Indeterminate pulmonary nodules in rectal cancer: a recommendation for follow-up guidelines

A prediction model for lung metastases in patients with indeterminate pulmonary nodules in newly diagnosed colorectal cancer

INTRODUCTION

Multidisciplinary teams treating patients with newly diagnosed Colorectal Cancer (CRC) often encounter the appearance of Indeterminate Pulmonary Nodules (IPNs) that warrants follow-up with repetitive medical imaging and anxiety for patients. We determined the incidence of IPNs in patients with newly diagnosed CRC and developed and validated a model for individualized risk prediction of IPNs being lung metastases.

MATERIAL AND METHODS

Newly diagnosed CRC who underwent surgery between November 2011 to June 2014 were included to create the risk model, developed using both clinical experience and statistical selection. Discrimination and calibration slopes of the risk score were evaluated in an independent temporal validation sample. A nomogram is presented to assist clinicians in estimating an individual risk score.

RESULTS

Out of 2111 CRC patients staged with chest CT, 204 (9.6%) had IPNs and 54/204 (26%) had lung metastases. We identified 4 predictors: "location of primary tumour", "pathological nodal stage", "size of the largest nodule" and "extrapulmonary synchronous metastases at diagnosis". Discrimination of the final model in the validation sample was demonstrated by the difference in mean predicted risk between progressed cases en non-progressed cases (49% versus 21%, p = <0.001).

CONCLUSION

A prediction model with 4 clinical risk factors can be used to assist multidisciplinary teams in the prediction of individualized risk of lung metastases and imaging strategy in patients with IPNs and newly diagnosed colorectal cancer. The model performed well in new patients not included in the model development.

Dealing with indeterminate pulmonary nodules in colorectal cancer patients; a systematic review

INTRODUCTION

Indeterminate pulmonary nodules (IPNs) are frequently encountered on staging computed tomography (CT) in colorectal cancer (CRC) patients and they create diagnostic dilemmas. This systematic review and pooled analysis aims to estimate the incidence and risk of malignancy of IPNs and provide an overview of the existing literature on IPNs in CRC patients.

MATERIALS AND METHODS

EMBASE, Pubmed and the Cochrane database were searched for papers published between January 2005 and April 2020. Studies describing the incidence of IPNs and the risk of malignancy in CRC patients and where the full text was available in the English language were considered for inclusion. Exclusion criteria included studies that used chest X-ray instead of CT, liver metastasis cohorts, studies with less than 60 CRC patients and reviews.

RESULTS

A total of 18 studies met the inclusion criteria, involving 8637 patients. Pooled analysis revealed IPNs on staging chest CT in 1327 (15%) of the CRC patients. IPNs appeared to be metastatic disease during follow up in 16% of these patients. Regional lymph node metastases, liver metastases, location of the primary tumour in the rectum, larger IPN size and multiple IPNs are the five most frequently reported parameters predicting the risk of malignancy of IPNs.

CONCLUSION

A risk stratification model for CRC patients with IPNs is warranted to enable an adequate selection of high risk patients for IPN follow up and to diminish the use of unnecessary repetitive chest CT-scans in the many low risk patients.

Early Systemic Failure After Preoperative Chemoradiotherapy for the Treatment of Patients With Rectal Cancer

Purpose

Distant metastasis can occur early after neoadjuvant chemoradiotherapy (CRT) in patients with rectal cancer. This study was conducted to evaluate the clinical characteristics of patients who developed early systemic failure.

Methods

The patients who underwent neoadjuvant CRT for a rectal adenocarcinoma between June 2007 and July 2015 were included in this study. Patients who developed distant metastasis within 6 months after CRT were identified. We compared short- and long-term clinicopathologic outcomes of patients in the early failure (EF) group with those of patients in the control group.

Results

Of 107 patients who underwent neoadjuvant CRT for rectal cancer, 7 developed early systemic failure. The lung was the most common metastatic site. In the EF group, preoperative carcinoembryonic antigen was higher (5 mg/mL vs. 2 mg/mL, P = 0.010), and capecitabine as a sensitizer of CRT was used more frequently (28.6% vs. 3%, P = 0.002). Of the 7 patients in the EF group, only 4 underwent a primary tumor resection (57.1%), in contrast to the 100% resection rate in the control group (P < 0.001). In terms of pathologic outcomes, ypN and TNM stages were more advanced in the EF group (P < 0.001 and P = 0.047, respectively), and numbers of positive and retrieved lymph nodes were much higher (P < 0.001 and P = 0.027, respectively).

Conclusion

Although early distant metastasis after CRT for rectal cancer is very rare, patients who developed early metastasis showed a poor nodal response with a low primary tumor resection rate and poor oncologic outcomes.

Expert consensus on multidisciplinary therapy of colorectal cancer with lung metastases (2019 edition)

The lungs are the second most common site of metastasis for colorectal cancer (CRC) after the liver. Rectal cancer is associated with a higher incidence of lung metastases compared to colon cancer. In China, the proportion of rectal cancer cases is around 50%, much higher than that in Western countries (nearly 30%). However, there is no available consensus or guideline focusing on CRC with lung metastases. We conducted an extensive discussion and reached a consensus of management for lung metastases in CRC based on current research reports and the experts' clinical experiences and knowledge. This consensus provided detailed approaches of diagnosis and differential diagnosis and provided general guidelines for multidisciplinary therapy (MDT) of lung metastases. We also focused on recommendations of MDT management of synchronous lung metastases and initial metachronous lung metastases. This consensus might improve clinical practice of CRC with lung metastases in China and will encourage oncologists to conduct more clinical trials to obtain high-level evidences about managing lung metastases.

Pre-operative staging of rectal cancer: a review of imaging techniques

INTRODUCTION

The treatment of rectal cancer has diversified in recent years, presenting the clinician and patient with increasingly challenging management decisions. At the heart of this decision-making process are two competing interests; more radical but more morbid treatments which optimize oncological outcome, and less radical treatments which preserve organs and function but may pose a greater risk of disease recurrence.

AREAS COVERED

Imaging plays a vital role informing this decision-making process, both by providing prognostic details about the cancer before the start of treatment and by updating this picture as the cancer responds or fails to respond to treatment. There is a range of available imaging modalities, each with its strengths and weaknesses. Optimizing rectal cancer treatment requires a clear understanding of the important questions that imaging needs to answer and the optimum imaging strategy. Expert Commentary: This article provides an evidence-based review of the available imaging techniques and an expert commentary on the best imaging strategy.

What is the Significance of Indeterminate Pulmonary Nodules in Patients Undergoing Resection for Pancreatic Adenocarcinoma?

OBJECTIVE

The significance of indeterminate pulmonary nodules (IPNs) in patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) is unknown. We sought to define the prevalence and impact of IPN in such patients.

METHODS

We studied all patients who underwent surgical resection of PDAC between 1980 and 2013. IPN was defined as ≥1 well-defined lung nodule(s) less than 3 cm in diameter. Survival was assessed using univariate and multivariate Cox models.

RESULTS

Of the 2306 resected patients, 374 (16.2 %) had a preoperative chest computed tomography (CT) scan. Of these patients, 183 (49 %) had ≥1 IPN. Demographic and clinicopathological characteristics were similar among patients with or without IPN (all P>0.05). Median survival was comparable among patients who did (15.6 months) or did not (18.0 months) have IPN (P=0.66). Of the 183 patients with IPN, 29 (16 %) progressed to clinically recognizable metastatic lung disease compared to 13 % without IPN (P=0.38). The presence of >1 IPN was associated with the development of lung metastasis (relative risk 1.58, 95 % CI 1.03-2.4; P=0.05). However, lung metastasis was not associated with survival (P=0.24).

CONCLUSIONS

An IPN proved to be a lung metastasis in only one of six patients with PDAC undergoing surgical resection in this study. Survival was not impacted, even among patients who developed lung metastasis. Patients with PDAC who have IPN should not be precluded from surgical consideration.

A nomogram predicting pulmonary metastasis of hepatocellular carcinoma following partial hepatectomy

BACKGROUND

Pulmonary metastasis (PM) following curative hepatectomy for hepatocellular carcinoma (HCC) is indicative of a poor prognosis. This study aimed to develop a nomogram to identify patients at high risks of PM.

METHODS

A primary cohort of patients who underwent curative hepatectomy for HCC at the Eastern Hepatobiliary Surgery Hospital from 2002 to 2010 was prospectively studied. A nomogram predicting PM was constructed based on independent risk factors of PM. The predictive performance was evaluated by the concordance index (c-index), calibration curve and decision curve analysis (DCA). During the study period, a validation cohort was included at the First Affiliated Hospital of Fujian Medical University.

RESULTS

Postoperative PMs were detected in 106 out of 620 and 45 out of 218 patients, respectively, in two cohorts. Factors included in the nomogram were microvascular invasion, serum alpha-fetoprotein, tumour size, tumour number, encapsulation and intratumoral CD34 staining. The nomogram had a c-index of 0.75 and 0.82 for the two cohorts for predicting PM, respectively. The calibration curves fitted well. In the two cohorts, the DCA demonstrated positive net benefits by the nomogram, within the threshold probabilities of PM >10%.

CONCLUSION

The nomogram was accurate in predicting PM following curative hepatectomy for HCC.