHODS

The patients included in this study had TNM stage I, II y III, and were subjected to elective surgery for cancer of the colon in the Girona University Hospital between 1990 and 2001. The BMI was classified according to the WHO classification. A total of 38 different variables were studied using a bivariate analysis with BMI. A Cox model was subsequently constructed with the most clinically relevant parameters, and with those most strongly associated with survival in the bivariate analysis.

RESULTS

BMI was not associated with survival in the bivariate analysis. Neither did the multivariate analysis show that BMI was an independent prognostic factor of long-term survival in cancer of the colon without metastasis, but it did show that the TNM stage, ASA score, surgical technique, age at surgery, and the immune cell response were prognostic factors.

CONCLUSIONS

The body mass index is not a prognostic factor of the long-term survival of patients with colonic cancer.

[Is body mass index a prognostic factor of survival in colonic cancer? A multivariate analysis]

INTRODUCTION

The long-term survival of patients operated on for colonic cancer depends on many factors. Obesity decreases the life expectancy of the general population who suffer from it, but it is not clear whether obesity, measured by the Body Mass Index (BMI), is a prognostic factor of survival for patients operated on for colonic cancer.

MATERIAL AND METHODS

The patients included in this study had TNM stage I, II y III, and were subjected to elective surgery for cancer of the colon in the Girona University Hospital between 1990 and 2001. The BMI was classified according to the WHO classification. A total of 38 different variables were studied using a bivariate analysis with BMI. A Cox model was subsequently constructed with the most clinically relevant parameters, and with those most strongly associated with survival in the bivariate analysis.

RESULTS

BMI was not associated with survival in the bivariate analysis. Neither did the multivariate analysis show that BMI was an independent prognostic factor of long-term survival in cancer of the colon without metastasis, but it did show that the TNM stage, ASA score, surgical technique, age at surgery, and the immune cell response were prognostic factors.

CONCLUSIONS

The body mass index is not a prognostic factor of the long-term survival of patients with colonic cancer.

TNM staging system of colorectal carcinoma: a critical appraisal of challenging issues

CONTEXT

Colorectal cancer is the leading cause of morbidity and death among gastrointestinal tumors and ranks fourth after lung, breast, and ovarian cancers. Despite a continuous refinement of the T (tumor), N (node), and M (metastasis) staging system to express disease extent and define prognosis, and eventually to guide treatment, the outcome of patients with colorectal cancer may vary considerably even within the same tumor stage. Therefore, the need for new factors, either morphologic or molecular, that could more precisely stratify patients into different risk categories is clearly warranted.

OBJECTIVES

To present the state of the art with regard to the colorectal cancer staging system and to discuss confusing and/or challenging issues, including the assessment of peritoneal membrane involvement, vascular invasion, tumor deposits, and pathologic tumor response to neoadjuvant chemoradiotherapy.

DATA SOURCES

Literature review of relevant articles indexed in PubMed (US National Library of Medicine) and primary material from the authors' institutions.

CONCLUSIONS

Two emerging needs exist for the TNM system, namely, further stratification of patients with the same tumor stage and incorporation of nonanatomic factors, the latter including molecular and treatment factors. The identification and classification of morphologic features encountered in the pathologic examination of colorectal cancer specimens may be difficult and a source of subjective variability. Enhanced pathologic analysis, agreed-upon standard protocols, and standardization should improve the completeness and accuracy of pathology reports.

Objective criteria for the grading of venous invasion in colorectal cancer

PURPOSE

To establish an objective histologic grading system of venous invasion.

METHODS

A total of 229 patients with pT3 and pT4 colorectal cancer who underwent curative surgery with lymph node dissection were retrospectively analyzed. Potential prognosis-related characteristics of venous invasion, including the number of venous invasion, morphologic type of venous invasion, maximum size of veins invaded, and location of venous vessel involved were evaluated on elastica van Gieson stained sections.

RESULTS

The relapse-free survival curves between the venous-invasion-positive group and the negative group were significantly different (5 y survival rates were 73.4% and 92.2%, respectively, P=0.001). When patients were divided into 3 groups according to the average number of venous invasions observed in a glass slide [G0 (none), G1 (positive but <4), and G2 (4 or more)], there was a significant difference in the survival rate among the 3 groups [5 y survival rates were 92.2%, 77.8%, and 56.4%, respectively, P=0.008 (G0 vs. G1), P=0.017 (G1 vs. G2)]. The postoperative recurrence rate was 10.8% in the G0 patients, whereas it was 32.5% in the G1 and 51.7% in the G2 patients [P=0.0007 (G0 vs. G1), P=0.047 (G1 vs. G2)]. Multivariate analysis showed the number of venous invasions [hazard ratio (HR) 2.72, P=0.027], depth of invasion (HR 2.26, P=0.014), and lymph node metastasis (HR 2.43, P=0.008) were independent prognostic factors.

CONCLUSIONS

Three ranked tumor grading system based on the number of venous invasion in a glass slide with elastica van Gieson staining could be an objective and important treatment index for colorectal cancer patients.

Tumor deposits are encountered in advanced colorectal cancer and other adenocarcinomas: an expanded classification with implications for colorectal cancer staging system including a unifying concept of in-transit metastases

The seventh edition of the TNM Classification of Malignant Tumors is due to be published soon. In the current version dating back to 2002, tumor deposits, which are metastatic lesions commonly encountered in the routine histopathological examination of advanced colorectal cancer specimens, are classified according to their shape with different implications for staging. So distinguished, these lesions are considered either as metastatic lymph nodes (N category) or as vascular invasions (T category). We recently proposed a more comprehensive classification approach that also includes the M category. Relying on two of our independent recent studies, we aim here to provide suggestions for a novel classification of tumor deposits with diverse implications for TNM staging system of colorectal cancer. Furthermore, we show that tumor deposits are not limited to colorectal cancer, but they are common to different adenocarcinoma types.

Tumor budding as a prognostic marker in stage-III rectal carcinoma

BACKGROUND AND AIM

Tumor budding along the invasive margin is known to be associated with biological behavior in colorectal carcinoma. The aims of this study were to explore if the semiquantitative assessment of tumor budding in rectal cancers correlates with oncological behavior and to appraise if the tumor budding is valid as a pathological parameter in distinguishing tumors with higher malignancy potential from those with lower one for prognostic stratification.

MATERIALS AND METHODS

Surgical specimens from 244 patients with well- or moderately differentiated rectal carcinoma were retrieved to assess the intensity of tumor budding at the invasive margin. Intensities were divided semiquantitatively into four groups based on quartiles, and the 5-year disease-free survivals (DFS) were analyzed to search for a cutoff point of prognostic stratification.

RESULTS

The cutoff of the intensity considered to be the best indicator for dividing patients into subgroups with different DFS was between quartiles 3 and 4, but this survival difference in subgroups in either side of the cutoff was significant only in stage-III disease [5-year DFS, 62.1 vs 35.1%; p = 0.0023; 95% confidence interval (CI), 0.1824-0.6919]. Based on multivariate analysis, the intensity of budding proved to be an independent variable associated with DFS (hazard ratio, 2.005; p = 0.0086; 95% CI, 1.021-3.934). When scores were given to grade of budding (lower, 0; higher, 1) and N stage (N1, 0; N2, 1) in stage III, a better prognostic stratification in terms of the 5-year DFS was obtained than the American Joint Committee on Cancer nodal staging only (0 vs 1 vs 2, 66.5 vs 42.6 vs 29.2%; p = 0.0101).

CONCLUSIONS

Quantitative assessment of tumor budding is a reliable biological prognostic variable to identify higher malignancy potential. Scoring system using tumor budding and N stage showed better prognostic stratification in stage-III rectal carcinoma. A prospective evaluation would confirm the clinical significance of tumor budding for prognostic stratification.

Pathological assessment of pericolonic tumor deposits in advanced colonic carcinoma: relevance to prognosis and tumor staging

The current TNM classification considers a tumor nodule in the pericolic/perirectal adipose tissue as venous invasion if the nodule has an irregular contour and as regional lymph node metastasis if the nodule has the form and smooth contour of a lymph node. However, detailed studies on the clinico-pathological implications of pericolonic tumor deposits and of extranodal extension are still lacking. We investigated the impact of these metastatic deposits in the pericolic fat in a series of 228 patients with advanced colon cancer. The pericolonic tumor deposits were characterized by their appearance, size, distance from the primary tumor and by their relation with the lymphatic tissue not organized in lymph nodes. These features were then compared with the clinico-pathological characteristics of the tumors and with the patients' survival. All these lesions were associated with reduced disease-free and overall survivals in a univariate analysis, but only pericolonic tumor deposits retained an independent prognostic role in the multivariate analysis. Our findings suggest that pericolonic tumor deposits are a destructive type of venous invasion different from other types of vessel involvement, and that these lesions may rather be included in the M category for staging purposes.

Colon cancer

Colon cancer is one of the leading tumours in the world and is considered among the big killers, together with lung, prostate and breast cancer. In the recent years very important advances occurred in the field of treatment of this frequent disease: adjuvant chemotherapy was demonstrated to be effective, chiefly in stage III patients, and surgery was optimized in order to achieve the best results with a low morbidity. Several new target-oriented drugs are under evaluation and some of them (cetuximab and bevacizumab) have already exhibited a good activity/efficacy, mainly in combination with chemotherapy. The development of updated recommendations for the best management of these patients is crucial in order to obtain the best results, not only in clinical research but also in everyday practice. This report summarizes the most important achievements in this field and provides the readers useful suggestions for their professional practice.

Improved prediction of recurrence after curative resection of colon carcinoma using tree-based risk stratification

BACKGROUND

Patients who are at high risk of recurrence after undergoing curative (R0) resection for colon carcinoma may benefit most from adjuvant treatment and from intensive follow-up for early detection and treatment of recurrence. However, in light of new clinical evidence, there is a need for continuous improvement in the calculation of the risk of recurrence.

METHODS

Six hundred forty-one patients with R0-resected colon carcinoma who underwent surgery between January 1, 1984 and December 31, 1996 were recruited from the Erlangen Registry of Colorectal Carcinoma. The study end point was time until first locoregional or distant recurrence. The factors analyzed were: age, gender, site in colon, International Union Against Cancer (UICC) pathologic tumor classification (pT), UICC pathologic lymph node classification, histologic tumor type, malignancy grade, lymphatic invasion, venous invasion, number of examined lymph nodes, number of lymph node metastases, emergency presentation, intraoperative tumor cell spillage, surgeon, and time period. The resulting prognostic tree was evaluated by means of an independent sample using a measure of predictive accuracy based on the Brier score for censored data. Predictive accuracy was compared with several proposed stage groupings.

RESULTS

The prognostic tree contained the following variables: pT, the number of lymph node metastases, venous invasion, and emergency presentation. Predictive accuracy based on the validation sample was 0.230 (95% confidence interval [95% CI], 0.227-0.233) for the prognostic tree and 0.212 (95% CI, 0.209-0.215) for the UICC TNM sixth edition stage grouping.

CONCLUSIONS

The prognostic tree showed superior predictive accuracy when it was validated using an independent sample. It is interpreted easily and may be applied under clinical circumstances. Provided that their classification system can be validated successfully in other centers, the authors propose using the prognostic tree as a starting point for studies of adjuvant treatment and follow-up strategies.

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The prognostic value of invariant chain (Ii) and Her-2/neu expression in curatively resected colorectal cancer

BACKGROUND

Current methods to predict outcome for patients with curatively resected colorectal cancer are not ideal. The combined use of molecular markers and clinicopathologic features may better identify patients who are at risk for recurrence. The Her-2/neu and invariant chain molecules may be important in cancer development and progression, but their usefulness as clinical predictors of outcome in colorectal cancer has not been well studied.

METHODS

We used immunohistochemistry to determine the expression of Her-2/neu, invariant chain, p27, and p53 in primary tumor samples from 156 patients with curatively resected stage I-III colorectal cancer. The association between expression and clinical outcomes was assessed by univariate and multivariate analysis.

RESULTS

Her-2/neu expression was detected in only 24% of cases, and high levels of invariant chain were detected in only 15%. Although patients whose tumors overexpressed Her-2/neu survived longer than those with non-overexpressing tumors, neither Her-2/neu nor invariant chain were independently associated with survival. Consistent with previous reports, high p27 expression was associated with improved outcome, whereas overexpression of p53 was associated with worse outcome.

CONCLUSIONS

Our study did not reveal a statistically significant association between Her-2/neu or invariant chain expression and clinical outcomes in patients with curatively resected colorectal cancer. However, the data suggest that Her-2/neu could be a favorable prognostic variable. Because of the low frequency of Her-2/neu expression, larger numbers of patients need to be studied for this question to be adequately answered.