Overall survival after resection for colon cancer in a national cohort study was adversely affected by TNM stage, lymph node ratio, gender, and old age

A two-phase approach to re-calibrating expensive computer simulation for sex-specific colorectal neoplasia development modeling

BACKGROUND

Medical evidence from more recent observational studies may significantly alter our understanding of disease incidence and progression, and would require recalibration of existing computational and predictive disease models. However, it is often challenging to perform recalibration when there are a large number of model parameters to be estimated. Moreover, comparing the fitting performances of candidate parameter designs can be difficult due to significant variation in simulated outcomes under limited computational budget and long runtime, even for one simulation replication.

METHODS

We developed a two-phase recalibration procedure. As a proof-of-the-concept study, we verified the procedure in the context of sex-specific colorectal neoplasia development. We considered two individual-based state-transition stochastic simulation models, estimating model parameters that govern colorectal adenoma occurrence and its growth through three preclinical states: non-advanced precancerous polyp, advanced precancerous polyp, and cancerous polyp. For the calibration, we used a weighted-sum-squared error between three prevalence values reported in the literature and the corresponding simulation outcomes. In phase 1 of the calibration procedure, we first extracted the baseline parameter design from relevant studies on the same model. We then performed sampling-based searches within a proper range around the baseline design to identify the initial set of good candidate designs. In phase 2, we performed local search (e.g., the Nelder-Mead algorithm), starting from the candidate designs identified at the end of phase 1. Further, we investigated the efficiency of exploring dimensions of the parameter space sequentially based on our prior knowledge of the system dynamics.

RESULTS

The efficiency of our two-phase re-calibration procedure was first investigated with CMOST, a relatively inexpensive computational model. It was then further verified with the V/NCS model, which is much more expensive. Overall, our two-phase procedure showed a better goodness-of-fit than the straightforward employment of the Nelder-Mead algorithm, when only a limited number of simulation replications were allowed. In addition, in phase 2, performing local search along parameter space dimensions sequentially was more efficient than performing the search over all dimensions concurrently.

CONCLUSION

The proposed two-phase re-calibration procedure is efficient at estimating parameters of computationally expensive stochastic dynamic disease models.

Are there sex differences among colorectal cancer patients in treatment and survival? A Swiss cohort study

BACKGROUND

Colorectal cancer (CRC) is among the three most common incident cancers and causes of cancer death in Switzerland for both men and women. To promote aspects of gender medicine, we examined differences in treatment decision and survival by sex in CRC patients diagnosed 2000 and 2001 in the canton of Zurich, Switzerland.

METHODS

Characteristics assessed of 1076 CRC patients were sex, tumor subsite, age at diagnosis, tumor stage, primary treatment option and comorbidity rated by the Charlson Comorbidity Index (CCI). Missing data for stage and comorbidities were completed using multivariate imputation by chained equations. We estimated the probability of receiving surgery versus another primary treatment using multivariable binomial logistic regression models. Univariable and multivariable Cox proportional hazards regression models were used for survival analysis.

RESULTS

Females were older at diagnosis and had less comorbidities than men. There was no difference with respect to treatment decisions between men and women. The probability of receiving a primary treatment other than surgery was nearly twice as high in patients with the highest comorbidity index, CCI 2+, compared with patients without comorbidities. This effect was significantly stronger in women than in men (p-interaction = 0.010). Survival decreased with higher CCI, tumor stage and age in all CRC patients. Sex had no impact on survival.

CONCLUSION

The probability of receiving any primary treatment and survival were independent of sex. However, female CRC patients with the highest CCI appeared more likely to receive other therapy than surgery compared to their male counterparts.

Specific causes of recurrence after surgery and mortality in patients with colorectal cancer: A competing risks survival analysis

Background

In situation where there are more than one cause of occurring the outcome such as recurrence after surgery and death, the assumption of classical survival analyses are not satisfied. To cover this issue, this study aimed at utilizing competing risks survival analysis to assess the specific risk factors of local-distance recurrence and mortality in patients with colorectal cancer (CRC) undergoing surgery.

Materials and Methods

In this retrospective cohort study, 254 patients with CRC undergoing resection surgery were studied. Data of the outcome from the available documents in the hospital were gathered. Furthermore, based on pathological report, the diagnosis of CRC was considered. We model the risk factors on the hazard of recurrence and death using competing risk survival in R3.6.1 software.

Results

A total of 114 patients had local or distant recurrence (21 local recurrences, 72 distant recurrences, and 21 local and distant recurrence). Pathological stage (adjusted hazard ratio [AHR] = 4.28 and 5.37 for stage 3 and 4, respectively), tumor site (AHR = 2.45), recurrence (AHR = 3.92) and age (AHR = 3.15 for age >70) was related to hazard of death. Also based on cause-specific hazard model, pathological stage (AHR = 7.62 for stage 4), age (AHR = 1.46 for age >70), T stage (AHR = 1.8 and 2.7 for T3 and T4, respectively), N stage (AHR = 2.59 for N2), and white blood cells (AHR = 1.95) increased the hazard of recurrence in patients with CRC.

Conclusion

This study showed that older age, higher pathological, rectum tumor site and presence of recurrence were independent risk factors for mortality among CRC patients. Also age, higher T/N stage, higher pathological stage and higher values of WBC were significantly related to higher hazard of local/distance recurrence of patients with CRC.

Factors related to mortality due to progression of disease in patients with colon cancer in the presence of competing risks: a retrospective cohort study in the west of Iran

AIM

This study aims to identify the risk factors of disease-related death in patients with colon cancer in the presence of competing risks.

BACKGROUND

Competing risk analysis is an effective method for identifying risk factors of death from disease, and the evidence related to the prognosis of death in patients with colon cancer in the country is rare.

METHODS

In this historical cohort study, the information of 196 patients with colon cancer who were referred to Imam Khomeini Clinic in Hamadan during the years 2003 to 2017 were examined. Death due to the progression of cancer was considered an interesting cause, and death related to other causes was considered a competing event. Predictors of death due to the progression of cancer were determined in the presence of competing risks. The cause-specific hazard regression model was used to determine the effects of covariates. Data was analyzed using R software vol. 3.4.3 and survival packages.

RESULTS

The mean (SD) age of patients was 57.1 (12.9) years, and 52.6% were male. The results of the multivariate cause-specific hazard regression model showed that the patient's age at the time of cancer diagnosis, T stage, stage of the disease and N stage had significant effects on the hazard of death due to cancer progression (p<0.05).

CONCLUSION

In the presence of various causes of death, using the cause-specific hazard model to identify the risk factors of each cause separately can better support clinical decisions compared to other models.

Role of circulating miRNA-17-3P as a potential diagnostic biomarker for sporadic colon cancer in Egyptian cohort

Background

Cancer colon is one of the leading causes of death and MiRNAs are incorporated in biological pathways that affect tumorigenesis as proved by multiple studies. The present study aimed to investigate whether miR-17-3p is elevated in the plasma free samples of colon cancer patients in correlation with other tumor markers (CEA, CA19.9).

Results

MiRNA 17-3P plasma free sample levels were significantly elevated in the plasma free samples of colon cancer patients compared with healthy controls (P < 0.001); on the other hand, serum levels of CA19.9 were significantly higher in colon cancer patients compared to healthy controls while serum levels of CEA were found to be of no statistical significance.

Conclusion

The detection miRNA-17-3p may be considered of clinical value for the detection of colon cancer; also, CA19.9 detection was found to significantly increase the sensitivity and specificity of a colon cancer diagnosis.

For debate; pharmacological priorities in advanced type 2 diabetes

A multitude of therapeutic agents have been available to treat patients with Type 2 diabetes. Unfortunately, many patients with advanced Type 2 diabetes continue to suffer from complications and premature death. To date, all available guidelines emphasize a variety of therapeutic aspects, goals, and pharmacological combinations, without directing the clinician as to which is a higher priority. The following review attempts to clarify which therapeutic option is more important for prognosis in patients with advanced type 2 diabetes. The body of evidence presented, reveal that the most important marker for prognosis is HbA1c. Each 1% incrementally higher HbA1c than ~7% is associated with 15%-45% reduced survival rates. Therefore, any agents that can achieve the time-sensitive objective of lowering HbA1c levels should be used.

Comparison of a Five-Year Survival and Cancer Recurrence between Laparoscopically Assisted and Open Colonic Resections due to Adenocarcinoma-a Single Centre Experience

Background and objectives: When resecting colon adenocarcinoma, surgeons decide between the use of laparoscopically assisted and open surgery. Laparoscopic resection is known to have short-term benefits over an open operation. However, researchers are not as unified about the long-term findings. The aim of this research is to elaborate on five-year post-operative differences in survival and cancer recurrence between these two different approaches. Materials and methods: 74 enrolled patients were evaluated five years after a primary operation. We collected dates of deaths of deceased patients and time after operation of possible recurrences. Carcinoma staging was done by a pathologist after operation. Blood samples were taken before surgery in order to measure tumor markers (CA19-9 and CEA). Results: Survival after colonic adenocarcinoma surgery did not differ between the two different surgical approaches (p = 0.151). Recurrence of cancer was not associated with the type of operation (p = 0.532). Patients with recurrence had a 37.6 times greater hazard ratio of dying (95% CI: [12.0, 118]; p < 0.001). Advanced age adversely affected survival: patients aged <65 and 65 years had a 97%, and 57% survival rate, respectively. Patients with elevated tumor markers at operation had a 19.1 greater hazard ratio of dying (95% CI: [5.16, 70.4]; p<0.001). Patients with different TNM stages did not have any statistically significant differences in survival (HR_II = 2.49; 95% CI: [0.67, 9.30]; p_II = 0.173) (HR_III = 2.18; 95% CI: [0.58, 8.12]; p_III = 0.246) or recurrence (p = 0.097). Conclusion: The obtained results suggest that laparoscopic resection of colon cancer is not inferior from an oncologic point of view and results in a similar long-term survival and disease-free interval. Recurrence of carcinoma, older age at initial operation and elevated tumor markers, above a pre-set threshold at operation, were found to be independent factors of lower survival. We believe that the obtained results will be of benefit when choosing treatment for colon adenocarcinoma.

A competing-risk nomogram to predict cause-specific death in elderly patients with colorectal cancer after surgery (especially for colon cancer)

Background

Clinically, when the diagnosis of colorectal cancer is clear, patients are more concerned about their own prognosis survival. Special population with high risk of accidental death, such as elderly patients, is more likely to die due to causes other than tumors. The main purpose of this study is to construct a prediction model of cause-specific death (CSD) in elderly patients using competing-risk approach, so as to help clinicians to predict the probability of CSD in elderly patients with colorectal cancer.

Methods

The data were extracted from Surveillance, Epidemiology, and End Results (SEER) database to include ≥ 65-year-old patients with colorectal cancer who had undergone surgical treatment from 2010 to 2016. Using competing-risk methodology, the cumulative incidence function (CIF) of CSD was calculated to select the predictors among 13 variables, and the selected variables were subsequently refined and used for the construction of the proportional subdistribution hazard model. The model was presented in the form of nomogram, and the performance of nomogram was bootstrap validated internally and externally using the concordance index (C-index).

Results

Dataset of 19,789 patients who met the inclusion criteria were eventually selected for analysis. The five-year cumulative incidence of CSD was 31.405% (95% confidence interval [CI] 31.402–31.408%). The identified clinically relevant variables in nomogram included marital status, pathological grade, AJCC TNM stage, CEA, perineural invasion, and chemotherapy. The nomogram was shown to have good discrimination after internal validation with a C-index of 0.801 (95% CI 0.795–0.807) as well as external validation with a C-index of 0.759 (95% CI 0.716–0.802). Both the internal and external validation calibration curve indicated good concordance between the predicted and actual outcomes.

Conclusion

Using the large sample database and competing-risk analysis, a postoperative prediction model for elderly patients with colorectal cancer was established with satisfactory accuracy. The individualized estimates of CSD outcome for the elderly patients were realized.

Low Socioeconomic Status Is Associated with Worse Outcomes After Curative Surgery for Colorectal Cancer: Results from a Large, Multicenter Study

BACKGROUND

Socioeconomic status (SES) has been associated with early mortality in cancer patients. However, the association between SES and outcome in colorectal cancer patients is largely unknown. The aim of this study was to investigate whether SES is associated with short- and long-term outcome in patients undergoing curative surgery for colorectal cancer.

METHODS

Patients who underwent curative surgery in the region of Rotterdam for stage I-III colorectal cancer between January 2007 and July 2014 were included. Gross household income and survival status were obtained from a national registry provided by Statistics Netherlands Centraal Bureau voor de Statistiek. Patients were assigned percentiles according to the national income distribution. Logistic regression and Cox proportional hazard regression were performed to assess the association of SES with 30-day postoperative complications, overall survival and cancer-specific survival, adjusted for known prognosticators.

RESULTS

For 965 of the 975 eligible patients (99%), gross household income could be retrieved. Patients with a lower SES more often had diabetes, more often underwent an open surgical procedure, and had more comorbidities. In addition, patients with a lower SES were less likely to receive (neo) adjuvant treatment. Lower SES was independently associated with an increased risk of postoperative complications (Odds ratio per percent increase 0.99, 95%CI 0.99-0.998, p = 0.004) and lower cancer-specific mortality (Hazard ratio per percent increase 0.99, 95%CI 0.98-0.99, p = 0.009).

CONCLUSION

This study shows that lower SES is associated with increased risk of postoperative complications, and poor cancer-specific survival in patients undergoing surgery for stage I-III colorectal cancer after correcting for known prognosticators.

Joint effect of pre-operative anemia and perioperative blood transfusion on outcomes of colon-cancer patients undergoing colectomy

Background

Both pre-operative anemia and perioperative (intra- and/or post-operative) blood transfusion have been reported to increase post-operative complications in patients with colon cancer undergoing colectomy. However, their joint effect has not been investigated. The purpose of this study was to evaluate the joint effect of pre-operative anemia and perioperative blood transfusion on the post-operative outcome of colon-cancer patients after colectomy.

Methods

We identified patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2006-2016 who underwent colectomy for colon cancer. Multivariate logistic regression analysis was employed to assess the independent and joint effects of anemia and blood transfusion on patient outcomes.

Results

A total of 35,863 patients-18,936 (52.8%) with left-side colon cancer (LCC) and 16,927 (47.2%) with right-side colon cancer (RCC)-were identified. RCC patients were more likely to have mild anemia (62.7%) and severe anemia (2.9%) than LCC patients (40.2% mild anemia and 1.4% severe anemia). A total of 2,661 (7.4%) of all patients (1,079 [5.7%] with LCC and 1,582 [9.3%] with RCC) received a perioperative blood transfusion. Overall, the occurrence rates of complications were comparable between LCC and RCC patients (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.95-1.07; P = 0.750). There were significant joint effects of anemia and transfusion on complications and the 30-day death rate (P for interaction: 0.010). Patients without anemia who received a transfusion had a higher risk of any complications (LCC, OR = 3.51; 95% CI = 2.55-4.85; P < 0.001; RCC, OR = 3.74; 95% CI = 2.50-5.59; P < 0.001), minor complications (LCC, OR = 2.54; 95% CI = 1.63-3.97; P < 0.001; RCC, OR = 2.27; 95% CI = 1.24-4.15; P = 0.008), and major complications (LCC, OR = 5.31; 95% CI = 3.68-7.64; P < 0.001; RCC, OR = 5.64; 95% CI = 3.61-8.79; P < 0.001), and had an increased 30-day death rate (LCC, OR = 6.97; 95% CI = 3.07-15.80; P < 0.001; RCC, OR = 4.91; 95% CI = 1.88-12.85; P = 0.001) than patients without anemia who did not receive a transfusion.

Conclusions

Pre-operative anemia and perioperative transfusion are associated with an increased risk of post-operative complications and increased death rate in colon-cancer patients undergoing colectomy.

Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis

Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.

Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.

Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.

Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.

Risk Factors for Complications following Introduction of Radical Surgery for Colon Cancer: A Consecutive Patient Series

BACKGROUND

Rectal cancer surgery is standardized, resulting in improved survival. Colon cancer has fallen behind and therefore more radical surgical techniques have been introduced. One technique is complete mesocolic excision. The aim of this article was to study the complications after the introduction of standardized complete mesocolic excision in a single center.

METHODS

Complete mesocolic excision was introduced in 2007, and data were collected from 286 patients prior to surgery (2007-2010). The surgeon decided on open or laparoscopic surgery. Follow-up information was recorded until 31 December 2015. Complications were classified according to a modified Clavien-Dindo classification.

RESULTS

Complications occurred in 47%, severe complications (grade III and IV) in 15%. In-hospital mortality was 3.5%. A total of 142 patients (49.7%) were operated by open surgery. Logistic regression revealed anemia (p = 0.001), open surgery (p < 0.001), and long operating time (p < 0.001) as significant factors for complications in general. Multinomial logistic regression revealed that severe complications occurred more often in males (odds ratio: 2.56; 95% confidence interval: 0.98-6.68), patients with anemia (odds ratio: 3.49; 95% confidence interval: 1.27-9.60), elevated body mass index (odds ratio: 1.14; 95% confidence interval: 1.02-1.28), and in open surgery (odds ratio: 9.95; 95% confidence interval: 2.58-38.35). Age was not associated with severe complications. Survival was not significantly influenced by complications. Overall survival (5 years) was 90% among patients with complications and 92% among those without complications.

CONCLUSION

Severe complications following the introduction of complete mesocolic excision are patient dependent and related to open surgery. Patients selected for laparoscopy had less number of complications; therefore, introducing complete mesocolic excision by laparoscopy is justified. Identification of these factors can improve selection of appropriate surgical approach and postoperative patient safety.

Gender differences in colorectal cancer survival: A meta-analysis

A meta-analysis was conducted to determine the influence of gender on overall survival (OS) and cancer-specific survival (CSS) in colorectal cancer patients. Major databases were searched for clinical trials, which compare survival differences between male and female for colorectal cancer patients. A list of these studies and references, published in English and Chinese from 1960 to 2017, was obtained independently by two reviewers from databases such as PubMed, Medline, ScienceDirect, the China National Knowledge Infrastructure (CNKI) and Web of Science. Overall survival and cancer-specific survival were compared using Review Manager 5.3. Females had significantly better OS (hazard ratio [HR] = 0.87; 95% confidence interval [CI] = 0.85-0.89) and CSS (HR = 0.92; 95% CI = 0.89-0.95) than males after meta-analysis. These results suggest that gender seems to be a significant factor influencing survival results among colorectal cancer patients.

Tailored Treatment of Colorectal Cancer: Surgical, Molecular, and Genetic Considerations

Colorectal cancer (CRC) is a complex cancer disease, and approximately 40% of the surgically cured patients will experience cancer recurrence within 5 years. During recent years, research has shown that CRC treatment should be tailored to the individual patient due to the wide variety of risk factors, genetic factors, and surgical complexity. In this review, we provide an overview of the considerations that are needed to provide an individualized, patient-tailored treatment. We emphasize the need to assess the predictors of CRC, and we summarize the latest research on CRC genetics and immunotherapy. Finally, we provide a summary of the significant variations in the colon and rectal anatomy that is important to consider in an individualized surgical approach. For the individual patient with CRC, a tailored treatment approach is needed in the preoperative, operative, and postoperative phase.

Leveraging the power of pooled data for cancer outcomes research

Background

Clinical trials continue to be the gold standard for determining the efficacy of novel cancer treatments, but they may also expose participants to the potential risks of unpredictable or severe toxicities. The development of validated tools that better inform patients of the benefits and risks associated with clinical trial participation can facilitate the informed consent process. The design and validation of such instruments are strengthened when we leverage the power of pooled data analysis for cancer outcomes research.

Main body

In a recent study published in the Journal of Clinical Oncology entitled “Determinants of early mortality among 37,568 patients with colon cancer who participated in 25 clinical trials from the adjuvant colon cancer endpoints database,” using a large pooled analysis of over 30,000 study participants who were enrolled in clinical trials of adjuvant therapy for early-stage colon cancer, we developed and validated a nomogram depicting the predictors of early cancer mortality. This database of pooled individual-level data allowed for a comprehensive analysis of poor prognostic factors associated with early death; furthermore, it enabled the creation of a nomogram that was able to reliably capture and quantify the benefit-to-risk profile for patients who are considering clinical trial participation. This tool can facilitate treatment decision-making discussions.

Conclusion

As China and other Asian countries continue to conduct oncology clinical trials, efforts to collate patient-level information from these studies into a large data repository should be strongly considered since pooled data can increase future capacity for cancer outcomes research, which, in turn, can enhance patient-physician discussions and optimize clinical care.

Impact of tumor location on lymph node metastasis in T1 colorectal cancer

PURPOSE

Data evaluating the risk of lymph node metastasis depending upon the location of the primary tumor are limited in patients with T1 colorectal cancer. We aimed to evaluate the impact of tumor location on lymph node metastasis in T1 colorectal cancer.

METHODS

Patients who underwent an oncologic resection with curative intent for T1 adenocarcinoma of the colon and rectum between January 1997 and October 2014 were assessed. Exclusion criteria were distant organ metastases, previous or concurrent cancer, past history of surgical or medical cancer treatment, preoperative chemoradiation, and patients with inflammatory bowel disease or polyposis syndromes.

RESULTS

Out of 232 (56 % male) patients fulfilling the study criteria, 24 (10 %) had lymph node metastasis. Age (65 vs 61 years, p = 0.1), gender (55 vs 63 % male, p = 0.5), tumor size (2 vs 2 cm, p = 0.49), and lymphovascular invasion (5 vs 8 %, p = 0.46) were not associated with lymph node metastasis. While there was no statistical significance (p = 0.2), lymph node positivity was higher in rectal cancer (14 %, n = 11/79) compared to colon cancer (9 %, n = 13/153).

CONCLUSIONS

Although it was not statistically significant, lymph node positivity varies based on tumor location of T1 colorectal adenocarcinoma regardless of fundamental tumor characteristics including size, differentiation, and lymphovascular invasion.

Assessment of lymph node involvement in colorectal cancer

Lymph node metastasis informs prognosis and is a key factor in deciding further management, particularly adjuvant chemotherapy. It is core to all contemporary staging systems, including the widely used tumor node metastasis staging system. Patients with node-negative disease have 5-year survival rates of 70%-80%, implying a significant minority of patients with occult lymph node metastases will succumb to disease recurrence. Enhanced staging techniques may help to identify this subset of patients, who might benefit from further treatment. Obtaining adequate numbers of lymph nodes is essential for accurate staging. Lymph node yields are affected by numerous factors, many inherent to the patient and the tumour, but others related to surgical and histopathological practice. Good lymph node recovery relies on close collaboration between surgeon and pathologist. The optimal extent of surgical resection remains a subject of debate. Extended lymphadenectomy, extra-mesenteric lymph node dissection, high arterial ligation and complete mesocolic excision are amongst the surgical techniques with plausible oncological bases, but which are not supported by the highest levels of evidence. With further development and refinement, intra-operative lymphatic mapping and sentinel lymph node biopsy may provide a guide to the optimum extent of lymphadenectomy, but in its present form, it is beset by false negatives, skip lesions and failures to identify a sentinel node. Once resected, histopathological assessment of the surgical specimen can be improved by thorough dissection techniques, step-sectioning of tissue blocks and immunohistochemistry. More recently, molecular methods have been employed. In this review, we consider the numerous factors that affect lymph node yields, including the impact of the surgical and histopathological techniques. Potential future strategies, including the use of evolving technologies, are also discussed.

Expression of ITGB1 predicts prognosis in colorectal cancer: a large prospective study based on tissue microarray

BACKGROUND

ITGB1 is a heterodimeric cell-surface receptor involved in cell functions such as proliferation, migration, invasion and survival. The aim of this study was to assess ITGB1 expression in colorectal cancer and correlate it with clinicopathological features, as well as to evaluate its potential prognostic significance.

MATERIALS AND METHODS

In this study, we examined the expression of ITGB1 using tissue microarrays containing analyzed specimens by immunohistochemistry. ITGB1 expression was further correlated with clinicopathological and prognostic data. The prognostic significance was assessed using Kaplan-Meier survival estimates and log-rank tests. A multivariate study with the Cox's proportional hazard model was used to evaluate the prognostic aspects.

RESULTS

ITGB1 expression was present in 88.5% of the analyzed specimens. Significant differences in ITGB1 expression were found between normal mucosa and carcinomas (P<0.001). High ITGB1 expression was associated with poor prognosis, and it independently correlated with shortened overall survival and disease-free survival in colorectal cancer patients (P<0.001). More so, ITGB1 expression, bowel wall invasion, lymph node metastasis and distant metastasis were independent prognostic factors for overall survival. Additionally, significant differences in ITGB1 expression were observed in adenomas and tumors from patients with familial adenomatous polyposis compared to normal colon mucosa (P<0.05) CONCLUSION: The results of this study indicate that ITGB1 overexpression in colorectal tumors is associated with poor prognosis, as well as aggressive clinicopathological features. Therefore, ITGB1 expression could be used as potential prognostic predictor in colorectal cancer patients.

Combined assays for serum carcinoembryonic antigen and microRNA-17-3p offer improved diagnostic potential for stage I/II colon cancer

Colorectal cancer is among the leading causes of cancer-related mortality, one of the main reasons for which is the lack of an effective screening method for early-stage disease. The levels of carcinoembryonic antigen (CEA) and microRNA (miR)-17-3p in the serum of 70 patients with stage I/II colon cancer and 70 healthy volunteers were determined, and the diagnostic value of CEA plus miR-17-3p detection for colon cancer was assessed. The levels of CEA were measured by a radioimmunoassay method, and those of miR-17-3p using the reverse transcription-quantitative polymerase chain reaction method. miR-16 was used as the endogenous control, as it displayed high stability, high abundance and low variability in the analyzed serum samples. The receiver operating characteristic (ROC) curve analysis indicated the potential diagnostic value of the two markers and the area under the ROC curve (AUC) for CEA and miR-17-3p was 0.719 (95% CI: 0.658-0.843) and 0.807 (95% CI: 0.748-0.906), respectively. At a threshold of 9.6 ng/ml for CEA, the optimal sensitivity and specificity were 74.6 and 84.3%, respectively, in discriminating colon cancer patients from healthy controls. At a threshold of 2.98 for miR-17-3p, the sensitivity and the specificity were 83.6 and 72.9%, respectively. A combined ROC analysis using CEA and miR-17-3p revealed an AUC of 0.929 (95% CI: 0.834-0.978) with a sensitivity of 96.4% and a specificity of 95.7% in discriminating colon cancer patients from healthy controls. In conclusion, both CEA and miR-17-3p were highly expressed in the serum of our series of colon cancer patients. CEA plus miR-17-3p detection significantly increased the sensitivity and specificity in discriminating stage I/II colon cancer patients from healthy controls. Therefore, combined detection of serum CEA and miR-17-3p levels may have the potential to become a new laboratory method for the early clinical diagnosis of colon cancer.

Incidence, clinical features and possible etiology of early onset (≤40 years) colorectal neoplasms

The aim of the study was to investigate the clinical features, including survival, of patients with colorectal malignancies developed at a very early age (≤40 years), together with possible factors involved in the pathogenesis of these rare neoplasms. The study took advantage of the existence of a specialized colorectal cancer Registry active from 1984. 57 patients met the criteria of early onset cancer; main epidemiological data, morphology, stage, familial aggregation, possible role of inheritance and survival were analyzed. Despite the relevant increase over time of all registered patients, joiningpoint analysis of crude incidence rate of early onset colorectal neoplasms revealed a certain stability of these tumors (EAPC: 2.4, CI 14-22) with a constant prevalence of the male sex. Stage at diagnosis did not show significant variations between early onset and maturity onset colorectal neoplasms. Hereditary as well as familial cases were significantly (P < 0.005 and 0.03) more frequent among patients with early onset tumors, although in the majority of them no specific etiological factor could be identified. Survival was more favorable in patients with early onset tumors, though this had to be attributed to the higher presence of some histological types in early onset cases. Survival was significantly more favorable for patients of all ages registered in the last decade. Incidence of early onset colorectal cancer was relatively stable between 1984 and 2008. A male preponderance was evident through the registration period. Hereditary and familial cases were significantly more frequent among early onset case. A well defined etiology could be observed in 16% of the cases (versus 2-3% in older individuals). Five-year survival showed a significant improvement over time.

MicroRNA profiles discriminate among colon cancer metastasis

MicroRNAs are being exploited for diagnosis, prognosis and monitoring of cancer and other diseases. Their high tissue specificity and critical role in oncogenesis provide new biomarkers for the diagnosis and classification of cancer as well as predicting patients' outcomes. MicroRNAs signatures have been identified for many human tumors, including colorectal cancer (CRC). In most cases, metastatic disease is difficult to predict and to prevent with adequate therapies. The aim of our study was to identify a microRNA signature for metastatic CRC that could predict and differentiate metastatic target organ localization. Normal and cancer tissues of three different groups of CRC patients were analyzed. RNA microarray and TaqMan Array analysis were performed on 66 Italian patients with or without lymph nodes and/or liver recurrences. Data obtained with the two assays were analyzed separately and then intersected to identify a primary CRC metastatic signature. Five differentially expressed microRNAs (hsa-miR-21, -103, -93, -31 and -566) were validated by qRT-PCR on a second group of 16 American metastatic patients. In situ hybridization was performed on the 16 American patients as well as on three distinct commercial tissues microarray (TMA) containing normal adjacent colon, the primary adenocarcinoma, normal and metastatic lymph nodes and liver. Hsa-miRNA-21, -93, and -103 upregulation together with hsa-miR-566 downregulation defined the CRC metastatic signature, while in situ hybridization data identified a lymphonodal invasion profile. We provided the first microRNAs signature that could discriminate between colorectal recurrences to lymph nodes and liver and between colorectal liver metastasis and primary hepatic tumor.

Association between socioeconomic status, surgical treatment and mortality in patients with colorectal cancer

BACKGROUND

High socioeconomic status is associated with better survival in colorectal cancer (CRC). This study investigated whether socioeconomic status is associated with differences in surgical treatment and mortality in patients with CRC.

METHODS

Patients diagnosed with stage I-III CRC between 2005 and 2010 in the Eindhoven Cancer Registry area in the Netherlands were included. Socioeconomic status was determined at a neighbourhood level by combining the mean household income and the mean value of the housing.

RESULTS

Some 4422 patients with colonic cancer and 2314 with rectal cancer were included. Patients with colonic cancer and high socioeconomic status were operated on with laparotomy (70·7 versus 77·6 per cent; P = 0·017), had laparoscopy converted to laparotomy (15·7 versus 29·5 per cent; P = 0·008) and developed anastomotic leakage or abscess (9·6 versus 12·6 per cent; P = 0·049) less frequently than patients with low socioeconomic status. These differences remained significant after adjustment for patient and tumour characteristics. In rectal cancer, patients with high socioeconomic status were more likely to undergo resection (96·3 versus 93·7 per cent; P = 0·083), but this was not significant in multivariable analysis (odds ratio (OR) 1·44, 95 per cent confidence interval 0·84 to 2·46). The difference in 30-day postoperative mortality in patients with colonic cancer and high and low socioeconomic status (3·6 versus 6·8 per cent; P < 0·001) was not significant after adjusting for age, co-morbidities, emergency surgery, and anastomotic leakage or abscess formation (OR 0·90, 0·51 to 1·57).

CONCLUSION

Patients with CRC and high socioeconomic status have more favourable surgical treatment characteristics than patients with low socioeconomic status. The lower 30-day postoperative mortality found in patients with colonic cancer and high socioeconomic status is largely explained by patient and surgical factors.

Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study

BACKGROUND

Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies.

METHODS

The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan-Meier curves.

RESULTS

During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3-4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35-76) in the laparoscopic group versus 43 % (95 % CI 32-58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20-60) versus 37 % (95 % CI 27-50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy.

CONCLUSIONS

Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.

The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference

BACKGROUND

It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors.

METHOD

There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction.

RESULT

The oncological rationale for CME and various technical aspects of the surgical management will be explored.

CONCLUSION

The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.

Depression in older patients with advanced colorectal cancer is closely connected with immunosuppressive acidic protein

Colorectal cancer (CRC) is one of the most common tumors. CRC patients are susceptible to suffering from depression. Whether the immune system of CRC patients with depression is impaired or stimulated is controversial. Possible reasons for this conflict are the involvement of confounding factors, such as the age of the patient, the stage of the CRC and the types of treatment in previous studies. To demonstrate clearly the relationship between depression and the immune system in the context of CRC, the present study included only older patients with advanced CRC who received only chemotherapy, and the study adopted immunosuppressive acidic protein (IAP) as an immune parameter for the first time. A total of 56 older patients with advanced CRC completed the Zung Self-Rating Depression Scale (SDS) and were divided into two groups according to SDS scores. The patients exhibiting depression were treated with fluoxetine until their symptoms remitted. The serum levels of IAP and the percentages of CD3-positive (CD3+), CD4+, CD8+ T lymphocytes and CD56+ natural killer (NK) cells and Neutrophil-lymphocyte ratio (NLR) were calculated at the time of enrollment and once the symptoms remitted. Correlation analyses revealed that the SDS score was positively associated with serum IAP levels but negatively associated with CD3 and CD4 levels. Among the depressed and non-depressed patients, serum IAP levels and the percentages of CD3 and CD4 cells were dramatically different. After the depression symptoms were treated, the IAP levels dramatically decreased, while the levels of CD3, CD4, CD8 and CD56 were unchanged. All of above suggested that IAP was closely correlated with depression and might be a relatively objective parameter for predicting depression.

The expression of chemokine receptors CXCR3 and CXCR4 in predicting postoperative tumour progression in stages I-II colon cancer: a retrospective study

OBJECTIVES

The prognostic significance of chemokine receptors in stage I/II colon cancer is unclear. We assessed the prognostic value of chemokine receptor CXCR3 and CXCR4 in stage I/II colon cancer.

METHODS

145 patients with stage I/II colon cancer who underwent curative surgery alone from 2000 to 2007 were investigated. Chemokine receptor expression was assessed by immunohistochemistry. The associations between CXCR3, CXCR4 and clinicopathological variables were analysed using the χ2 test, and the relationships between chemokine receptors and a 5-year disease-free survival were analysed by univariate and multivariate analyses.

RESULTS

The high-expression rates of CXCR3 and CXCR4 were 17.9% (26/145) and 38.6% (56/145), respectively. There were no significant associations between the expressions of CXCR3, CXCR4 and clinicopathological factors including gender, age, tumour location, histological differentiation, pathological stage, lymphovascular invasion and pretreatment serum carcinoembryonic antigen (CEA). The 5-year disease-free survival was not significantly different between low-expression groups and high-expression groups of CXCR3 and CXCR4. Multivariate analysis revealed that serum CEA and a number of retrieved lymph nodes, rather than chemokine receptors, were independent prognosticators.

CONCLUSIONS

CXCR3 and CXCR4 are not independent prognosticators for stage I/II colon cancer after curative surgery.

Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II

BACKGROUND

The aim of the present study was to investigate whether the new method of complete mesocolic excision (CME) with a high (apical) vascular tie (D3 resection) had an immediate effect compared with a conventional (standard) approach even in those patients without lymph node metastases.

METHODS

A cohort of 189 consecutive patients with tumour-nodal-metastasis (TNM) stages I-II and a mean age of 73 years were operated on in the period from January 2007 to December 2008 in three community teaching hospitals. The CME approach (n = 89), used in hospital A, was compared to the standard technique used (n = 105) in two other hospitals, B and C. Lymph node yields from the specimens were used as a surrogate measure of radical resections. Outcome was analysed after a median follow-up of 50.2 months.

RESULTS

In-hospital mortality rate was 2.8 % in the CME group and 8.6 % in the standard group. The 3-year overall survival (OS) in the CME group was 88.1 versus 79.0 % (p = 0.003) in the standard group, and the corresponding disease-free survival (DFS) was 82.1 versus 74.3 % (p = 0.026). Cancer-specific survival was 95.2 % in the CME group versus 90.5 % in the standard group (p = 0.067). Age, operative technique, and T category were significant in multiple Cox regressions of OS and DFS.

CONCLUSIONS

Compared with the standard (D2) approach, introduction of CME surgical management of colon cancer resulted in a significant immediate improvement of 3-year survival for patients with TNM stage I-II tumours as assessed by OS and DFS.

The total number of lymph nodes in resected colon cancer specimens is affected by several factors but the lymph node ratio is independent of these

The number of lymph nodes retrieved from the specimen may be a surrogate measure of the adequacy of extensive colon cancer surgery, but many variables may influence the total lymph node yield of any specimen. We examined which variables would be influential both for negative and positive node sampling.The combined results from 428 patients from three hospitals A to C treated in 2007-2009 with single colon cancers having R0 segmental resections were analysed. The surgical technique and pathology staining methods were slightly different between the hospitals.The mean number of lymph nodes was 15.8 (range 1-60). Twelve or more lymph nodes were harvested in 78% of the specimens. In the multivariate Poisson regression analysis of all TNM stages, the factors associated with the total lymph node harvest were age, pathology handling, tumour location and size (p < 0.001), whereas for TNM stage III alone the pathology handling (p < 0.001) and a radical operating technique (p = 0.003) were highly significant. The total number of lymph nodes was the only significant factor for the number of positive lymph nodes (Posln) according to the multivariate negative regression analysis (p = 0.02) but the analysis of the lymph node ratio (LNR) detected no statistically significant variable.Several factors, and especially the specimen processing technique, were important for the total number of harvested lymph nodes. The number of Posln varied between segments and increased with the total number of harvested lymph nodes, but for LNR no variable was important. LNR seemed to abolish the combined effect of tumour location and the total lymph node yield in prognosis assessment.

Proposal of a new classification for stage III colorectal cancer based on the number and ratio of metastatic lymph nodes

BACKGROUND

The objective of this retrospective study was to determine whether the current staging system for stage III colorectal cancer (CRC) is appropriate and to assess the value of the metastatic lymph node ratio (LNR) in predicting the prognosis of patients with stage III CRC.

METHODS

From 2000 to 2006 inclusively, 245 patients with stage III CRC underwent curative resection. The follow-up was closed in March 2012. Kaplan-Meier survival curves and log-rank tests were used for the survival analysis.

RESULTS

Survival time of patients with T3N1M0 was significantly better than that for patients in other subgroups of stage IIIB and similar to that of patients with stage IIIA disease. The greatest survival difference was found with 0.30 as the LNR cutoff point for patients with current stage III CRC. Survival time of patients with LNR ≤ 0.30 was significantly better than that of those with LNR > 0.30. rN1 included stage III patients with LNR ≤ 0.30, and rN2 included patients with LNR > 0.30. Survival time of patients with T4aN1(rN2)M0 staging was significantly worse than that for patients with T4aN1(rN1)M0 staging and similar to that of patients with stage IIIC CRC.

CONCLUSIONS

We propose an algorithm to incorporate LNR into the current American Joint Committee on Cancer staging system. In it the patients with T3N1M0 are excluded from the current stage IIIB and included in the stage IIIA group. Also, patients with T4aN1(rN2)M0 are excluded from the current stage IIIB group and included in the stage IIIC group.

Proposal of a new classification for stage III colorectal cancer based on the number and ratio of metastatic lymph nodes

BACKGROUND

The objective of this retrospective study was to determine whether the current staging system for stage III colorectal cancer (CRC) is appropriate and to assess the value of the metastatic lymph node ratio (LNR) in predicting the prognosis of patients with stage III CRC.

METHODS

From 2000 to 2006 inclusively, 245 patients with stage III CRC underwent curative resection. The follow-up was closed in March 2012. Kaplan-Meier survival curves and log-rank tests were used for the survival analysis.

RESULTS

Survival time of patients with T3N1M0 was significantly better than that for patients in other subgroups of stage IIIB and similar to that of patients with stage IIIA disease. The greatest survival difference was found with 0.30 as the LNR cutoff point for patients with current stage III CRC. Survival time of patients with LNR ≤ 0.30 was significantly better than that of those with LNR > 0.30. rN1 included stage III patients with LNR ≤ 0.30, and rN2 included patients with LNR > 0.30. Survival time of patients with T4aN1(rN2)M0 staging was significantly worse than that for patients with T4aN1(rN1)M0 staging and similar to that of patients with stage IIIC CRC.

CONCLUSIONS

We propose an algorithm to incorporate LNR into the current American Joint Committee on Cancer staging system. In it the patients with T3N1M0 are excluded from the current stage IIIB and included in the stage IIIA group. Also, patients with T4aN1(rN2)M0 are excluded from the current stage IIIB group and included in the stage IIIC group.

Teng-Long-Bu-Zhong-Tang, a Chinese herbal formula, enhances anticancer effects of 5--Fluorouracil in CT26 colon carcinoma

Background

Colorectal cancer remains one of the leading causes of cancer death worldwide. Traditional Chinese Medicine (TCM) has played a positive role in colorectal cancer treatment. There is a great need to establish effective herbal formula for colorectal cancer treatment. Based on TCM principles and clinical practices, we have established an eight herbs composed formula for colorectal cancer treatment, which is Teng-Long-Bu-Zhong-Tang (TLBZT). We have demonstrated the anticancer effects of TLBZT against colorectal carcinoma in vitro. In present study, we evaluated the anticancer potential of TLBZT, used alone or in combination with low dose of 5-Fluorouracil (5-Fu), in CT26 colon carcinoma in vivo.

Methods

CT26 colon carcinoma was established in BALB/c mice and treated with TLBZT, 5-Fu, or TLBZT plus 5-Fu. The tumor volumes were observed. Apoptosis was detected by TUNEL assay. Caspases activities were detected by colorimetric assay. Cell senescence was indentified by senescence β-galactosidase staining. Gene expression and angiogenesis was observed by immunohistochemistry or western blot.

Results

TLBZT significantly inhibited CT26 colon carcinoma growth. TLBZT elicited apoptosis in CT26 colon carcinoma, accompanied by Caspase-3, 8, and 9 activation and PARP cleavage, and downregulation of XIAP and Survivin. TLBZT also induced cell senescence in CT26 colon carcinoma, with concomitant upregulation of p16 and p21 and downregulation of RB phosphorylation. In addition, angiogenesis and VEGF expression in CT26 colon carcinoma was significantly inhibited by TLBZT treatment. Furthermore, TLBZT significantly enhanced anticancer effects of 5-Fu in CT26 colon carcinoma.

Conclusions

TLBZT exhibited significantly anticancer effect, and enhanced the effects of 5-Fu in CT26 colon carcinoma, which may correlate with induction of apoptosis and cell senescence, and angiogenesis inhibition. The present study provides new insight into TCM approaches for colon cancer treatment that are worth of further study.

The relation between lymph node status and survival in Stage I-III colon cancer: results from a prospective nationwide cohort study

AIM

This study involved a large nationwide Danish cohort to evaluate the hypothesis that a high lymph node harvest has a positive effect on survival in curative resected Stage I-III colon cancer and a low lymph node ratio has a positive effect on survival in Stage III colon cancer.

METHOD

Analysis of overall survival was conducted using a nationwide Danish cohort of patients treated with curative resection of Stage I-III colon cancer. All 8901 patients in Denmark diagnosed with adenocarcinoma of the colon and treated with curative resection in the period 2003-2008 were identified from the Danish Colorectal Cancer Group (DCCG). The impact of lymph node count and lymph node ratio was analysed.

RESULTS

Overall 5-year survival was 56.8 and 66.6%, (P < 0.0001) for lymph node counts of fewer than 12 and 12 or more, respectively. The percentages of lymph node positive patients in the two groups were 29.8 and 40.3% (P < 0.0001), respectively. When putting the Stage III patients into four subgroups according to the lymph node ratio (cut-off points 1/12, 1/4 and 1/2) we found an overall 5-year survival rate of 68.1, 57.2, 49.3 and 32.4% (P < 0.0001). Lymph node count and lymph node ratio were independent prognostic factors in multivariate analysis.

CONCLUSION

High lymph node count was associated with improved overall survival in colon cancer. Lymph node ratio was superior to N-stage in differentiating overall survival in Stage III colon cancer. Stage migration was observed.

Expression and prognostic significance of GATA-binding protein 2 in colorectal cancer

GATA-binding protein 2 (GATA2) is a nuclear transcription factor that plays a critical role in tumorigenesis. High levels of GATA2 expression are correlated with poor survival outcomes in many types of cancer. However, the expression and prognostic significance of GATA2 in colorectal cancer remain unknown. In this study, GATA2 protein expression was examined using immunohistochemistry in 307 colorectal cancer tissues, and its association with clinicopathological features and prognosis was analyzed. The expression of GATA2 was found to be significantly higher in colorectal cancer tissues than in matched adjacent noncancerous tissues (60.3 vs. 9.0 %, P < 0.0001). The expression of GATA2 was significantly correlated with tumor location (P = 0.005), histological type (P = 0.019), and recurrence (P = 0.009). Kaplan-Meier survival analysis demonstrated that patients with high levels of GATA2 expression had worse disease-free survival outcomes than those with low levels of GATA2 expression (P = 0.016). Univariate analysis showed high levels of GATA2 expression to be significantly associated with shorter periods of disease-free survival (HR 2.196; 95 % CI 1.142-4.226; P = 0.018). Multivariate analysis showed GATA2 expression to be an independent prognostic factor for patients with colorectal cancer (HR 1.952; 95 % CI 1.010-3.775; P = 0.047). These findings suggest that high levels of GATA2 expression may be a useful indicator of disease recurrence after curative colorectal cancer treatment.

Preoperative carcinoembryonic antibody is predictive of distant metastasis in pathologically T1 colorectal cancer after radical surgery

AIM: To identify the predictors of distant metastasis in pathologically T1 (pT1) colorectal cancer (CRC) after radical resection.

METHODS: Variables including age, gender, preoperative carcinoembryonic antibody (CEA) level, tumor location, tumor size, lymph node status, and histological grade were recorded. Patients with and without metastasis were compared with regard to age, gender, CEA level and pathologic tumor characteristics using the independent t test or χ² test, as appropriate. Risk factors were determined by logistic regression analysis.

RESULTS: Metastasis occurred in 6 (3.8%) of the 159 patients during a median follow-up of 67.0 (46.5%) mo. The rates of distant metastasis in patients with pT1 cancer of the colon and rectum were 6.7% and 2.9%, respectively (P < 0.001). The rates of distant metastasis between male and female patients with T1 CRC were 6.25% and 1.27%, respectively (P < 0.001). The most frequent site of distant metastasis was the liver. Age (P = 0.522), gender (P = 0.980), tumor location (P = 0.330), tumor size (P = 0.786), histological grade (P = 0.509), and high serum CEA level (P = 0.262) were not prognostic factors for lymph node metastasis. Univariate analysis revealed that age (P = 0.231), gender (P = 0.137), tumor location (P = 0.386), and tumor size (P = 0.514) were not risk factors for distant metastasis after radical resection for T1 colorectal cancer. Postoperative metastasis was only significantly correlated with high preoperative serum CEA level (P = 0.001). Using multivariate logistic regression analysis, high preoperative serum CEA level (P = 0.004; odds ratio 15.341; 95%CI 2.371-99.275) was an independent predictor for postoperative distant metastasis.

CONCLUSION: The preoperative increased serum CEA level is a predictive risk factor for distant metastasis in CRC patients after radical resection. Adjuvant chemotherapy may be necessary in such patients, even if they have pT1 colorectal cancer.

Prognostic factors assessed for 15,096 patients with colon cancer in stages I and II

BACKGROUND

We focused on the risk factors for poor outcome after curative resection of a colon cancer in UICC stages I and II based on the data of the Germany-wide quality assurance study "colon/rectum cancer (primary tumor)." In some countries, all stage II colon cancer patients are encouraged to participate in a clinical trial. We feel that this approach is too broad.

METHODS

Using the data of 15,096 patients operated on from January 1, 2000 to December 31, 2004, the following factors were analyzed with the Cox regression model: age, comorbidities, ASA score, gender, localization of the tumor (left colon vs. right colon), perioperative complications (yes/no), pT stage, grading (G1/G2 vs. G3/G4), L-status (lymph vessels invasion yes/no), and V-status (venous invasion yes/no).

RESULTS

The probability of a local relapse in stages I and II was 1.5 and 4.6%, respectively, or distant metastases 4.7 and 10.2%, respectively. Only pT stage [hazard ratio (HR) for pT1 = 1, pT2 = 1.821, pT3 = 2.735, and pT4 = 5.881], L-status (HR for L1 = 1.393), age (HR per year = 1.021), as well as ASA score IV (HR = 4.536) had significant influence on tumor-free survival.

CONCLUSIONS

Despite favorable prognosis and R0 resection, a small percentage of patients will still relapse. The most important risk factor comprising the tumor-free survival is the pT stage followed by L-status and age. These results should be taken into consideration when determining the course for adjuvant chemotherapy, especially if the course includes the recommendation of clinical trial participation for stage II colon cancer patients after an R0 resection.

Pathologic lymph node ratio is a predictor of survival in esophageal cancer

BACKGROUND

A ratio between pathologic and examined lymph nodes may have predictive relevance in esophageal cancer. We sought to determine the prognostic value of lymph node ratio (LNR) compared with TNM and N stage using the seventh edition American Joint Commission on Cancer and International Union Against Cancer criteria.

METHODS

We abstracted data from 347 consecutive patients undergoing esophagectomy for esophageal cancer between 1999 and 2010 at our institution. Patients were stratified into surgery alone or induction therapy followed by surgery. Kaplan-Meier and Cox proportional hazard models estimated the survival function using LNR as a continuous variable or categorized into 0, more than 0.0 to less than 0.1, 0.1 to less than 0.2, 0.2 to less than 0.3, and 0.3 or greater. The influence of LNR on survival was assessed by the Wald χ(2) statistic and survival plots.

RESULTS

A total of 173 patients (49.9%) underwent induction therapy. The pathologic complete response rate was 55 of 173 (32%). The median number of examined nodes in surgery alone was 14 (interquartile range, 8 to 21), and induction was 12 (interquartile range, 7 to 17). Patients with nodal disease (n = 137) had a median LNR of 0.2 with equivalent survival regardless of induction therapy. Examination of LNR as a continuous variable demonstrated that LNR is an independent predictor of survival in both groups. After categorization, LNR contributed more toward estimating survival than pN stage in both groups.

CONCLUSIONS

Lymph node ratio is an independent predictor of survival in patients undergoing esophagectomy for esophageal cancer. The LNR makes a greater contribution in estimating overall survival than pN stage, regardless of the utilization of induction therapy.