Prognostic factors in colorectal cancer: current status and new trends

Emergency surgery for complicated colorectal cancer in central Brazil

Objective to report clinical and pathological features of patients with colorectal cancer diagnosed during emergency abdominal surgery.

Methods records of 107 patients operated between 2006 and 2010 were reviewed.

Results there were 58 women and 49 men with mean age of 59.8 years. The most frequent symptoms were: abdominal pain (97.2%), no bowel movements (81.3%), vomiting (76.6%), and anorexia (40.2%). Patients were divided into five groups: obstructive acute abdomen (n = 68), obstructive acute perforation (n = 21), obstructive acute inflammation (n = 13), abdominal sepsis (n = 3), and severe gastrointestinal bleeding (n = 2). Tumors were located in the rectosigmoid (51.4%), transverse colon (19.6%), ascendent colon (12.1%), descendent colon (11.2%), and 5.6% of the cases presented association of two colon tumors (synchronic tumors). The surgical treatment was: tumor resection with colostomy (85%), tumor resection with primary anastomosis (10.3%), and colostomy without tumor resection (4.7%). Immediate mortality occurred in 33.4% of the patients. Bivariate analysis of sex, tumor location and stage showed no relation to death (p > 0.05%).

Conclusions colorectal cancer may be the cause of colon obstruction or perfuration in patients with nonspecific colonic complaints. Despite the high mortality rate, resection of tumor is feasible in most patients.

Investigation of clinicopathological parameters in emergency colorectal cancer surgery: a study of 67 patients

INTRODUCTION

The aim of the present study was to establish, having adjusted for case mix, the size of the differences in postoperative mortality and 5-year survival between patients presenting as an emergency with evidence of obstruction and perforation and the association of clinicopathological factors with mortality (bivariate analyses).

MATERIAL AND METHODS

The study included 67 patients who presented with colorectal cancer (CRC) between 2009 and 2013 in Iran. The mean age of the patients was 59.7 years. Of the 67 patients, 37 (55.22%) were male and 30 (44.77%) were female. Certain parameters that correlated with CRC and surgical treatment were investigated.

RESULTS

Our results showed that 46 (68.65%) patients had obstruction, while perforation was observed in 21 (31.34%) cases. Among the patients with obstruction, obstruction of the right colon was observed in 29 (43.28%) cases. There was no significant difference in mortality rate between right and left colonic obstruction. Based on the bivariate analyses, our findings showed that death of patients was significantly related to tumor grade (p = 0.02) and TNM staging (p = 0.026), but no association was found between other parameters and death, including age, sex, and tumor site.

CONCLUSIONS

Compared with patients who undergo elective surgery for colon cancer, those who present as an emergency with evidence of obstruction or perforation have higher postoperative mortality rates and poorer cancer-specific survival. Also, colorectal cancer patients with emergency surgery showed aggressive histopathology and an advanced stage.

Predictors of pathologic complete response after preoperative concurrent chemoradiotherapy of rectal cancer: a single center experience

Purpose:

To identify possible predictors of pathologic complete response (pCR) of rectal cancer after preoperative concurrent chemoradiotherapy (CCRT).

Materials and Methods:

We conducted a retrospective review of 53 patients with rectal cancer who underwent preoperative CCRT followed by radical surgery at a single center between January 2007 and December 2012. The median radiotherapy dose to the pelvis was 54.0 Gy (range, 45.0 to 63.0 Gy). Five-fluorouracil-based chemotherapy was administered via continuous infusion with leucovorin.

Results:

The pCR rate was 20.8%. The downstaging rate was 66%. In univariate analyses, poor and undifferentiated tumors (p = 0.020) and an interval of ≥7 weeks from finishing CCRT to surgery (p = 0.040) were significantly associated with pCR, while female gender (p = 0.070), initial carcinoembryonic antigen concentration of <5.0 ng/dL (p = 0.100), and clinical stage T2 (p = 0.100) were marginally significant factors. In multivariate analysis, an interval of ≥7 weeks from finishing CCRT to surgery (odds ratio, 0.139; 95% confidence interval, 0.022 to 0.877; p = 0.036) was significantly associated with pCR, while stage T2 (odds ratio, 5.363; 95% confidence interval, 0.963 to 29.877; p = 0.055) was a marginally significant risk factor.

Conclusion:

We suggest that the interval from finishing CCRT to surgery is a predictor of pCR after preoperative CCRT in patients with rectal cancer. Stage T2 cancer may also be an important predictive factor. We hope to perform a robust study by collecting data during treatment to obtain more advanced results.

Pathologic Assessment of Rectal Carcinoma after Neoadjuvant Radio(chemo)therapy: Prognostic Implications

Neoadjuvant radio(chemo)therapy is increasingly used in rectal cancer and induces a number of morphologic changes that affect prognostication after curative surgery, thereby creating new challenges for surgical pathologists, particularly in evaluating morphologic changes and tumour response to preoperative treatment. Surgical pathologists play an important role in determining the many facets of rectal carcinoma patient care after neoadjuvant treatment. These range from proper handling of macroscopic specimens to accurate microscopic evaluation of pathological features associated with patients' prognosis. This review presents the well-established pathological prognostic indicators and discusses challenging features in order to provide both surgical pathologists and treating physicians with a checklist that is useful in a neoadjuvant setting.

Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery

BACKGROUND

Self-expandable metallic stents (SEMS) are now regarded as an effective and safe intervention for malignant colorectal obstruction (MCO). However, manipulation of the tumor might lead to the spillage of tumor cells and result in distant metastases. We aimed to compare the long-term oncologic outcomes of SEMS as a bridge to surgery with those of emergency surgery for MCO.

METHODS

Between June 2005 and December 2011, 60 patients who underwent elective curative resection after endoscopic SEMS insertion were included in the "SEMS group". The SEMS group was matched to 180 patients who underwent emergency curative surgery for MCO during the same period ["Emergency surgery (ES) group"]. The clinicopathologic characteristics, recurrence-free survival (RFS), and overall survival (OS) were compared between the two groups.

RESULTS

There were no significant differences in demographics, tumor stage, location, and histology between the SEMS group and the ES group. The median follow-up times were 41.4 months (IQR, 22.2-60.0 months) for the SEMS group and 45.0 months (IQR, 20.9-68.1 months) for the ES group. The proportions of patients who received postoperative adjuvant chemotherapy were comparable (SEMS group vs. ES group, 68.3 % vs. 77.8 %; P = 0.210). The long-term prognosis did not significantly differ between two groups in either the 5-year RFS rate (79.6 % vs. 70.2 %; P = 0.218) or the 5-year OS rate (97.8 % vs. 94.3 %; P = 0.469).

CONCLUSIONS

Long-term oncologic outcomes of SEMS insertion as a bridge to surgery were comparable to those of primary curative surgery.

Randomized multicentre trial of gadoxetic acid-enhanced MRI versus conventional MRI or CT in the staging of colorectal cancer liver metastases

BACKGROUND

This multicentre international randomized trial compared the impact of gadoxetic acid-enhanced magnetic resonance imaging (MRI), MRI with extracellular contrast medium (ECCM-MRI) and contrast-enhanced computed tomography (CE-CT) as a first-line imaging method in patients with suspected colorectal cancer liver metastases (CRCLM).

METHODS

Between October 2008 and September 2010, patients with suspected CRCLM were randomized to one of the three imaging modalities. The primary endpoint was the proportion of patients for whom further imaging after initial imaging was required for a confident diagnosis. Secondary variables included confidence in the therapeutic decision, intraoperative deviations from the initial imaging-based surgical plan as a result of additional operative findings, and diagnostic efficacy of the imaging modalities versus intraoperative and pathological extent of the disease.

RESULTS

A total of 360 patients were enrolled. Efficacy was analysed in 342 patients (118, 112 and 112 with gadoxetic acid-enhanced MRI, ECCM-MRI and CE-CT respectively as the initial imaging procedure). Further imaging was required in 0 of 118, 19 (17.0 per cent) of 112 and 44 (39.3 per cent) of 112 patients respectively (P < 0.001). Diagnostic confidence was high or very high in 98.3 per cent of patients for gadoxetic acid-enhanced MRI, 85.7 per cent for ECCM-MRI and 65.2 per cent for CE-CT. Surgical plans were changed during surgery in 28, 32 and 47 per cent of patients in the respective groups.

CONCLUSION

The diagnostic performance of gadoxetic acid-enhanced MRI was better than that of CE-CT and ECCM-MRI as the initial imaging modality. No further imaging was needed in the gadoxetic acid-enhanced MRI group and comparison of diagnostic efficacy parameters demonstrated the diagnostic superiority of gadoxetic acid-enhanced MRI.

REGISTRATION NUMBER

NCT00764621(http://clinicaltrials.gov); EudraCT number: 2008-000583-16 (https://eudract.ema.europa.eu/).

Interval between Surgery and Radiation Therapy Is an Important Prognostic Factor in Treatment of Rectal Cancer

Purpose

The purpose of this study is to evaluate survival and prognostic factors for rectal cancer, including interval between surgery and radiation therapy after surgery, radiation therapy, and chemotherapy.

Materials and Methods

We conducted a retrospective study of 153 patients with rectal cancer who were treated with surgery, radiotherapy with/without chemotherapy at Keimyung University Dongsan Medical Center from January, 1988 to December, 2005. The study included 89 males and 64 females, with a median age of 56 years (range, 23 to 81 years). Tumor, node and metastasis (TNM) was I in 23 patients, II in 39, and III in 91. Radiation therapy was performed on pelvic fields using a median dose of 54 Gy five days per week, 1.8 Gy once per day. Ninety two patients were treated with radiotherapy, 43 with concurrent chemo-radiation therapy and 18 with sequential therapy after surgery. The median follow-up period was 52 months (range, 4 to 272 months). The interval between surgery and radiation was 1-25 weeks (median, 5 weeks).

Results

Two-year and five-year overall survival rate was 64.7% and 46.4%, respectively. Two-year and five-year disease-free-survival (DFS) rate was 58.6% and 43.1%, respectively. Median DFS was 39 months. Loco-regional failure was evident in 10.5% of patients, 8.4% had distant metastasis, and 9.2% had both. In multivariate analysis, TNM stage and interval between surgery and radiation therapy (≤5 weeks vs. >5 weeks; 95% confidence interval, 1.276 to 2.877; hazard ratio, 1.916; p=0.002) were significant prognostic factors of DFS.

Conclusion

Survival rates for rectal cancer after surgery, chemotherapy, and radiation therapy were similar to those reported in previous studies. Starting radiation therapy as soon as possible after surgery, especially within the first five weeks after surgery, is suggested.

Staging and survival of rectal cancer in Vila Nova de Gaia, Portugal

INTRODUCTION

In the county of Vila Nova de Gaia (northern Portugal) in the period of 2004-2006, there were an average of 35 new cases of colorectal cancer per 100,000 population, which constitutes one of the highest rates in the world. The latest research has shown that there are many differences between colon and rectal cancers, thereby justifying an independent approach.

PATIENTS AND METHODS

The study pertained to the period 1995-2004, by using the census of 1991 and 2001 for calculating specific rates. The 399 diagnosed cases of rectal cancer were drawn from a specialized and active cancer registry, oncological registry of Gaia. Overall survival was calculated using the Kaplan-Meier method and the curves were compared using a Log Rank test. The effect of topography and histological type on survival was obtained by controlling the stage disease, using a Cox proportional hazards regression model.

RESULTS

There was a slight predominance of males, with a ratio between sexes of 1 : 3. The 50% overall survival rate after 5 years increased over time. The localization of the tumour and the histological type, after adjusting by stage, were not significant factors in the prognosis.

CONCLUSION

Our study shows an increase in the number of cases over time, particularly in elderly women. The cumulative risk of having rectal cancer remains unchanged from 1981 to 2004. Unlike other studies, an increase in early lesions was not observed.

The impact of spontaneous tumour perforation on outcome following colon cancer surgery

OBJECTIVE

The impact of spontaneous tumour perforation on survival following surgery for colon cancer is unclear. This study compares survival outcomes for patients with perforated colonic cancer with stage-matched nonperforated cancer.

METHOD

A prospective histological database was searched for all patients undergoing resection for adenocarcinoma of the colon between 1996 and 2002. Patients with T4 cancer were selected and classified into those with spontaneous perforation at the tumour site and those with nonperforated tumour. Patients with synchronous colonic and rectal cancers, familial polyposis, inflammatory bowel disease, iatrogenic or remote colonic perforation were excluded. Histological variables were combined with clinical data obtained by case note review. Data were analysed for differences in demographics, histological variables, operative mortality, disease-free and overall survival. Multivariate analysis of factors predictive of overall survival in both groups was performed.

RESULTS

Of 960 patients identified, 52 patients had spontaneous tumour perforation and 82 patients served as the T-stage matched control group. Overall survival at 2 years was 47% and 54% and at 5 years was 28% and 33% for perforated and nonperforated cancers respectively. Patients with perforated cancers were more likely to present with metastatic disease and undergo emergency surgery with a higher 30-day mortality. There was a trend towards reduced overall survival in the perforated group (P = 0.06), but no difference in disease-free survival (P = 0.43). On multivariate testing, 'emergency surgery' and 'age >75 years' were the only independent predictors of mortality in the perforated and nonperforated group respectively.

CONCLUSION

Both perforated and nonperforated T4 colon cancers have a poor prognosis. Spontaneous perforation of the cancer is associated with reduced overall survival, due to higher 30-day mortality, but in itself does not appear to significantly impact on disease-free survival. Rather, it is the advanced oncological stage at which perforated cancers present that determines outcome.

Direct tumor invasion in colon cancer: correlation with tumor spread and survival

PURPOSE

This study examined the correlation between depth of local invasion in colon cancer and tumor spread and patient survival.

METHODS

A cohort of 796 patients with a complete set of TNM staging information following an elective resection for colon cancer was selected. The rates of lymph node and distant metastasis, tumor differentiation, and extramural venous invasion for different tumor (T) categories were compared. The effects of initial tumor (T) category on overall patient survival were studied.

RESULTS

The depth of local tumor invasion correlated strongly with nodal involvement (P = 0.0001), rates of extramural venous invasion (P = 0.0002), poor differentiation (P = 0.0001), and distant metastasis (P = 0.0001). Fifty-seven percent of the patients remained lymph node-negative and distant metastasis-negative irrespective of their depth of tumor invasion had no impact on overall survival (P = 0.49). For patients with lymph node or distant metastasis (43 percent), depth of tumor invasion had significant impact on overall survival (P = 0.001). Thirteen percent of T3N1, 33 percent of T3N2, 40 percent of T4N1, and 68.percent of T4N2 cases had distant metastasis at presentation.

CONCLUSION

Two types of colon cancer were observed: locally active and tendency to metastasize. For the latter, overall mortality and the risk of metastasis increased with depth of tumor invasion.

Correlação de fatores anatomopatológicos com a sobrevida de pacientes operados por adenocarcinoma colorretal

OBJETIVO: Avaliar a influência de fatores anatomopatológicos como prognóstico na sobrevida de pacientes operados de adenocarcinoma colorretal. MÉTODOS: Estudo tipo coorte histórica aberta, baseado na análise de 119 pacientes operados de adenocarcinoma colorretal com intenção curativa no Hospital Universitário Júlio Muller, no período de 1984 a 2002. Os dados foram obtidos dos prontuários médicos e de exames anatomopatológicos revisados, sendo submetidos à análise estatística de sobrevida em cinco anos pelo método de Kaplan & Méier. O reto foi o segmento mais acometido em 44,5% dos casos. O aspecto macroscópico tumoral predominante foi o ulcerado ou infiltrante (50,4%), com tamanhos entre 2 e 17 cm, sendo que a maioria dos tumores (64,7%) infiltrava até a camada serosa. O número médio de linfonodos analisados foi de 11,8(±7,3) por peça cirúrgica, indentificando-se nestes, 42,8% de metástases. A maioria dos tumores (85,4%) era bem ou moderadamente diferenciada. Foram observadas embolização angiolinfática e perineural em respectivamente 51,2% e 23,5%. RESULTADOS: Não houve significância estatística quanto a morfologia (p=0,87), tamanho do tumor (p=0,56) e grau de diferenciação celular (p=0,83). Os fatores que se correlacionaram com a sobrevida foram o sítio do tumor primário (p=0,04), a invasão angiolinfática intra-tumoral (p=0,02), invasão perineural (p<0,01), a infiltração das camadas (p=0,02), e o comprometimento linfonodal (p<0,01). CONCLUSÃO: A análise dos fatores anatomopatológicos mostrou correlação significativa da sobrevida com o sítio primário, a camada acometida, invasão perineural, invasão angiolinfática e comprometimento dos linfonodos.

Optimal pathologic staging: defining stage II disease

Tumor stage remains the most important determinant of prognosis in colorectal cancer and is the basis of all authoritative patient management guidelines. The pathologic assessment of stage II disease is especially critical because it may help to identify patients at additional risk for whom surgery alone may not be curative. Accurate analysis of regional lymph nodes, extent of tumor penetration, and circumferential resection margins constitute the most crucial issues. For assignment of pN0, adequacy of the surgical resection and thoroughness of the lymph node harvest from the resection specimen are both essential. The minimum number of lymph nodes has been variably determined to be between 12 and 18 for assignment of pN0, but the confidence level increases with increasing numbers of nodes examined. The ability of exhaustive analysis of sentinel lymph nodes using special techniques to substitute for an exhaustive lymph node harvest and standard node examination has not been definitively shown. Although special techniques may facilitate the identification of minute amounts of tumor (i.e., isolated tumor cells) in regional lymph nodes, the prognostic significance of such findings remains unclear. Additional stage-independent pathologic features that have been validated as adverse prognostic factors include involvement by tumor of mural lymphovascular channels, venous vessels, or the surgical resection margin of the operative specimen and high tumor grade. The presence of these features may help to identify patients for whom surgery alone will not be curative and adjuvant therapies may be appropriate.

Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review

BACKGROUND

Early diagnosis of colorectal cancer before the onset of symptoms improves survival. Once symptoms have occurred, however, the effect of delay on survival is unclear. We review here evidence on the relationship of diagnostic and therapeutic delay with survival in colorectal cancer.

METHODS

We conducted a systematic of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1962 and 2006 dealing with delay, survival and colon cancer. A meta-analysis was performed based on the calculation of the relative risk (RR) and on a model of random effects.

RESULTS

We identified 40 studies, representing 20,440 patients. Fourteen studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction, with tumours at stage C or D at the time of diagnosis, or who died 1-3 months after surgery); or because they studied only a portion of the delay. Of the 26 remaining studies, 20 showed no association between delay and survival. In contrast, four studies showed that delay was a factor contributing to better prognosis, and two showed that it contributed to poorer prognosis. There was no association between delay and survival when the colon and rectum were considered separately, when a multivariate analysis was performed, and when the effects of tumour stage and degree of differentiation were taken into account. To perform a meta-analysis, 18 additional studies were excluded, since the published articles did not specify the absolute numbers. In the remaining eight studies, the combined relative risk (RR) of delay was 0.92 (confidence interval (CI) 95%: 0.87-0.97).

CONCLUSIONS

The results of the review suggest that there is no association between diagnostic and therapeutic delay and survival in colorectal cancer patients. Colon and rectum should be assessed separately, and it is necessary to adjust for other relevant variables such as tumour stage.

Clinical and pathologic evaluation of patients with recurrence of colorectal cancer five or more years after curative resection

PURPOSE

This study was designed to evaluate the characteristics of recurrences that occur five or more years after curative resection for colorectal cancer.

METHODS

This study included a total of 352 patients who were confirmed as having recurrence after curative resection for colorectal cancer during the period from January 1995 to December 2000. Of the 352 patients, 231 had early recurrence (less than 2 years after operation), 103 had intermediate recurrence (2-5 years after operation), and 18 had late recurrence (more than 5 years after operation). The clinicopathologic findings of the patients with late recurrence were compared with those of the other two recurrence groups, with special reference to the pattern of recurrence.

RESULTS

The rate of late recurrence was 1.2 percent. In the late recurrence group, males outnumbered females by a ratio of 3.5:1 and the mean level of preoperative carcinoembryonic antigen was 4.5 ng/ml, whereas that of the early recurrence group was 30.5 ng/ml. All the lesions in the cases with late recurrence except one lesion were located in the left colon or rectum, the tumors were small-sized and polypoid, and well-differentiated adenocarcinomas were more frequently observed. Distant metastasis, especially lung metastasis, was most frequently observed.

CONCLUSIONS

Late recurrent colorectal cancer has some characteristics compared with early or intermediate recurrence. Although recurrence at more than five years postoperatively is not common, its possibility should be considered whenever performing follow-up, and surveillance for lung metastasis is recommended after more than five years of surgery.

[Survival and prognostic factors of colorectal adenocarcinoma: analytic multifactor review of 150 cases]

INTRODUCTION

Prognostic factors have a pivotal role in clinical oncology. They are helpful in the selection of treatment; provide insights into the disease process and the therapic response. The number of possibility useful prognosis factors in the colorectal cancer is large. This study attempts to observe the survival of colorectal adenocarcinoma and to find prognostic factors and other variables potentially associated with outcome of colorectal adenocarcinoma.

MATERIAL AND METHODS

It's a retrospective study based on 150 patients with colorectal adenocarcinoma from 1990 to 2002. There were 150 patients aged of 58 years (median 61 years) with 1.4 sex-ratio. 84 patients had colon adenocarcinoma and 66 patients had rectal adenocarcinoma. In histological exam the adenocarcinoma was well differenced in 69 cases (46%), and undifferentiated in 17 cases (18, 3%).

RESULTS

Locoregional extension was found in 18 cases and metastatic extension in 45 cases with hepatic metastasis in 37 cases and pulmonary metastasis in 8 cases. There were 6 cases of peritoneal localized carcinosis and 6 cases of ovary metastasis. There were 6 patients (4%) Dukes stage I TNM, 61 stage II (40, 7%), 51 stage III TNM (34%) and 32 patients stage IV TNM (34%). All patients had surgical curative resection associated with adjuvant chemotherapy in 60 cases of colon adenocarcinoma and preoperative radiotherapy in 33 cases of rectal adenocarcinoma. After a follow up of 46 months, 52 patients was died (10 operative mortality), 35 patients were lost of view and 63 patients were still alive at the point date. Median survival was 20 months with 95% confidence interval: (4, 2-7, 8). Overall one year and 5 years survival were respectively 92,8% and 26,3%. Various prognostic factors had been identified through univariate (Kaplan-Meier) then multivariate (Cox) analyze. In addition to the clinical factors, we found of significant prognostic value undifferentiated adenocarcinoma and an elevated value of serum carcinoembryonic antigen>5 ng/ml.

The mesenteric and antimesenteric location of colorectal cancer: the relationship with lymph nodes

AIM

Purpose of the study was to evaluate if the circumferential location of colorectal cancer may be identified as a possible prognostic factor. The hypothesis is that tumours located on the antimesenteric (AM) side could have a better prognosis than tumours located on the mesenteric (M) side.

METHODS

All patients undergoing curative resection for colorectal cancer were enrolled in the study. The specimens were sent to the pathologist to define the exact location of the tumour, the histological type, grading, T, N status as well as lymphatic, vascular and neural invasion, peritumoural lymphoid reaction, desmoplasia and microsatellite instability. Statistical analyses were performed using the test for proportions (with continuity correction), the Pearson Chi-square test and generalised linear models; p<0.05 were considered statistically significant.

RESULTS

From August 2000 to August 2002, 255 patients were enrolled in the study. There was a significantly higher incidence of tumours located on the M (101) compared with the AM (37) site (p<0.0001). M located tumours were associated with higher numbers of metastatic lymph nodes (N1 and N2; p-value=0.014), whereas AM tumours were associated with involved lymph nodes in only 5/37 (13.5%) of tumours. There was no statistically significant relation between AM versus M location and T status: the Pearson Chi-Square test showed that the lymph node involvement and the location (M versus AM) are not statistically independent variables (p-value=0.014).

CONCLUSIONS

Our preliminary results show that when M or AM tumour identification is possible, tumour location can be regarded as a prognostic factor. Further longer studies on recurrence rate and survival are required to validate these findings and the clinical usefulness of this putative prognostic factor.

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.

Pathologic prognostic factors in the recurrence of rectal cancer

For rectal cancer, local recurrence following surgical treatment is a grave complication that occurs in as many as 25% of cases. Pathological examination of the surgical resection specimen plays a primary role in assessing both the surgery- and tumor-related factors that contribute to the risk of recurrence. Among the tumor-related factors, stage has long been considered the single most accurate indicator of survival. However, recent evidence strongly suggests that the most powerful predictor of both local recurrence and overall outcome in the absence of distant metastatic disease is the macroscopic quality of the mesorectum in the resection specimen and the proximity of the tumor to the circumferential (radial) resection margin. Additional pathologic features have been shown to have stage-independent prognostic significance in colorectal cancer and may help to further define risk of adverse outcome. Such features include: tumor grade; histologic type; extent of extramural penetration by tumor; neural, venous, and/or lymphatic invasion; tumor border configuration; tumor budding; and host lymphoid response. The predictive value of tumor-specific molecular features is currently under investigation and may help to further improve prognostication and refine individual patient management in rectal cancer.

Primary prevention: phytoprevention and chemoprevention of colorectal cancer

Considering the various stages of carcinogenesis and the numerous tumor types and available chemoprevention agents, knowledge of the etiology and the type of cancer to be treated, or possibly prevented, and understanding of the mechanisms by which agents exert their chemoprevention benefits may provide for improved strategy in designing therapeutic regimens. Because cancer usually develops over a 10- to 20-year period, it may be necessary for some agents to be provided before or early in the initiation steps of carcinogenesis to have beneficial effects. On the other hand, some agents may be more suitable for CRC prevention if provided at a later stage of carcinogenesis. Gene array, genomics, and proteomics are useful tools in advancing our understanding of the molecular events involved in carcinogenesis and in identifying markers of risk and surrogate end-points for colorectal cancer progression. These techniques may also serve for screening, identifying, and providing treatment targets for high-risk patients populations. Treatment could be developed depending on a patient's individual needs and genomic tumor profile. Clinical markers and surrogate end-points should be considered, together with molecular measurements, to more accurately assess risk. NSAIDs and COXIBs are clinically recognized as chemoprevention agents, and clinical trials evaluating their efficacy are ongoing. Treatment protocols, including dose and timing, remain to be determined, however. DFMO may best be used in combination with other chemoprevention agents. Dietary fiber and calcium supplements, as part of an overall low-fat diet, may decrease CRC risk. Long-term compliance with this regimen may be necessary to effect a beneficial outcome. Folate holds promise but needs further investigation, especially because its beneficial effects may depend on cancer type. Phytochemicals have been identified as strong candidates for use as agents to prevent colorectal cancer in cell culture and in rodent models of carcinogenesis. Their potential as chemoprevention agents must be demonstrated in clinical trials. In vitro and animal studies indicated that combination therapy may be a promising strategy over the monotherapy approach; clinical trials addressing the safety and efficacy of some combinations (DFMO/sulindac, fiber/calcium) are underway. The gastrointestinal tract and other organs are constantly exposed to a mixture of potentially toxic compounds and molecules considered favorable to health. Homeostasis between stress-mediated by toxic compounds and defensive mechanisms, is key for the maintenance of health and the prevention of disease. Whereas aggressive pharmacologic treatment may be necessary for patients at high risk for cancer, dietary supplements may be useful for populations at normal risk. The message for cancer prevention in the general population may well remain: keep a balanced healthy diet, eating a variety from all food groups, as part of a healthy lifestyle that includes moderate exercise.

Serum arginase activity in postsurgical monitoring of patients with colorectal carcinoma

BACKGROUND

Colorectal carcinoma (CRC) is one of the most common malignancies. In the current work, the role of arginase as a diagnostic marker in patients with recurrent CRC and colorectal liver metastases (CRCLM) was studied.

METHODS

Arginase activity was monitored in serum from 40 patients with primary CRC and from 100 patients with CRCLM. Blood was taken before and after patients underwent tumor resection. Studies were conducted for 3 years.

RESULTS

Preoperative arginase activity in serum from patients with CRC and CRCLM was much greater compared with the arginase activity in serum from healthy control blood donors. One and two cut-off levels of increased arginase activity were observed in patients with CRC and CRCLM, respectively. After patients underwent tumor resection, the arginase activity decreased to normal values in both patients with CRC and patients with CRCLM. Activity levels remained low in patients who did not develop recurrent CRC or CRCLM (first or second). In patients who developed subsequent recurrences or metastases that appeared after surgery, during 3 years of surveillance, a significant rise in serum arginase activity was observed. The clinical prognosis for patients was worst when the postoperative serum arginase activity was very high, because those patients more often developed second liver metastases or died.

CONCLUSIONS

The authors conclude that the determination of serum arginase activity may be a complementary test to confirm the occurrence of CRC and may be useful for the early diagnosis of patients who develop recurrent CRC and/or CRCLM.

Potential roles of genetic biomarkers in colorectal cancer chemoprevention

Colorectal cancer is a significant cause of morbidity and mortality in industrialized societies and the second most frequent cause of cancer death in the United States. Surrogate endpoint biomarkers are gaining wide acceptance in early diagnosis and short-term cancer chemoprevention trials in place of cancer endpoints. Molecular genetic biomarkers can be useful tools in identifying subjects at risk of developing cancer and screening for early cancers amenable to complete cure. They may be useful both in predicting and assessing response to a given therapy and in determining prognosis after an initial diagnosis has been made. Ideally, biomarkers should fulfill some, if not all, of the following criteria: variability of expression between phases of carcinogenesis, association with cancer risk, ability to undergo modification in response to a chemopreventive agent, and finally, permit ease of measurement. In consideration of colorectal cancer chemoprevention, several genetic biomarkers seem to meet many of these criteria, as they do exhibit distinct variability of expression at different phases of carcinogenesis, are often strongly associated with increased cancer risk (especially the hereditary/familial syndromes), are generally able to be measured relatively easily through peripheral blood sampling (germline mutations) or by colonic mucosal sampling by endoscopic techniques (somatic mutations). In some cases, genetic biomarkers have also been demonstrated to undergo modification in response to a chemopreventive agent. With further understanding of the genetic and molecular changes involved in sporadic and familial colorectal carcinogenesis, genetic biomarkers appear to hold great potential for the identification of subjects at high risk of developing colorectal cancer, as well as the development of novel chemopreventive approaches and form a promising area for further research.

Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, the current state of knowledge regarding pathologic prognostic factors (factors linked to outcome) and predictive factors (factors predicting response to therapy) in colorectal carcinoma was evaluated. A multidisciplinary group of clinical (including the disciplines of medical oncology, surgical oncology, and radiation oncology), pathologic, and statistical experts in colorectal cancer reviewed all relevant medical literature and stratified the reported prognostic factors into categories that reflected the strength of the published evidence demonstrating their prognostic value. Accordingly, the following categories of prognostic factors were defined. Category I includes factors definitively proven to be of prognostic import based on evidence from multiple statistically robust published trials and generally used in patient management. Category IIA includes factors extensively studied biologically and/or clinically and repeatedly shown to have prognostic value for outcome and/or predictive value for therapy that is of sufficient import to be included in the pathology report but that remains to be validated in statistically robust studies. Category IIB includes factors shown to be promising in multiple studies but lacking sufficient data for inclusion in category I or IIA. Category III includes factors not yet sufficiently studied to determine their prognostic value. Category IV includes factors well studied and shown to have no prognostic significance.

MATERIALS AND METHODS

The medical literature was critically reviewed, and the analysis revealed specific points of variability in approach that prevented direct comparisons among published studies and compromised the quality of the collective data. Categories of variability recognized included the following: (1) methods of analysis, (2) interpretation of findings, (3) reporting of data, and (4) statistical evaluation. Additional points of variability within these categories were defined from the collective experience of the group. Reasons for the assignment of an individual prognostic factor to category I, II, III, or IV (categories defined by the level of scientific validation) were outlined with reference to the specific types of variability associated with the supportive data. For each factor and category of variability related to that factor, detailed recommendations for improvement were made. The recommendations were based on the following aims: (1) to increase the uniformity and completeness of pathologic evaluation of tumor specimens, (2) to enhance the quality of the data needed for definitive evaluation of the prognostic value of individual prognostic factors, and (3) ultimately, to improve patient care.

RESULTS AND CONCLUSIONS

Factors that were determined to merit inclusion in category I were as follows: the local extent of tumor assessed pathologically (the pT category of the TNM staging system of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer [AJCC/UICC]); regional lymph node metastasis (the pN category of the TNM staging system); blood or lymphatic vessel invasion; residual tumor following surgery with curative intent (the R classification of the AJCC/UICC staging system), especially as it relates to positive surgical margins; and preoperative elevation of carcinoembryonic antigen elevation (a factor established by laboratory medicine methods rather than anatomic pathology). Factors in category IIA included the following: tumor grade, radial margin status (for resection specimens with nonperitonealized surfaces), and residual tumor in the resection specimen following neoadjuvant therapy (the ypTNM category of the TNM staging system of the AJCC/UICC). (ABSTRACT TRUNCATED)

American Joint Committee on Cancer Prognostic Factors Consensus Conference: Colorectal Working Group

BACKGROUND

The American Joint Committee on Cancer (AJCC), which regularly reviews TNM staging systems, established a working party to develop recommendations for colorectal carcinoma.

METHODS

A multidisciplinary consensus conference using published literature developed an arbitrary classification system of prognostic marker value (Category I, IIA, IIB, III, and IV), which forms the framework for this report.

RESULTS

The working party concluded that several T categories should be subdivided: pTis into intraepithelial carcinoma (pTie) and intramucosal carcinoma (pTim); pT1 into pT1a and pT1b corresponding to the absence or presence of blood or lymphatic vessel invasion, respectively; and pT4 into pT4a and pT4b according to the absence or presence of tumor involving the surface of the specimen, respectively. The working party also recommended that TNM groups be stratified based on the presence or absence of elevated serum levels of carcinoembryonic antigen (CEA) (>/= 5 ng/mL) on preoperative clinical examination. In addition, the working party also concluded that carcinoma of the appendix should be excluded from the colorectal carcinoma staging system because of fundamental differences in natural history.

CONCLUSIONS

The TNM categories and stage groupings for colorectal carcinoma published in the current AJCC manual have clinical and academic value. However, a few categories require subdivision to provide increasing discrimination for individual patients. The serum marker CEA should be added to the staging system, whereas multiple other factors should be recorded as part of good clinical practice. Although many molecular and oncogenic markers show promise to supplement or modify the current staging systems eventually, to the authors' knowledge none have yet been evaluated sufficiently to recommend their inclusion in the TNM system.

Emergency admission for surgery predicts disease progression during adjuvant 5-Fluouracil (5-FU)-based chemotherapy

OBJECTIVE

To determine the prognostic significance of a number of variables in patients that receive adjuvant chemotherapy for colorectal cancer.

PATIENTS AND METHODS

We reviewed the Cancer Centre records of 194 patients who received adjuvant chemotherapy following potentially curative resection of Dukes' B or C colorectal cancer. Eight variables were examined to determine which factor(s) predicted disease progression during the 6-month chemotherapy period.

RESULTS

Admission for emergency resection (due to bowel obstruction or perforation) rather than elective resection, and a poorly differentiated tumour rather than moderately/well differentiated were independent significant factors in predicting disease progression (P < 0.001 and P=0.011, respectively). However, sex, age, Dukes' stage, number of involved lymph nodes, delays in starting chemotherapy and compliance with chemotherapy regime had no significant effect on 6-month tumour progression.

CONCLUSION

These preliminary findings confirm data which suggest that emergency admission patients may suffer from intrinsically more aggressive disease than the average population with colorectal cancer.

Prognostic factors in colorectal cancer. Literature review for clinical application

PURPOSE

Identification of prognostic factors is a primary basis for planning the treatment and predicting the outcome of patients with colorectal cancer. Reviewing studies from the literature performed using univariate and multivariate analyses and their own study, the authors critically discuss the prognostic value of the clinicopathologic parameters of the tumor.

METHODS

Among 853 patients with colorectal tumors seen at the Department of Clinical Surgery of the Catholic University of Rome, Italy, 690 cases that were curatively resected the study. Overall survival rate, related to the clinicopathologic variables, was calculated, and univariate and multivariate analyses were performed.

RESULTS

Five-year and ten-year overall survival rates were 70 and 55 percent, respectively. Univariate and multivariate analyses showed that node involvement, distant metastases, bowel obstruction, and patient gender are factors independently related to outcome.

CONCLUSIONS

Data from the literature and the present study suggest that only a few clinical parameters, particularly bowel obstruction, and some pathologic factors (tumor stage, vessels invasion, and tumor ploidy) are related to patient survival rate and are the most reliable prognostic criteria. In prospective clinical studies, any other new pathologic or molecular factors should be matched with these parameters to confirm their value in outcome prediction.

Adjuvant therapy for colorectal cancer: present and future perspectives

In recent years, adjuvant therapy for colorectal cancer has advanced considerably. This article reviews these advances and provides an update of the most recent and ongoing trials. In 1990, adjuvant therapy became the "standard of care" for patients with Stage III colon cancer (Dukes C) in the United States. Recent clinical trial data indicate that adjuvant treatment may also be effective in patients with Stage II (Dukes B2) colon cancer. The combination of 5-fluorouracil plus leucovorin may slightly improve survival (5-10 percent) compared with the standard 5-fluorouracil plus levamisole combination. The three-drug regimen (5-fluorouracil plus levamisole plus leucovorin) is more toxic, with no superior effect on survival. Intraportal chemotherapy, although it may significantly improve patient survival, does not decrease the frequency of liver metastases. However, it is still a promising form of adjuvant therapy owing to its short treatment period and relatively equivalent effects in survival compared with that of systemic therapy. For patients with Stage II or Stage III rectal cancer, postoperative systemic 5-fluorouracil plus radiation therapy plus protracted venous 5-fluorouracil infusion is the most effective postoperative adjuvant regimen. However, results from several studies show that preoperative radiation alone or chemoradiation for advanced local rectal cancers might also be effective while also improving resectability, decreasing morbidity, and increasing the chance that a sphincter-sparing procedure may be performed. The role of leucovorin in rectal cancer remains to be determined. Immune therapies with agents such as interferon-alpha-2a, monoclonal antibody 17-1A, and autologous tumor vaccines are being assessed and could further improve survival.

Incidence and patterns of recurrence following curative resection for colorectal carcinoma

PURPOSE

This study was designed to determine incidence and patterns of recurrence after curative resection of colorectal carcinoma and to determine which variables are significant in predicting outcome.

METHOD

A retrospective review of 524 patients operated on by one surgeon from 1975 to 1992 was conducted. Variables recorded included age, gender, location, gross morphology, histology, stage of each primary and evidence of perforation and direct extension at time of original operation. Overall survival and pattern of recurrence were documented.

RESULTS

Overall recurrence rate was 27.9 percent. Anastomotic recurrence rate was 11.7 percent. Anastomotic recurrences were higher for rectal than colon lesions (20.3 vs. 6.2 percent; P = 0.001). Distant metastases developed in 14.4 percent of patients, 13.9 percent for colon carcinoma and 15.5 percent for rectal carcinoma. Average time for anastomotic recurrence was 16.2 months vs. 22.9 months for distant disease. T1,2,N0,M0 lesions had a 17.6 percent recurrence rate, T3,N0,M0 was 23.4 percent, and T1,2,3,N1,M0 was 43.7 percent (P = .001). Patients who did not undergo any intervention after diagnosis of recurrence survived an average of 28 months. Those who received palliative treatment survived an average of 39 months. Twenty-four percent of patients had reresection for cure, and 47 percent of these patients were alive at a mean of 80 months; those who died of their disease did so at an average of 53 months. Positive predictive factors for recurrence include site of lesion (rectum vs. colon), stage, invasion of contiguous organs, and presence of perforation. Age, gender, degree of differentiation, mucin secretion, and gross morphology were not found to be predictive factors in this study.

CONCLUSIONS

Recurrence after resection for rectal carcinoma is higher than after colon carcinoma. In those patients in whom reresection is possible, up to 50 percent may have long-term survival. Understanding patterns of recurrence and features that predispose to them may guide the physician in aggressive but more selective adjuvant therapy and recommendations for targeted surveillance in follow-up.

Prognostic value of neural invasion in rectal carcinoma: a multivariate analysis on 339 patients with curative resection

To determine whether neural invasion or other clinico-pathological factors are prognostic, we performed a retrospective study on 339 rectal carcinomas. The overall 5-year survival was 62%. In the multivariate analysis, age over 60 years, a distance from the anal verge of less than 6 cm, the number of positive lymph nodes, neural invasion and tumour penetration were found to be prognostic. A scoring system identified five prognostic groups of patients. Neural invasion is an independent prognostic factor in our scoring system and it is suggested that this parameter should be taken into consideration for postsurgical treatment.

Staging gastrointestinal cancer as a precondition for multimodal treatment

Staging gastrointestinal cancer is useful only if it has an impact on treatment. When applying modern multimodal therapies (i.e., neoadjuvant, adjuvant, or additive treatment), meticulous staging is mandatory. Preoperative staging should include all relevant prognostic factors. If possible, modern cellular biology-related parameters should also be investigated, although their validity has not yet been analyzed properly. Using such modern techniques as endoluminal ultrasonography or video-laparoscopy, a preoperative diagnostic accuracy of 85% can be achieved, providing a sound foundation for therapeutic decisions. Assessment by TNM staging (UICC) and surgical resection without residual tumor (UICC/R0) are crucial, as it has been shown by multivariate analyses that these factors have the most impact on prognosis. Postoperative staging is mainly done by pathohistologic evaluation of the surgical specimen. It is the basis for any postoperative adjuvant or additive therapy. In this paper the diagnostic methods and their validity are discussed in relation to the various gastrointestinal tumors.

Current options in the management of gastrointestinal cancer

Surgery is the standard approach for localized gastrointestinal malignancy both in the upper GI tract and for cancer of the large bowel. Adjuvant chemotherapy following curatively resected colorectal cancer, results in a definite survival advantage. The use of chemotherapy in an attempt to downstage inoperable gastric cancer to allow for subsequent radical resection has yielded promising results. Likewise improved survival rate in patients treated with adjuvant chemotherapy after resection, justify further exploration of perioperative chemotherapy in operable gastric cancer. In squamous oesophageal cancer, modem chemo-radiation regimens are superior to radiotherapy alone in localized disease. Some series demonstrate impressive survival rates in the absence of surgical intervention raising the question as to the precise role of surgery in a combined modality approach. Ongoing randomized trials will clarify the relative contributions of these treatment modalities in the management of this disease. In metastatic disease of both upper GI and colonic tumours maintenance of good quality of life should be the primary endpoint. Randomised trials of chemotherapy against best supportive care have provided strong justification for the use of chemotherapy in the management of advanced gastric, pancreatic and colorectal cancer.