Incidence and patterns of recurrence following curative resection for colorectal carcinoma

Analysis of risk factors for postoperative recurrence of stage I colorectal cancer: a retrospective analysis of a large population

Background

Colorectal cancer (CRC) is the third most common cancer worldwide. Patients diagnosed with stage I CRC typically do not require postoperative adjuvant treatment. However, postoperative recurrence is present in at least 40% of patients with CRC and often occurs in those with stage I disease. This study aimed to elucidate the current status of recurrence and clinicopathological characteristics in patients with stage I CRC.

Methods

Data of indicated patients were obtained from 18 registries in Surveillance, Epidemiology, and End Results (SEER). The multivariable Fine-Gray regression model was used to identify the mortality risk of patients. Disparities in survival were analyzed using Kaplan-Meier curves. Logistic regression was employed to identify factors associated with recurrent risk overestimation.

Results

Our study indicated a recurrence rate of 15.04% (1,874/12,452) in stage I CRC cases. Notably, we identified race, age, T stage, and carcinoembryonic antigen (CEA) levels as independent risk factors for tumor recurrence, substantially impacting prognosis. Furthermore, gender, race (Black), age (>65 years), elevated CEA levels, and refusal or unknown status regarding radiotherapy significantly correlated with an adverse prognosis in patients with stage I CRC.

Conclusions

We identified certain key clinicopathological features of patients with stage I CRC and demonstrated the survival benefits of radiotherapy, offering a new perspective on stage I CRC follow-up and treatment recommendations.

Effectiveness and safety of intraoperative intraperitoneal 5-Fu drug implantation in patients with colorectal cancer: a retrospective cohort study

PURPOSE

The purpose of this clinical study was to evaluate the efficacy and safety of intraoperative chemotherapy (IOC) with intraoperative intraperitoneal implantation of 5-fluorouracil (5-FU) in colorectal cancer (CRC) patients.

METHODS

In this study, 165 patients who underwent colorectal radical surgery were selected, of whom 111 in the experimental group received surgical treatment with an intraperitoneal 5-fluorouracil (5-FU) implantation. Fifty-four patients who did not undergo intraperitoneal implantation of 5-FU were matched to compare the progression-free survival (PFS) and overall survival (OS) with the former.

RESULTS

We also studied the differences in the changes of different biochemical indicators between the two groups before and after surgery, and there were significant differences in leukocytes, neutrophils, and lymphocytes before and after (P < 0.05), while for sodium ions, potassium ions, platelets, alanine transaminase, aspartate transaminase, creatinine, urea, and albumin, there were no significant differences. This may be related to the intraperitoneal chemotherapy implant entering the blood circulation. For 5-year OS, there were 85/111 (76.58%) in the 5-FU group (P = 0.013) and 35/54 (64.81%) in the control group; for 5-year PFS, there were 84/111 (75.68%) in the 5-FU group and 29/54 (53.70%) in the control group (P = 0.02). All the experimental groups were better than the control group with a significant difference in the experimental results.

CONCLUSION

For CRC surgery patients, intraperitoneal implantation of slow-release 5-FU drugs, which is a safe and simple procedure, can improve the prognosis of the patients.

CLINICAL TRIAL REGISTRATION

No clinical trials were performed in the study.

KLF15 transcriptionally activates LINC00689 to inhibit colorectal cancer development

Colorectal cancer is a grievous health concern, we have proved long non-coding RNA LINC00689 is considered as a potential diagnosis biomarker for colorectal cancer, and it is necessary to further investigate its upstream and downstream mechanisms. Here, we show that KLF15, a transcription factor, exhibits the reduced expression in colorectal cancer. KLF15 suppresses the proliferative and metastatic capacities of colorectal cancer cells both in vitro and in vivo by transcriptionally activating LINC00689. Subsequently, LINC00689 recruits PTBP1 protein to enhance the stability of LATS2 mRNA in the cytoplasm. This stabilization causes the suppression of the YAP1/β-catenin pathway and its target downstream genes. Our findings highlight a regulatory network involving KLF15, LINC00689, PTBP1, LATS2, and the YAP1/β-catenin pathway in colorectal cancer, shedding light on potential therapeutic targets for colorectal cancer therapy.

Survival outcomes of lung metastases from colorectal cancer treated with pulmonary metastasectomy or modern systemic chemotherapy: a single institution experience

BACKGROUND

Although pulmonary metastasectomy is an accepted treatment strategy for resectable lung metastases (LM) from colorectal cancer (CRC), its survival benefits are controversial. In contrast, recent advancements in chemotherapy have significantly improved metastatic CRC prognosis. This study aimed to evaluate survival outcome of LM from CRC in the age of newly developed chemotherapy.

METHODS

We retrospectively reviewed 50 patients who underwent complete resection and 22 patients who received chemotherapy as definitive treatment for LM from resected CRC at our hospital. The present study was limited to patients who started treatment for isolated LM after molecular targeted drugs became available in Japan.

RESULTS

Overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS) rates after pulmonary resection were 64.5%, 66.4%, and 32.6% at five years, respectively. OS and CSS rates of chemotherapy patients were 26.8% and 28.3% at five years, with a median progression-free survival time of 10.0 months. When compared the characteristics of surgical and chemotherapy patients, patients with pN factors of CRC (p = 0.013), smaller size (p < 0.001), larger number (p < 0.001), and bilateral (p < 0.001) LM received chemotherapy. Univariate analysis showed that multiple LM and rectal lesions were poor prognostic factors for OS (p = 0.012) and DFS (p = 0.017) in surgical patients, and rectal lesions were a poor prognostic factor for OS (p = 0.013) in chemotherapy patients.

CONCLUSIONS

Pulmonary metastasectomy showed a favorable survival in patients with LM from CRC. Despite the high recurrence rate after metastasectomy and recent advances in chemotherapy, surgical resection could still be considered as a valid option among multidisciplinary treatments.

TRIAL REGISTRATION

The research plan was approved by the Institutional Review Board of Shinko Hospital (No. 2142) on February 7, 2022.

Impact of regional lymph node metastasis on pulmonary metastasis as the first recurrence site

Little is known about the impact of regional lymph node metastasis (LNM) on the first recurrence sites following curative colorectal cancer (CRC) surgery. The present study aimed to clarify the relationship between regional LNM stratified by N status and the first recurrence pattern in patients with stage I-III CRC. We performed a retrospective analysis of 1181 consecutive patients with stage I-III CRC who underwent curative surgery between 2010 and 2018. The total sample size included 1181 patients who underwent elective stage I-III CRC surgery. Median follow-up time was 60 months, and median time to recurrence was 12 months. Overall, the numbers of liver recurrence and pulmonary recurrence were 94 (7.9%) and 70 (5.9%), respectively. Higher N status was significantly associated with increased risk of pulmonary recurrence (N0 vs. N1a, p = 0.02; N0 vs. N1b, p < 0.01; N0 vs. N2a, p < 0.01; N0 vs. N2b, p < 0.01) and worse pulmonary recurrence-free survival, but not other recurrences. In Non-LNM patients, on the other hand, advanced T status was associated with increased risk of pulmonary recurrence. The regional LNM was strongly associated with pulmonary metastasis as the first recurrence site following stage I-III CRC resection.

Surveillance strategies following curative resection and non-operative approach of rectal cancer: How and how long? Review of current recommendations

Different follow-up strategies are available for patients with rectal cancer following curative treatment. A combination of biochemical testing and imaging investigation, associated with physical examination are commonly used. However, there is currently no consensus about the types of tests to perform, the timing of the testing, and even the need for follow-up at all has been questioned. The aim of this study was to review the evidence of the impact of different follow-up tests and programs in patients with non-metastatic disease after definitive treatment of the primary. A literature review was performed of studies published on MEDLINE, EMBASE, the Cochrane Library and Web of Science up to November 2022. Current published guidelines from the most authoritative specialty societies were also reviewed. According to the follow-up strategies available, the office visit is not efficient but represents the only way to maintain direct contact with the patient and is recommended by all authoritative specialty societies. In colorectal cancer surveillance, carcinoembryonic antigen represents the only established tumor marker. Abdominal and chest computed tomography scan is recommended considering that the liver and lungs are the most common sites of recurrence. Since local relapse in rectal cancer is higher than in colon cancer, endoscopic surveillance is mandatory. Different follow-up regimens have been published but randomized comparisons and meta-analyses do not allow to determine whether intensive or less intensive follow-up had any significant influence on survival and recurrence detection rate. The available data do not allow the drawing of final conclusions on the ideal surveillance methods and the frequency with which they should be applied. It is very useful and urgent for clinicians to identify a cost-effective strategy that allows early identification of recurrence with a special focus for high-risk patients and patients undergoing a “watch and wait” approach.

A bayesian approach to model the underlying predictors of early recurrence and postoperative death in patients with colorectal Cancer

Objective

This study aimed at utilizing a Bayesian approach semi-competing risks technique to model the underlying predictors of early recurrence and postoperative Death in patients with colorectal cancer (CRC).

Methods

In this prospective cohort study, 284 patients with colorectal cancer, who underwent surgery, referred to Imam Khomeini clinic in Hamadan from 2001 to 2017. The primary outcomes were the probability of recurrence, the probability of Mortality without recurrence, and the probability of Mortality after recurrence. The patients ‘recurrence status was determined from patients’ records. The Bayesian survival modeling was carried out by semi-competing risks illness-death models, with accelerated failure time (AFT) approach, in R 4.1 software. The best model was chosen according to the lowest deviance information criterion (DIC) and highest logarithm of the pseudo marginal likelihood (LPML).

Results

The log-normal model (DIC = 1633, LPML = -811), was the optimal model. The results showed that gender(Time Ratio = 0.764: 95% Confidence Interval = 0.456–0.855), age at diagnosis (0.764: 0.538–0.935 ), T₃ stage (0601: 0.530–0.713), N₂ stage (0.714: 0.577–0.935 ), tumor size (0.709: 0.610–0.929), grade of differentiation at poor (0.856: 0.733–0.988), and moderate (0.648: 0.503–0.955) levels, and the number of chemotherapies (1.583: 1.367–1.863) were significantly related to recurrence. Also, age at diagnosis (0.396: 0.313–0.532), metastasis to other sites (0.566: 0.490–0.835), T₃ stage (0.363: 0.592 − 0.301), T₄ stage (0.434: 0.347–0.545), grade of differentiation at moderate level (0.527: 0.387–0.674), tumor size (0.595: 0.500–0.679), and the number of chemotherapies (1.541: 1.332–2.243) were the significantly predicted the death. Also, age at diagnosis (0.659: 0.559–0.803), and the number of chemotherapies (2.029: 1.792–2.191) were significantly related to mortality after recurrence.

Conclusion

According to specific results obtained from the optimal Bayesian log-normal model for terminal and non-terminal events, appropriate screening strategies and the earlier detection of CRC leads to substantial improvements in the survival of patients.

Efficacy of various adjuvant chemotherapy methods in preventing liver metastasis from potentially curative colorectal cancer: A systematic review network meta-analysis of randomized clinical trials

PURPOSE

Various chemotherapy administration methods have been used to prevent liver metastasis (LM) in patients with colorectal cancer (CRC). This network meta-analysis evaluated the efficacy of these different methods in preventing LM in CRC patients who underwent curative surgery.

METHOD

A systematic search of randomized controlled trials reporting the efficacy of various adjuvant chemotherapy methods in patients with colorectal cancer who underwent curative surgery was conducted. The primary outcome was the LM rate.

RESULTS

This network meta-analysis included 19 studies reporting on 12,588 participants, comparing portal vein infusion chemotherapy (PVIC) versus hepatic arterial infusion chemotherapy (HAIC) versus systematic chemotherapy (SC) versus surgery alone. The HAIC group had the lowest LM rate when compared to the other three groups (odds ratio [OR] of PVIC vs. HAIC: 1.86; OR of SC vs. HAIC: 1.98; and HAIC vs. surgery alone: 0.43). The LM rate did not differ significantly between PVIC, SC, and surgery alone. The recurrence rates were lower for PVIC and HAIC than for surgery alone (the ORs for PVIC and HAIC were 0.73 [95% CI: 0.58-0.92] and 0.45 [95% CI: 0.26-0.77]). The mortality rates of patients undergoing PVIC and HAIC were lower than that of patients undergoing surgery alone (the ORs for PVIC and HAIC were 0.77 [95% CI: 0.64-0.93] and 0.49 [95% CI: 0.24-0.98]). Anastomotic leakage, cardiopulmonary leakage, diarrhea, nausea and vomiting, oral ulceration, wound infection, or ileus did not differ significantly between the four groups. PVIC showed the highest hepatic toxicity rate compared to those for SC, HAIC, and surgery alone.

CONCLUSION

HAIC might be a satisfactory method for preventing LM in patients with CRC undergoing curative surgery.

Transcriptome Profiling of HCT-116 Colorectal Cancer Cells with RNA Sequencing Reveals Novel Targets for Polyphenol Nano Curcumin

Colorectal cancer is one of the leading causes of cancer-related deaths worldwide. The gemini nanoparticle formulation of polyphenolic curcumin significantly inhibits the viability of cancer cells. However, the molecular mechanisms and pathways underlying its toxicity in colon cancer are unclear. Here, we aimed to uncover the possible novel targets of gemini curcumin (Gemini-Cur) on colorectal cancer and related cellular pathways. After confirming the cytotoxic effect of Gemini-Cur by MTT and apoptotic assays, RNA sequencing was employed to identify differentially expressed genes (DEGs) in HCT-116 cells. On a total of 3892 DEGs (padj < 0.01), 442 genes showed a log2 FC >|2| (including 244 upregulated and 198 downregulated). Gene ontology (GO) enrichment analysis was performed. Protein−protein interaction (PPI) and gene-pathway networks were constructed by using STRING and Cytoscape. The pathway analysis showed that Gemini-Cur predominantly modulates pathways related to the cell cycle. The gene network analysis revealed five central genes, namely GADD45G, ATF3, BUB1B, CCNA2 and CDK1. Real-time PCR and Western blotting analysis confirmed the significant modulation of these genes in Gemini-Cur-treated compared to non-treated cells. In conclusion, RNA sequencing revealed novel potential targets of curcumin on cancer cells. Further studies are required to elucidate the molecular mechanism of action of Gemini-Cur regarding the modulation of the expression of hub genes.

Dissection of Immune Profiles in Microsatellite Stable and Low Microsatellite Instability Colon Adenocarcinoma by Multiomics Data Analysis

Background

Although microsatellite instability (MSI) is an indicator for active immunotherapy response, only 15% of colon adenocarcinoma (COAD) patients are with MSI. An investigation into the immune profiles in low MSI (MSI-L) and microsatellite stable (MSS) COAD remains lacking, whereas such exploration may provide new insights into COAD immunity.

Methods

We hierarchically clustered MSI-L/MSS COAD based on the enrichment levels of 28 immune signatures to identify its immune-specific subtypes. We also comprehensively compared molecular and clinicopathologic profiles among these subtypes.

Results

We identified three immune subtypes of MSI-L/MSS COAD (IM-H, IM-M, and IM-L), which had high, medium, and low immune signature scores, respectively. We demonstrated that this subtyping method was reproducible and predictable by analyzing five different datasets, including four bulk tumor datasets and one single-cell dataset. IM-H was characterized by high immunity, high stemness, strong potential of proliferation, invasion and metastasis, epithelial-mesenchymal transition, elevated expression of oncogenic pathways, low tumor purity, low intratumor heterogeneity (ITH), genomic instability, inferior response to chemotherapy, and unfavorable prognosis. IM-M was characterized by the highest ratio of immunostimulatory to immunosuppressive signatures, the best response to chemotherapy, and favorable prognosis. IM-L was characterized by low immunity, high tumor purity, high ITH, and genomic stability.

Conclusion

The immune-specific subtyping of MSI-L/MSS COAD may provide new insights into the tumor immunity as well as clinical implications for immunotherapy of the COAD patients who lack MSI.

Suppressive effect of α-mangostin for cancer stem cells in colorectal cancer via the Notch pathway

Background

Since colon cancer stem cells (CSCs) play an important role in chemoresistance and in tumor recurrence and metastasis, targeting of CSCs has emerged as a sophisticated strategy for cancer therapy. α-mangostin (αM) has been confirmed to have antiproliferative and apoptotic effects on cancer cells. This study aimed to evaluate the selective inhibition of αM on CSCs in colorectal cancer (CRC) and the suppressive effect on 5-fluorouracil (5-FU)-induced CSCs.

Methods

The cell viability assay was performed to determine the optimal concentration of αM. A sphere forming assay and flow cytometry with CSC markers were carried out to evaluate the αM-mediated inhibition of CSCs. Western blot analysis and quantitative real-time PCR were performed to investigate the effects of αM on the Notch signaling pathway and colon CSCs. The in vivo anticancer efficacy of αM in combination with 5-FU was investigated using a xenograft mouse model.

Results

αM inhibited the cell viability and reduced the number of spheres in HT29 and SW620 cells. αM treatment decreased CSCs and suppressed the 5-FU-induced an increase in CSCs on flow cytometry. αM markedly suppressed Notch1, NICD1, and Hes1 in the Notch signaling pathway in a time- and dose-dependent manner. Moreover, αM attenuated CSC markers CD44 and CD133, in a manner similar to that upon DAPT treatment, in HT29 cells. In xenograft mice, the tumor and CSC makers were suppressed in the αM group and in the αM group with 5-FU treatment.

Conclusion

This study shows that low-dose αM inhibits CSCs in CRC and suppresses 5-FU–induced augmentation of CSCs via the Notch signaling pathway.

Identification of a 3-gene signature for predicting the prognosis of stage II colon cancer based on microsatellite status

Background

Though colon cancer (CC) is one of the most malignant tumors across the world, CC patients with microsatellite instability-high (MSI-H) in stage II seem to have a better prognosis. However, the molecular mechanisms underlying the phenomena haven't been elucidated yet.

Methods

This study enrolled 322 CCs with known microsatellite status from GSE143985, GSE39582 and GSE92921 in the Gene Expression Omnibus (GEO) database. Robust rank aggregation (RRA) analysis, univariate Cox regression analysis and multivariate Cox stepwise regression analysis were performed to identify genes and construct risk score signature. Kaplan-Meier and receiver operating characteristic (ROC) curves analyses were used to evaluate the prognostic value of the signature. The potential mechanisms underlying this signature were assessed in the Metascape database, gene set enrichment analysis (GSEA) and immune infiltration analysis.

Results

RRA analysis identified 40 differently expressed genes (DEGs). A 3-gene risk score signature (MKQ signature) associated with disease-free survival (DFS) was generated. DFS was significantly longer in CC patients with lower than higher scores (P=0.0046). The areas under curves (AUCs) of the time-dependent ROC curves of MKQ signature at 1-, 3- and 5-year DFS were 1, 0.963 and 0.961 respectively. Recurrence-free survival (RFS) was significantly longer in patients in GSE39582 with lower than higher risk scores (P=0.032). The AUCs for 1-, 3- and 5-year RFS in GSE39582 were 0.63, 0.618 and 0.583, respectively, validating the value of the MKQ signature. Functional annotation and GSEA revealed that the MKQ signature was associated with multiple immune-related pathways. Immune cell infiltration was found to differ in patients differing in the MKQ signature.

Conclusions

Gene expression and microsatellite status identified a 3-gene signature (MKQ signature) that could facilitate risk-stratified management in patients with stage II CC. Dysregulation of MSMB, KRT23, and QPRT can serve as prognostic markers in stage II CC.

Clinicopathological Features of Stage I-III Colorectal Cancer Recurrence Over 5 Years After Radical Surgery Without Receiving Neoadjuvant Therapy: Evidence From a Large Sample Study

Late recurrence (5 or more years) after radical resection of colorectal cancer (CRC) is rare. This study aims to investigate the features of late recurrence in stage I–III CRC. A total of 9,754 stage I–III patients with CRC who underwent radical surgery without receiving neoadjuvant therapy, at the Fudan University Shanghai Cancer Center (FUSCC), were enrolled in this study. These patients were divided into three groups: early recurrence (3 months−2 years), intermediate recurrence (2–5 years), and late recurrence (over 5 years). The median duration of follow-up was 53.5 ± 30.1 months. A total of 2,341 (24.0%) patients developed recurrence. The late recurrence rate was 11.7%. Patients with a higher risk of late recurrence were more likely to be older, to be at the T4 stage, to have a higher degree of colon cancer, to have a lower frequency of signet ring cell carcinoma, to have fewer poorly differentiated tumors, to be at the early stage of CRC, along with less perineural and vascular invasions. Multivariate logistic regression analysis identified age, differentiation, T stage, N stage, perineural, and vascular invasions as independent factors for late recurrence. Late recurrent CRC has some distinctive characteristics. Although recurrence over 5 years after surgery is infrequent, an enhanced follow-up is still needed for the selected patients after 5 years.

Development and validation of a novel miRNA classifier as a prognostic signature for stage II/III colorectal cancer

Background

The TNM staging remains the gold standard for determining the prognosis of patients with colorectal cancer (CRC), which is inadequate at identifying the subset of high-risk stage II and III patients that have a high potential of developing tumor recurrence and may experience death. Emerging evidence indicates that not only microRNAs (miRNAs) play important functional role in CRC development but may serve as important disease biomarkers. In this study we aimed to develop a miRNA-based classifier as a prognostic signature for improving the clinical outcome of patients with stage II/III CRC.

Methods

We performed a systematic and comprehensive discovery step to identify differentially expressed miRNAs in CRC. We subsequently determined the prognostic relevance of these miRNAs in stage II/III patients using qRT-PCR and developed a miRNA-based classifier for predicting disease-free survival (DFS) in a clinical cohort (n=186).

Results

Based upon miRNA expression profiling studies, we identified a panel of 10 miRNAs which are consistently differentially expressed in CRC vs. normal tissues. By using cox proportional hazard models, we then developed 6-miRNA-classifier (miR-183, -20a, -21, -195, -139 and -20a) to predict prognosis in clinical cohort, that had significantly superior predictive performance compared to other clinicopathological factors, and could successfully identify high-risk stage II and III CRC patients with poor prognosis [hazard ratio (HR) =2.16; P=0.0048]. In a multivariate analysis, this miRNA-based classifier emerged as an independent prognostic signature for poor DFS.

Conclusions

Our miRNA-based classifier is a reliable predictive tool for determining prognosis in patents with stage II/III CRC, and might be able to identify high-risk patients that are candidates for more targeted personalized clinical management and surveillance.

Metformin Inhibits the Urea Cycle and Reduces Putrescine Generation in Colorectal Cancer Cell Lines

The urea cycle (UC) removes the excess nitrogen and ammonia generated by nitrogen-containing compound composites or protein breakdown in the human body. Research has shown that changes in UC enzymes are not only related to tumorigenesis and tumor development but also associated with poor survival in hepatocellular, breast, and colorectal cancers (CRC), etc. Cytoplasmic ornithine, the intermediate product of the urea cycle, is a specific substrate for ornithine decarboxylase (ODC, also known as ODC1) for the production of putrescine and is required for tumor growth. Polyamines (spermidine, spermine, and their precursor putrescine) play central roles in more than half of the steps of colorectal tumorigenesis. Given the close connection between polyamines and cancer, the regulation of polyamine metabolic pathways has attracted attention regarding the mechanisms of action of chemical drugs used to prevent CRC, as the drug most widely used for treating type 2 diabetes (T2D), metformin (Met) exhibits antitumor activity against a variety of cancer cells, with a vaguely defined mechanism. In addition, the influence of metformin on the UC and putrescine generation in colorectal cancer has remained unclear. In our study, we investigated the effect of metformin on the UC and putrescine generation of CRC in vivo and in vitro and elucidated the underlying mechanisms. In nude mice bearing HCT116 tumor xenografts, the administration of metformin inhibited tumor growth without affecting body weight. In addition, metformin treatment increased the expression of monophosphate (AMP)-activated protein kinase (AMPK) and p53 in both HCT116 xenografts and colorectal cancer cell lines and decreased the expression of the urea cycle enzymes, including carbamoyl phosphate synthase 1 (CPS1), arginase 1 (ARG1), ornithine trans-carbamylase (OTC), and ODC. The putrescine levels in both HCT116 xenografts and HCT116 cells decreased after metformin treatment. These results demonstrate that metformin inhibited CRC cell proliferation via activating AMPK/p53 and that there was an association between metformin, urea cycle inhibition and a reduction in putrescine generation.

Effect and safety of intraoperative intraperitoneal chemotherapy on patients suffering from colorectal cancer

Background

Colorectal cancer (CRC), the third most commonly diagnosed malignant carcinoma and the third most common cause of carcinoma-related mortality, continues to be a major international health problem. And approximately 33% of patients suffer from recurrence after radical surgery. Free malignant cell implanting in the peritoneum is generally accepted as one of the main reasons of such outcome. We did this present clinical study with the aim of evaluating the effects and safety of intraoperative intraperitoneal chemotherapy (IOC) on patients suffering from colorectal cancer, with hoping to find a novel, effective, and available approach to deal with malignant cell implanting during surgeries.

Methods

In total, 391 patients who went through colorectal radical surgery were considered eligible between June 1, 2017, and December 31, 2018. 220 patients were treated with surgery without IOC, while other 171 patients received surgery plus IOC. Clinical characteristics, operative findings, postoperative short-term outcomes, disease-free survival (DFS), and overall survival (OS) were compared between these above 2 groups in the selected population.

Result

The present research included 391 patients (251 men and 140 women) who underwent surgery without IOC (n = 171) or surgery plus IOC (n = 220), with a mean (SD) age of 60.4 (9.7) years in the surgery without IOC group and 60.6 (8.7) in the surgery plus IOC group (P=.85). No significant differences were witnessed between the two groups in surgery-related information and postoperative complications. It is worth noting that IOC independent of other factors was associated with a favor prognosis in CRC patients with stage II/III (HR 0.50, 95%CI 0.30–0.82, P=.006). Moreover, for patients with stage II colorectal carcinoma, DFS did not differ between two groups (P=.553, Kaplan-Meier log-rank), and OS was no exception. In stage III CRC patients, the estimated DFS rate for patients receiving IOC was 82.2% and patients without IOC was 66.4% after 3 years, which demonstrated that IOC was associated with a favorable prognosis in stage III patients (P=.012, Kaplan-Meier log-rank). Furthermore, the differences were still remained between the two groups when considering the influence about postoperative chemotherapy (P=.014, Kaplan-Meier log-rank). IOC can also significantly improve patients’ overall survival whether they get treatment with POC (P=.006, Kaplan-Meier log-rank; P=.025, Kaplan-Meier log-rank).

Conclusions

In the present study, we have found that surgery plus IOC generated a favorable prognosis for stage III CRC patients but not stage II without any side-effects when the dosage of lobaplatin was 0.1g/L. As a new, safe, and simple procedure, IOC therapy is easily performed—and does not require any special devices or techniques. Thus, IOC is a promising and exciting therapeutic strategy for patients with CRC.

Emerging trends in colorectal cancer: Dysregulated signaling pathways (Review)

Colorectal cancer (CRC) is the third most frequently detected type of cancer, and the second most common cause of cancer‑related mortality globally. The American Cancer Society predicted that approximately 147,950 individuals would be diagnosed with CRC, out of which 53,200 individuals would succumb to the disease in the USA alone in 2020. CRC‑related mortality ranks third among both males and females in the USA. CRC arises from 3 major pathways: i) The adenoma‑carcinoma sequence; ii) serrated pathway; and iii) the inflammatory pathway. The majority of cases of CRC are sporadic and result from risk factors, such as a sedentary lifestyle, obesity, processed diets, alcohol consumption and smoking. CRC is also a common preventable cancer. With widespread CRC screening, the incidence and mortality from CRC have decreased in developed countries. However, over the past few decades, CRC cases and mortality have been on the rise in young adults (age, <50 years). In addition, CRC cases are increasing in developing countries with a low gross domestic product (GDP) due to lifestyle changes. CRC is an etiologically heterogeneous disease classified by tumor location and alterations in global gene expression. Accumulating genetic and epigenetic perturbations and aberrations over time in tumor suppressor genes, oncogenes and DNA mismatch repair genes could be a precursor to the onset of colorectal cancer. CRC can be divided as sporadic, familial, and inherited depending on the origin of the mutation. Germline mutations in APC and MLH1 have been proven to play an etiological role, resulting in the predisposition of individuals to CRC. Genetic alterations cause the dysregulation of signaling pathways leading to drug resistance, the inhibition of apoptosis and the induction of proliferation, invasion and migration, resulting in CRC development and metastasis. Timely detection and effective precision therapies based on the present knowledge of CRC is essential for successful treatment and patient survival. The present review presents the CRC incidence, risk factors, dysregulated signaling pathways and targeted therapies.

Joint modelling of colorectal cancer recurrence and death after resection using multi-state model with cured fraction

Curing of colorectal cancer (CRC) occurs at the time of resection but it is not immediately observable. If the cancer is not completely eliminated, the patient will not be cured of cancer and will experience recurrence as the tumor has regrown to a detectable size. The main propose of the present study was to assess the effects of different covariates on the probability of being cured as well as the time-to-recurrence, and time-to-death in CRC patients by using multi-state cure model. The information of 283 patients with CRC, who underwent resection, from 2000 to 2015 in Imam Khomeini Hospital of Hamadan, Iran, were analyzed. The results of multi-state cure model reveal that females and who experience metastasis were more likely to be apparently cured. It has been shown that sex has a significant effect on the time-to-recurrence given patient was in the not cured group. The survival time of patients of the not cured group was affected by the stage of disease. However, the survival of the apparently cured patients were affected by age at diagnosis and metastasis status. The multi-state cure model provided a flexible framework to study the effects of prognostic factors simultaneously on the transition between different states and the probability of being apparently cured of CRC.

Prognostic Significance of Preoperative Fibrinogen-to-Prealbumin Ratio in Patients with Stage I-III Colorectal Cancer Undergoing Surgical Resection: A Retrospective Cohort Study

Background

The objective of this study was to explore the role of preoperative fibrinogen-to-prealbumin ratio (FPR) in evaluating the prognosis of patients with stage I–III colorectal cancer (CRC).

Methods

This retrospective study enrolled 584 stage I–III CRC patients undergoing surgical resection. Logistic regression analysis was used to explore the correlation between FPR and postoperative complications. The Kaplan-Meier curve and Cox proportional hazards model were used to identify the prognostic factors. The nomograms were constructed based on the prognostic factors. The concordance index and calibration curve were used to determine the accuracy of the nomograms. Time-dependent receiver operating characteristic was used to compare the predictive prognostic efficacy of nomograms and TNM stage.

Results

FPR was determined to be an independent factor affecting postoperative complications. Patients with a low-FPR had a significantly better prognosis than those with a high-FPR (disease-free survival, p = 0.028; overall survival, p = 0.027), especially patients with stage I CRC (disease-free survival, p = 0.015; overall survival, p = 0.017). The Cox proportional hazards model identified FPR as an independent poor prognostic factor of disease-free survival (hazard ratio (HR) = 1.459, 95% confidence interval (CI) = 1.074–1.954, p = 0.011) and overall survival (HR = 1.405, 95% CI = 1.034–1.909, p = 0.030). The prognostic nomograms had good accuracy and were superior to the traditional TNM stage.

Conclusions

FPR is a potential indicator for predicting short- and long-term prognosis of stage I–III CRC patients undergoing surgical resection.

Metachronous peritoneal metastases following curative resection for colon cancer: Understanding risk factors and patterns of recurrence

BACKGROUND

A subset of metachronous colon cancer recurrence manifests as peritoneal metastases (PM). Risk factors for metachronous PM recurrence are not well-defined in patients with stage II or III colon cancers after curative resection and standard adjuvant treatments.

METHODS

Population data from the California Cancer Registry for patients with Stage II or III colon cancer were collected between 2004 and 2012. Multivariate analysis was used to identify factors associated with metachronous PM.

RESULTS

Of the 2077 patients with stage II or III colon cancer, female patients (odds ratio [OR] = 1.84, p = 0.02), T4 primary tumor (OR = 2.36, p = 0.02), mucinous (OR = 3.97, p < 0.01) or signet-ring histology (OR = 6.01, p = 0.01), and right-sided cancer (OR = 2.2, p < 0.01) were found with increased risk of metachronous isolated PM recurrence after curative resection. Median survival after diagnosis for patients without PM recurrence was 22 months, compared with 12 months for PM recurrence (p < 0.001).

CONCLUSION

PM recurrence groups have a worse overall survival than patients with recurrent disease in other sites. A better understanding of the tumor biology and molecular characteristics of colon cancers likely to recur as PM is needed to explain behavior and identify potential targeted therapy.

Metachronous metastasis confined to isolated lymph node after curative treatment of colorectal cancer

BACKGROUND

The incidence of lymph node metastasis (LNM) in colorectal cancer is known to be 2-6%, but little data are available regarding metachronous metastasis confined to isolated LN. The aim of this study is to determine the distribution of isolated LNM and the risk factors for survival of isolated LNM in colorectal cancer.

METHODS

We retrospectively reviewed consecutive patients with colorectal adenocarcinoma between January 2008 and December 2015 at a tertiary referral center. A total of 5902 patients with biopsy-proven colorectal adenocarcinoma treated via surgery were included. Multivariate Cox proportional hazards analysis was used to identify prognostic factors for overall survival.

RESULTS

Of the 5902 patients, recurrent cases were 1326. Among the relapsed patients, 301 patients had isolated LNM (22.69%). Para-aortic (48.8%), pelvic (29.9%), and Lung hilum (10.0%) were the most common sites of isolated LNM; there were statistically significant differences in the distribution of isolated LNM between the colon and rectal cancer (p = 0.02). Approximately 80% of isolated LNM were diagnosed within 3 years. Multidisciplinary therapy for LNM, diagnosis time to LNM, the T-stage, and histological type of primary cancer were identified as independent prognostic factors for overall survival.

CONCLUSION

This study suggests that multidisciplinary management is a potentially effective treatment strategy for isolated LNM. Since time to LNM, the T-stage, and histological type are prognostic factors, an active follow-up program for colorectal cancer is required.

DSTYK Promotes Metastasis and Chemoresistance via EMT in Colorectal Cancer

Objective

Tumor metastasis and resistance to chemotherapy are two critical factors that contribute to the high death rate of colorectal cancer (CRC) patients. Metastasis is facilitated by the epithelial-mesenchymal transition (EMT) of tumor cells, which has emerged not only as a fundamental process during metastasis, but is also a key process leading to chemoresistance of cancer cells. However, the underlying mechanisms of EMT in CRC cell remain unknown. Here, we aim to assess the role of dual serine/threonine and tyrosine protein kinase (DSTYK) in CRC metastasis and chemoresistance.

Methods

To study the role of DSTYK in TGF-β-induced EMT, we employed techniques including Crispr/Cas9 knockout (KO) to generate DSTYK KO cell lines, RT-PCR to detect the mRNA expression, immunofluorescence analyses, and western blots to detect protein levels of DSTYK in the following 4 cell lines: control LS411N-TβRII and LS411N-TβRII/DSTYK KO, control LS513 and LS513/DSTYK KO cells, treated with/without TGF-β. The effects of DSTYK on apoptosis were investigated by MTT assays, flow cytometry assays, and TUNEL assays. The expression of DSTYK in CRC patients and its correlation with EMT markers were determined by bioinformatics analysis. For in vivo analysis, both xenograft and orthotopic tumor mouse models were employed to investigate the function of DSTYK in chemoresistance and metastasis of tumors.

Results

In this study, we demonstrate that the novel kinase DSTYK promotes both TGF-β-induced EMT and the subsequent chemoresistance in CRC cells. DSTYK KO significantly attenuates TGF-β–induced EMT and chemoresistance in CRC cells. According to the Gene Expression Omnibus (GEO) database, the expression of DSTYK is not only positively correlated to the expression of TGF-β, but proportional to the death rate of CRC patients as well. Evidently, the expression of DSTYK in the metastatic colorectal cancer samples from patients was significantly higher than that of primary colorectal cancer samples. Further, we demonstrate in mouse models that chemotherapeutic drug treatment suppresses the growth of DSTYK KO tumors more effectively than control tumors.

Conclusion

Our findings identify DSTYK as a novel protein kinase in regulating TGF-β–mediated EMT and chemoresistance in CRC cells, which defines DSTYK as a potential therapeutic target for CRC therapy.

Personalized Adjuvant Treatment of Colon Cancer

Introduction

Colon cancer (CC) is one of the most frequent malignant diseases. Adjuvant chemotherapy is of utmost importance in the management of localized disease. With the emergence of precision medicine, treatment approaches are becoming increasingly personalized and complex. This review contributes to a broader understanding of the role and relevance of personalized adjuvant treatment strategies in colon carcinoma, and summarizes the current status in this disease entity.

Methods

We searched the websites ClinicalTrials.gov, PubMed, and ASCO (American Society of Medical Oncology) Meeting Library for clinical trials and retrospective analyses in the field of adjuvant treatment of CC with special attention to personalized approaches.

Results

Various factors, including gender, age, sidedness, stage, dMMR/MSI-H, mutations, molecular profile, CMS, immunoscore, minimal residual disease, type of adjuvant therapy, therapy duration, and the patient's wish play an important role in the adjuvant setting of CC and should be considered in treatment decision making.

Conclusion

Future molecular profiling ideally assessed and monitored by liquid biopsy might personalize decision making even more in the adjuvant setting of CC patients. Further research and clinical trials are needed to clarify relevant questions and to highlight important clinical aspects.

Curative-intent surgery for isolated locoregional recurrence of colon cancer: Review of the literature and institutional experience

BACKGROUND

Locoregional recurrence of colon cancer (LRCC) following curative resection is an underreported clinical entity, especially regarding isolated LRCC which is amenable for surgery. The purpose of this study was to review the literature on incidence of LRCC and surgical treatment with corresponding outcome, and to describe an institutional experience with curative-intent surgery, whether or not as part of a multimodality approach.

METHODS

The PubMed and Medline literature databases 1978-2017 were searched and retrieved articles were assessed for eligibility. Based on a prospectively maintained database since 2010 at a tertiary referral center, original patient files were retrospectively reviewed.

RESULTS

Systematic literature review resulted in 11 studies reporting on incidence of LRCC, which ranged from 3.1% to 19.0% before 2010, and from 4.4% to 6.7% in three most recent studies. Twelve identified studies reported on outcome of surgically treated LRCC, with a median survival of 30 and 33 months in the two largest studies. The institutional database entailed 17 patients who underwent resection of isolated LRCC between 2010 and 2018. Median time to recurrence was 19 months. After a median follow-up after resection of LRCC of 20 months, 7 patients had died, 9 patients were alive without evidence of disease and 1 patient with evidence of disease; Median DFS was 36 months and 3-year OS was 65%.

CONCLUSION

Locoregional recurrence of colon cancer occurs in about 5% in most recent series, of whom selected patients are eligible for surgical treatment, with a fair chance of long-term disease control.

Efficacy of adjuvant cytokine-induced killer cell immunotherapy in patients with colorectal cancer after radical resection

Adjuvant chemotherapy after surgery is the standard treatment modality for stage III and part of stage II or stage IV colorectal cancer (CRC) patients. However, the 5-year overall survival (OS) rate remains unsatisfactory. Thus, developing combination therapies is essential to improve the prognosis of patients with CRC. The present study aimed to determine the effect of a sequential combination of cytokine-induced killer cell (CIK) infusion and chemotherapy for patients with CRC. 122 patients with CRC treated with postoperative adjuvant chemotherapy were retrospectively included in this study. Among them, 62 patients received adjuvant chemotherapy only (control group), while the other 60 patients, with similar demographic and clinical characteristics, received adjuvant chemotherapy and sequential CIK cell immunotherapy (CIK group). Survival analysis showed significantly improved disease free survival (DFS) and OS rates in the CIK group compared with the control group (log-rank test, P = .0024; P = .008, respectively). Univariate and multivariate analyses indicated that sequential CIK cell treatment was an independent prognostic factor for patients’ DFS and OS. Subgroup analyses showed that sequential CIK cell treatment significantly improved the DFS and OS of patients with high-risk T4 stage and insufficient chemotherapy duration. In conclusion, these data indicate that sequential adjuvant CIK cell treatment combined with chemotherapy is an effective therapeutic strategy to prevent disease recurrence and prolong survival of patients with CRC, particularly for patients with high-risk T4 stage and insufficient chemotherapy duration.

Curcumin and colorectal cancer: An update and current perspective on this natural medicine

Colorectal cancer (CRC) is one of most common malignancies worldwide and its incidence is still growing. In spite of recent advances in targeted therapies, their clinical efficacy has been limited, non-curative and unaffordable. A growing body of literature indicates that CRC is a multi-modal disease, where a variety of factors within the tumor microenvironment play a significant role in its pathogenesis. For instance, imbalance in gut microbial profiles and impaired intestinal barrier function contribute to the overall intestinal inflammation and initiation of CRC. Moreover, persistent chronic inflammation favors a tumor microenvironment for the growth of cancer. In addition, autophagy or 'self-eating' is a surveillance mechanism involved in the degradation of cellular constituents that are generated under stressful conditions. Cancer stem cells (CSCs), on the other hand, engage in the onset of CRC and are able to endow cancer cells with chemo-resistance. Furthermore, the aberrant epigenetic alterations promote CRC. These evidences highlight the need for multi-targeted approaches that are not only safe and inexpensive but offer a more effective alternative to current generation of targeted drugs. Curcumin, derived from the plant Curcuma longa, represents one such option that has a long history of its use for a variety of chronic disease including cancer, in Indian ayurvedic and traditional Chinese medicine. Scientific evidence over the past few decades have overwhelmingly shown that curcumin exhibits a multitude of anti-cancer activities orchestrated through key signaling pathways associated with cancer. In this article, we will present a current update and perspective on this natural medicine - incorporating the basic cellular mechanisms it effects and the current state of clinical evidence, challenges and promise for its use as a cancer preventative and potential adjunct together with modern therapies for CRC patients.

3-month versus 6-month adjuvant chemotherapy for patients with high-risk stage II and III colorectal cancer: 3-year follow-up of the SCOT non-inferiority RCT

BACKGROUND

Oxaliplatin and fluoropyrimidine chemotherapy administered over 6 months is the standard adjuvant regimen for patients with high-risk stage II or III colorectal cancer. However, the regimen is associated with cumulative toxicity, characterised by chronic and often irreversible neuropathy.

OBJECTIVES

To assess the efficacy of 3-month versus 6-month adjuvant chemotherapy for colorectal cancer and to compare the toxicity, health-related quality of life and cost-effectiveness of the durations.

DESIGN

An international, randomised, open-label, non-inferiority, Phase III, parallel-group trial.

SETTING

A total of 244 oncology clinics from six countries: UK (England, Scotland, Wales and Northern Ireland), Denmark, Spain, Sweden, Australia and New Zealand.

PARTICIPANTS

Adults aged ≥ 18 years who had undergone curative resection for high-risk stage II or III adenocarcinoma of the colon or rectum.

INTERVENTIONS

The adjuvant treatment regimen was either oxaliplatin and 5-fluorouracil or oxaliplatin and capecitabine, randomised to be administered over 3 or 6 months.

MAIN OUTCOME MEASURES

The primary outcome was disease-free survival. Overall survival, adverse events, neuropathy and health-related quality of life were also assessed. The main cost categories were chemotherapy treatment and hospitalisation. Cost-effectiveness was assessed through incremental cost comparisons and quality-adjusted life-year gains between the options and was reported as net monetary benefit using a willingness-to-pay threshold of £30,000 per quality-adjusted life-year per patient.

RESULTS

Recruitment is closed. In total, 6088 patients were randomised (3044 per group) between 27 March 2008 and 29 November 2013, with 6065 included in the intention-to-treat analyses (3-month analysis, n = 3035; 6-month analysis, n = 3030). Follow-up for the primary analysis is complete. The 3-year disease-free survival rate in the 3-month treatment group was 76.7% (standard error 0.8%) and in the 6-month treatment group was 77.1% (standard error 0.8%), equating to a hazard ratio of 1.006 (95% confidence interval 0.909 to 1.114; p-value for non-inferiority = 0.012), confirming non-inferiority for 3-month adjuvant chemotherapy. Frequent adverse events (alopecia, anaemia, anorexia, diarrhoea, fatigue, hand-foot syndrome, mucositis, sensory neuropathy, neutropenia, pain, rash, altered taste, thrombocytopenia and watery eye) showed a significant increase in grade with 6-month duration; the greatest difference was for sensory neuropathy (grade ≥ 3 was 4% for 3-month vs.16% for 6-month duration), for which a higher rate of neuropathy was seen for the 6-month treatment group from month 4 to ≥ 5 years (p < 0.001). Quality-of-life scores were better in the 3-month treatment group over months 4-6. A cost-effectiveness analysis showed 3-month treatment to cost £4881 less over the 8-year analysis period, with an incremental net monetary benefit of £7246 per patient.

CONCLUSIONS

The study achieved its primary end point, showing that 3-month oxaliplatin-containing adjuvant chemotherapy is non-inferior to 6 months of the same regimen; 3-month treatment showed a better safety profile and cost less. For future work, further follow-up will refine long-term estimates of the duration effect on disease-free survival and overall survival. The health economic analysis will be updated to include long-term extrapolation for subgroups. We expect these analyses to be available in 2019-20. The Short Course Oncology Therapy (SCOT) study translational samples may allow the identification of patients who would benefit from longer treatment based on the molecular characteristics of their disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN59757862 and EudraCT 2007-003957-10.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 64. See the NIHR Journals Library website for further project information. This research was supported by the Medical Research Council (transferred to NIHR Evaluation, Trials and Studies Coordinating Centre - Efficacy and Mechanism Evaluation; grant reference G0601705), the Swedish Cancer Society and Cancer Research UK Core Clinical Trials Unit Funding (funding reference C6716/A9894).

The long-term survival characteristics of a cohort of colorectal cancer patients and baseline variables associated with survival outcomes with or without time-varying effects

BACKGROUND

Colorectal cancer is the third most common cancer in the world. In this study, we assessed the long-term survival characteristics and prognostic associations and potential time-varying effects of clinico-demographic variables and two molecular markers (microsatellite instability (MSI) and BRAF Val600Glu mutation) in a population-based patient cohort followed up to ~ 19 years.

METHODS

The patient cohort included 738 incident cases diagnosed between 1999 and 2003. Cox models were used to analyze the association between the variables and a set of survival outcome measures (overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), metastasis-free survival (MFS), recurrence/metastasis-free survival (RMFS), and event-free survival (EFS)). Cox proportional hazard (PH) assumption was tested for all variables, and Cox models with time-varying effects were used if any departure from the PH assumption was detected.

RESULTS

During the follow-up, ~ 61% patients died from any cause, ~ 26% died from colorectal cancer, and ~ 10% and ~ 20% experienced recurrences and distant metastases, respectively. Stage IV disease and post-diagnostic recurrence or metastasis were strongly linked to risk of death from colorectal cancer. If a patient had survived the first 6 years without any disease-related event (i.e., recurrence, metastasis, or death from colorectal cancer), their risks became very minimal after this time period. Distinct sets of markers were associated with different outcome measures. In some cases, the effects by variables were constant throughout the follow-up. For example, MSI-high tumor phenotype and older age at diagnosis predicted longer MFS times consistently over the follow-up. However, in some other cases, the effects of the variables varied with time. For example, adjuvant radiotherapy treatment was associated with increased risk of metastasis in patients who received this treatment after 5.5 years post-diagnosis, but not before that.

CONCLUSIONS

This study describes the long-term survival characteristics of a prospective cohort of colorectal cancer patients, relationships between baseline variables and a detailed set of patient outcomes over a long time, and time-varying effects of a group of variables. The results presented advance our understanding of the long-term prognostic characteristics in colorectal cancer and are expected to inspire future studies and clinical care strategies.

Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma

Aims and background

Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1-5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients.

Methods

Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes.

Results

Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis.

Conclusions

Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.

Combination of 5-fluorouracil and thymoquinone targets stem cell gene signature in colorectal cancer cells

Cancer stem cells (CSCs) residing in colorectal cancer tissues have tumorigenic capacity and contribute to chemotherapeutic resistance and disease relapse. It is well known that the survival of colorectal CSCs after 5-fluorouracil (5-FU)-based therapy leads to cancer recurrence. Thus CSCs represent a promising drug target. Here, we designed and synthesized novel hybrid molecules linking 5-FU with the plant-derived compound thymoquinone (TQ) and tested the potential of individual compounds and their combination to eliminate colorectal CSCs. Both, Combi and SARB hybrid showed augmented cytotoxicity against colorectal cancer cells, but were non-toxic to organoids prepared from healthy murine small intestine. NanoString analysis revealed a unique signature of deregulated gene expression in response to the combination of TQ and 5-FU (Combi) and SARB treatment. Importantly, two principle stem cell regulatory pathways WNT/ß-Catenin and PI3K/AKT were found to be downregulated after Combi and hybrid treatment. Furthermore, both treatments strikingly eliminated CD133+ CSC population, accompanying the depleted self-renewal capacity by eradicating long-term propagated 3D tumor cell spheres at sub-toxic doses. In vivo xenografts on chicken eggs of SARB-treated HCT116 cells showed a prominent nuclear ß-Catenin and E-cadherin staining. This was in line with the reduced transcriptional activity of ß-Catenin and diminished cell adhesion under SARB exposure. In contrast to 5-FU, both, Combi and SARB treatment effectively reduced the angiogenic capacity of the remaining resistant tumor cells. Taken together, combination or hybridization of single compounds target simultaneously a broader spectrum of oncogenic pathways leading to an effective eradication of colorectal cancer cells.

Computational analysis of mRNA expression profiles identifies a novel triple-biomarker model as prognostic predictor of stage II and III colorectal adenocarcinoma patients

Introduction

Although remarkable progress has been made to determine the prognosis of patients with colorectal cancer (CRC), it is inadequate to identify the subset of high-risk TNM stage II and stage III patients that have a high potential of developing tumor recurrence and may experience death. In this study, we aimed to develop biomarkers as a prognostic signature for the clinical outcome of CRC patients with stage II and stage III.

Materials and methods

We performed a systematic and comprehensive discovery step to identify recurrence-associated genes in CRC patients through publicly available GSE41258 (n=253) and GSE17536 (n=107) datasets. We subsequently determined the prognostic relevance of candidate genes in stage II and III patients and developed a triple-biomarker for predicting RFS in GSE17536, which was later validated in an independent cohort GSE33113 dataset (n=90).

Results

Based upon mRNA expression profiling studies, we identified 45 genes which differentially expressed in recurrent vs non-recurrent CRC patients. By using Cox proportional hazard models, we then developed a triple-marker model (THBS2, SERPINE1, and FN1) to predict prognosis in GSE17536, which successfully identified poor prognosis in stage II and stage III, particularly high-risk stage II CRC patients.

Discussion

Notably, we found that our triple-marker model once again predicted recurrence in stage II patients in GSE33113. Kaplan-Meier survival analysis demonstrated that patients with high scores have a poor outcome compared to those with low scores. Our triple-marker model is a reliable predictive tool for determining prognosis in CRC patients with stage II and stage III, and might be able to identify high-risk patients that are candidates for more targeted personalized clinical management and surveillance.

Use of a biological mesh for the treatment of perineal fistula following radical colorectal resection

Patients with postradiation therapy for malignancies and/or extensive colorectal surgery are prone to the development of enteroperineal fistulas. Application of biological meshes may prove beneficial in treating complicated enteroperineal fistulas as they provide a stable ground for closing pelvic defects even in contaminated fields.

Selected proliferation markers correlated with dynamics of growth in colorectal cancer

For treatment of metastatic colorectal cancer, the dynamics of tumor growth is an important factor for treatment decision. However, it is difficult to evaluate the dynamics of tumor growth, especially those of synchronous metastatic diseases. This study aimed to find some indicators related to tumor proliferation to judge the dynamics of tumor progression. The pathological reports and clinical data of 1205 patients with metastatic colorectal cancer were retrospectively reviewed; 75 patients with known relapse time after radical resection were included, and the expression of proliferation-associated proteins was detected by immunohistochemistry. Relapse-free time (RFT) from radical resection to relapse was obtained to analyze the relationship with expression of these factors. Kaplan-Meier univariate analysis showed that the overexpression of cyclin D1 and epidermal growth factor receptor (EGFR) and late pathological stage after surgery indicated shorter RFT. Multivariate analysis showed that EGFR and the stage were independent predictors of RFT. Expression of EGFR and cyclin D1 and the pathological stage were included as combination risk factors for RFT analysis; more risk factors were correlated with shorter RFT. EGFR and cyclin D1 seemed to be indicators of the dynamics of tumor growth, and overexpression of those molecules may suggest rapid growth and poor prognosis.

Colon cancer with perforation

Perforation of the colon is a rare complication for patients with colon cancer and usually requires emergent surgery. The characteristics of perforation differ based on the site of perforation, presenting as either perforation at the cancer site or perforation proximal to the cancer site. Peritonitis due to perforation tends to be more severe in cases of perforation proximal to the cancer site; however, the difference in the outcome between the two types remains unclear. Surgical treatment of colon cancer with perforation has changed over time. Recently, many reports have shown the safety and effectiveness of single-stage operation consisting of resection and primary anastomosis with intraoperative colonic lavage. Under certain conditions, laparoscopic surgery can be feasible and help minimize the invasion. However, emergent surgery for colon cancer with perforation is associated with a high rate of mortality and morbidity. The long-term prognosis seems to have no association with the existence of perforation. Oncologically curative resection may be warranted for perforated colon cancer. In this report, we perform a literature review and investigate the characteristics and surgical strategy for colon cancer with perforation.

Clinical Significance of Preoperative Serum Sialic Acid Levels in Colorectal Cancer: Utility in the Detection of Patients at High Risk of Tumor Recurrence

This study was conducted to evaluate the significance of preoperative serum sialic acid levels in the diagnosis and prognosis of colorectal cancer (CRC). Total sialic acid (TSA) was determined by the thiobarbituric acid method and normalized to total protein (TP). A postoperative follow-up of CRC patients classified as Dukes’ stages A, B or C was performed and survival analysis was carried out to evaluate the impact of sialic acid levels on tumor recurrence. Our diagnostic studies indicate that TSA/TP is a better marker than either TSA or carcinoembryonic antigen (CEA), especially for the detection of CRC patients at an early stage. At a cutoff of 30.90 nmol/mg of protein, TSA/TP showed a sensitivity of 85% with a specificity of 97% to discriminate CRC patients from healthy donors. In survival analysis, both TSA and TSA/TP were found to be significant prognostic factors for tumor recurrence in CRC. Furthermore, TSA/TP could distinguish patients at high risk of recurrence within Dukes’ stage B and in multivariate analysis it was identified as the best independent prognostic factor. According to our results, preoperative serum TSA/TP content could supply additional information to that provided by Dukes’ stage about the prognosis of CRC patients.

Improved anti-tumor efficacy via combination of oxaliplatin and fibrin glue in colorectal cancer

Colorectal cancer is very common worldwide and advanced colorectal cancer exhibited very poor clinical outcome. Oxaliplatin (OXP) is one of the principal chemotherapeutic agents in colorectal cancer treatment presenting impressive anti-tumor ability, limited by adverse effect in clinical practice. Fibrin glue (FG) is a biocompatible formulation made of fibrinogen and thrombin, extensively used in surgery for hemostasis, tissue adhesion and sealing. In this study, FG was innovatively applied as OXP delivery system and results showed enhanced anti-tumor performance in subcutaneous model and abdominal metastasis model of murine colorectal cancer compared with that of OXP used alone. It is revealed that combination of OXP and FG could increase activated CD8⁺ T cells, reduce regulatory T (Treg) cells and increase interferon-γ (IFN-γ). Furthermore, results showed promoted tumor apoptosis, decreased proliferation and inhibited tumor angiogenesis by OXP and FG combination. No obvious systemic toxicity was observed in this study. Finally, our findings provided basis for promising application of OXP and FG combination in colorectal cancer treatment.

Identification of Key Genes in Colorectal Cancer Regulated by miR-34a

Background

The aim of this study was to screen the molecular targets of miR-34a in colorectal cancer (CRC) and construct the regulatory network, to gain more insights to the pathogenesis of CRC.

Material/Methods

The microarray data of CRC samples and normal samples (GSE4988), as well as CRC samples transformed with miR-34a and non-transfected CRC samples (GSE7754), were downloaded from the Gene Expression Omnibus (GEO) database. The differently expressed genes (DEGs) were identified via the LIMMA package in R language. The Database for Annotation, Visualization and Integrated Discovery (DAVID) was used to identify significant Gene Ontology (GO) terms and pathways in DEGs. The targets of miR-34a were obtained via the miRWalk database, and then the overlaps between them were selected out to construct the regulatory network of miR-34a in CRC using the Cytoscape software.

Results

A total of 392 DEGs were identified in CRC samples compared with normal samples, including 239 upregulated genes and 153 downregulated ones. These DEGs were enriched in 75 GO terms and one Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway. At the same time, 332 DEGs (188 upregulated and 144 downregulated) were screened out between miR-34a transformed CRC and miR-34a non-transfected CRC samples and they were enriched in 20 GO terms and eight KEGG pathways. Six overlapped genes were identified in two DEGs groups. There were 1,668 targets of miR-34a obtained via the miRWalk database, among which 21 were identified differently expressed in miR-34a transformed CRC samples compared with miR-34a non-transfected CRC samples. Two regulatory networks of miR-34a in CRC within these two groups of overlapped genes were constructed respectively.

Conclusions

Pathways related to cell cycle, DNA replication, oocyte meiosis, and pyrimidine metabolism might play critical roles in the progression of CRC. Several genes such as SERPINE1, KLF4, SEMA4B, PPARG, CDC45, and KIAA0101 might be the targets of miR-34a and the potential therapeutic targets of CRC.

CD133-targeted oncolytic adenovirus demonstrates anti-tumor effect in colorectal cancer

Oncolytic Adenoviruses (OAds) are one of the most promising anti-cancer agents that can induce cancer specific cell death. Recently, we generated infectivity-selective OAd, and the resultant OAd tumor-specific binding shows strong efficacy and mitigates toxicity. In this study, we applied this strategy based on adenovirus library screening system for generation of CD133-targeted OAd, and examined their oncolytic activity against colorectal cancer (CRC) in vitro and in vivo. CD133 (Prominin-1) is an important cell surface marker of cancer stem (like) cells (CSCs) in various cancers, including CRC. Elimination of CSCs has a high likelihood to improve CRC treatment because CSCs population in the tumor contributes to recurrence, metastases, chemotherapy resistance, and poor survival. The OAd with CD133-targeting motif (AdML-TYML) selectively infected CD133⁺ cultured cells and lysed them efficiently. Treatment with AdML-TYML prior to tumor inoculation inhibited the establishment of tumor of CD133⁺ CRC cell lines in nude mice. AdML-TYML also showed strong antitumor effect after intratumoral injections in already established CD133⁺ CRC subcutaneous xenografts. Our results indicate that CD133-targeted OAd selectively infected CD133⁺ CRC, and exhibited anti-tumorigenicity and therapeutic effect in established tumors. This novel infectivity selective virus could be a potent tool for the prevention of metastases and relapses in CRC.

CD133-targeted oncolytic adenovirus demonstrates anti-tumor effect in colorectal cancer

Oncolytic Adenoviruses (OAds) are one of the most promising anti-cancer agents that can induce cancer specific cell death. Recently, we generated infectivity-selective OAd, and the resultant OAd tumor-specific binding shows strong efficacy and mitigates toxicity. In this study, we applied this strategy based on adenovirus library screening system for generation of CD133-targeted OAd, and examined their oncolytic activity against colorectal cancer (CRC) in vitro and in vivo. CD133 (Prominin-1) is an important cell surface marker of cancer stem (like) cells (CSCs) in various cancers, including CRC. Elimination of CSCs has a high likelihood to improve CRC treatment because CSCs population in the tumor contributes to recurrence, metastases, chemotherapy resistance, and poor survival. The OAd with CD133-targeting motif (AdML-TYML) selectively infected CD133+ cultured cells and lysed them efficiently. Treatment with AdML-TYML prior to tumor inoculation inhibited the establishment of tumor of CD133+ CRC cell lines in nude mice. AdML-TYML also showed strong antitumor effect after intratumoral injections in already established CD133+ CRC subcutaneous xenografts. Our results indicate that CD133-targeted OAd selectively infected CD133+ CRC, and exhibited anti-tumorigenicity and therapeutic effect in established tumors. This novel infectivity selective virus could be a potent tool for the prevention of metastases and relapses in CRC.

Descriptive characteristics of colon and rectal cancer recurrence in a Danish population-based study

BACKGROUND

Recurrence is a common outcome among patients that have undergone an intended curative resection for colorectal cancer. However, data on factors that influence colorectal cancer recurrence are sparse. We report descriptive characteristics of both colon and rectal cancer recurrence in an unselected population.

MATERIAL AND METHODS

We identified 21,152 patients with colorectal cancer diagnosed between May 2001 and December 2011 and registered with the Danish Colorectal Cancer Group. Recurrences were identified in 3198 colon and 1838 rectal cancer patients during follow-up. We calculated the frequency, proportion, and incidence rates of colon and rectal cancer recurrence within descriptive categories, and the cumulative five- and ten-year incidences of recurrence, treating death as a competing risk. We used a Cox proportional hazard model to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Recurrence risk was highest in the first three years of follow-up. Patients <55 years old at initial diagnosis (incidence rate for colon: 7.2 per 100 person-years; 95% CI: 6.5-7.9; rectum: 8.1 per 100 person-years; 95% CI: 7.2-9.0) and patients diagnosed with stage III cancer (colon HR: 5.70; 95% CI: 4.61-7.06; rectal HR: 7.02; 95% CI: 5.58-8.82) had increased risk of recurrence. Patients diagnosed with stage III cancer from 2009 to 2011 had a lower incidence of recurrence than those diagnosed with stage III cancer in the years before. Cumulative incidences of colon and rectal cancer recurrence were similar for both cancer types among each descriptive category.

CONCLUSIONS

In this population, increases in colorectal cancer recurrence risk were associated with younger age and increasing stage at diagnosis. Cumulative incidence of recurrence did not differ by cancer type. Descriptive characteristics of colon and rectal cancer recurrence may help to inform patient-physician decision-making, and could be used to determine adjuvant therapies or tailor surveillance strategies so that recurrence may be identified early, particularly within the first 3 years of follow-up.

Prognostic value of positron emission tomography/computed tomography for adjuvant chemotherapy of colon cancer

BACKGROUND

To assess the prognostic value of preoperative ¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with high-risk stage II or stage III colon cancer who underwent FOLFOX chemotherapy.

METHODS

The study included 166 patients with high-risk stage II or stage III colon cancer who received FOLFOX4 chemotherapy. Retrospective patient data were analysed including pathological stage, histology, disease-free survival (DFS) and the maximum standardized uptake value (SUV_max ) of the primary tumour on ¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography. The primary end point was DFS.

RESULTS

There were recurrences in 29 of the 166 patients (17.4%). Measuring the area under the receiver operating characteristic curve, the cut-off value of SUV_max with maximum sensitivity and specificity was 10.95. Using the Kaplan-Meier method, the DFS of the patients categorized by SUV_max tended to differ (P = 0.055). In univariate analyses, the risk factors for DFS were age over 70 years, higher N stage and neural invasion. SUV_max ≤ 10.95 showed a tendency, but was not significant (P = 0.0604). In multivariate analyses, the risk factors for DFS were age over 70 and neural invasion.

CONCLUSIONS

The results of this study suggest that high fluorodeoxyglucose uptake of the primary mass in high-risk stage II and stage III colon cancer does not significantly correlate with DFS.

Local recurrences at the anastomotic area are clonally related to the primary tumor in sporadic colorectal carcinoma

PURPOSE

Anastomotic recurrences (AR) occur in 2-10% of colorectal carcinoma cases after resection of primary tumor (PT). Currently, there are no molecular data investigating their genetic profile and multiple theories exist about their pathogenesis. The aim of our study was to compare the genomic profile of AR to that of the patients' corresponding matched PT and, when available, to a distant metastasis (DM).

EXPERIMENTAL DESIGN

Thirty-six tumors from 14 patients were genotyped using a capture-based, next-generation assay to define the mutational status of 341 cancer-associated genes. All patients had R0 resection of their PT and AR occurred 1.1-7.0 years following PT resection. A DM or a second AR was analyzed in 8 patients. All tumors were microsatellite stable except in one patient with Lynch syndrome.

RESULTS

A total of 254 somatic mutations were detected including 138 mutations in the microsatellite stable (MSS) cases. The most commonly mutated genes were APC, KRAS, TP53, PIK3CA, ATM and PIK3R1. In all patients with MSS tumors the AR and PT shared between 50-100% of mutations, including mutations in key driver genes, consistent with these tumors being clonally related. Genetic events private to DM were not detected in AR and phylogenetic analysis showed that ARs were more closely related to PT than DM. In the Lynch syndrome patient the PT and AR showed distinct somatic mutations consistent with independent primaries.

CONCLUSIONS

ARs are clonally related to PT in sporadic colorectal carcinomas and do not appear to represent seeding of the anastomotic site by distant metastases.

Combined Detection of Preoperative Neutrophil-to-Lymphocyte Ratio and CEA as an Independent Prognostic Factor in Nonmetastatic Patients Undergoing Colorectal Cancer Resection Is Superior to NLR or CEA Alone

Objective

To explore the role of combined detection of carcinoembryonic antigen (CEA) and neutrophil-to-lymphocyte ratio (NLR) in the prognostic assessment of colorectal cancer (CRC).

Methods

We investigated preoperative NLR and CEA in 125 surgical CRC patients, determined the patients' thresholds by receiver operating characteristic (ROC) curve analysis, and assessed their prognostic values by Kaplan–Meier curve and Cox regression models. In addition, we used nomograms of several risk factors to evaluate the risk in survival and predictive accuracy by using Harrell's concordance index (c-index).

Results

Results of multivariate analysis showed high NLR, high CEA, and high COCN (combination of CEA and NLR) were significantly correlated with decreased disease-free survival (DFS) [HR: 2.229, 95% CI: 1.012–4.911, and P = 0.047; HR: 3.652, 95% CI: 1.630–8.179, and P = 0.002; HR: 3.139, 95% CI: 1.800–5.472, and P < 0.001]. But high CEA and COCN remained significant only for decreased overall survival (OS) [HR: 3.713, 95% CI: 1.396–9.873, and P = 0.009; HR: 3.106, 95% CI: 1.576–6.123, and P = 0.001]. High NLR showed higher mortality rates with worse OS (P = 0.058), and nomograms containing NLR improved the predictive accuracy. Area under the curve of COCN was higher than that of CEA or NLR.

Conclusion

COCN acts as a better independent prognostic biomarker of CRC than NLR or CEA alone.