Identification of patients likely to benefit from metastasectomy in stage IV colorectal cancer

Nomogram to Predict the Occurrence and Prognosis of Distant Metastasis in T1N0 Colon Cancer: A SEER Data-Based Study

Purpose

Distant metastasis (DM) is relatively rare in T1 colon cancer (CC) patients, especially in those with negative lymph node metastasis. The aim of this study was to explore the main clinical factors and build nomogram for predicting the occurrence and prognosis of DM in T1N0 colon cancer patients.

Methods

Patients with T1N0 stage CC were collected from the Surveillance, Epidemiology, and End Result (SEER) database. All patients were divided into development and validation cohorts with the 3:1 ratio. Logistic regressions were performed to analyze the clinical risk factors for DM. Cox regression model was used to identify potential prognostic factors for patients with DM. The performance of nomogram was evaluated by concordance index (C-index), calibration curves, receiver operating characteristic (ROC) curves and decision curve analyses (DCAs). Based on cancer-specific survival (CSS), Kaplan-Meier curves were generated and analyzed using Log rank tests.

Results

A total of 6770 patients were enrolled in this study, including 428 patients (6.3%) with DM. Age, size, grade, CEA were independent risk factors associated with DM. Age, grade, CEA, surgery and chemotherapy were independent prognostic factors for CSS. Nomograms were applied and C-index, calibration curves, ROC curves and DCA curves proved good discrimination, calibration and clinical practicability of the nomogram in predicting the occurrence and prognosis of DM in T1N0 CC patients. In the DM nomogram, the AUCs for development and validation cohort were 0.901 (95% CI = 0.879-0.922) and 0.899 (95% CI=0.865-0.940), respectively. The calibration curves (development cohort: S: p = 0.712; validation cohort: S: p = 0.681) showed the relatively satisfactory prediction accuracy. Similarly, the AUCs of the nomogram at 1-, 2-, and 3-year were 0.763 (95% CI=0.744-0.782), 0.794 (95% CI=0.775-0.813), and 0.822 (95% CI=0.803-0.841) for the development cohort, and 0.785 (95% CI=0.754-0.816), 0.748 (95% CI=0.717-0.779) and 0.896 (95% CI=0.865-0.927) for the validation cohort in the CSS nomogram. The C-indices of the development and validation cohort were 0.718 (95% CI=0.639-0.737) and 0.712 (95% CI=0.681-0.743).

Conclusion

The population-based nomogram could help clinicians predict the occurrence and prognosis of DM in T1N0 CC patients and provide a reference to perform appropriate metastatic screening plans and rational therapeutic options for the special population.

Complete resection of rectal cancer with a synchronous solitary adrenal metastasis: A case report

•

Adrenal metastasis is usually associated with systemic spread of the disease and is considered to be unsuitable for surgical resection.

•

Adrenalectomy should be considered in patients who can undergo complete resection.

•

Adrenalectomy may offer a better long-term prognosis.

Introduction

Solitary adrenal metastasis derived from colorectal cancer is rare. Adrenal metastasis is usually associated with systemic spread of the disease and is considered to be unsuitable for surgical resection. However, it has been reported that an aggressive surgical resection of adrenal metastasis results in improved overall survival in selected patients. We herein report an extremely rare case of complete resection of rectal cancer with a synchronous solitary adrenal metastasis.

Presentation of case

A 70-year-old woman who presented with bloody stool was diagnosed with rectal cancer with a synchronous solitary adrenal metastasis and was suspected of having liver invasion. After a total of 2 cycles of chemotherapy with capecitabine and oxaliplatin, an abdominoperineal resection with D2 (proxD3) lymph node dissection and right adrenalectomy was performed and complete resection was possible. According to the TNM classification, the diagnosis was stage IVA (fT3N1bM1a[ADR]). At 18 months after surgery, the patient is alive with no evidence of recurrence and distant metastasis.

Discussion

Complete resection of adrenal metastasis may have a possibility of leading to a good prognosis in patients with a synchronous solitary adrenal metastasis.

Conclusion

Adrenalectomy should be considered in patients who can undergo complete resection, as it may offer a good long-term prognosis.

Construction of a nomogram to predict overall survival for patients with M1 stage of colorectal cancer: A retrospective cohort study

BACKGROUND

The M1 stage of colorectal cancer (CRC) has a poor prognosis. The aim of this study is to develop a reliable tool for the prediction for CRC patients with M1 stage, thus assisting the strategy of clinical diagnosis and treatment.

METHODS

CRC patient information collected in the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015 was extracted and evaluated. Multivariate analysis with Cox proportional hazards regression identified risk factors that predicted overall survival (OS) and the results were used to construct a nomogram to predict 3-, and 5-year OS in CRC patients with M1 stage. The Kaplan-Meier curve was plotted to evaluate OS differences.

RESULTS

A total of 19,796 patients from the SEER database were included for analysis. All patients were randomly allocated to 2 cohorts, the training cohort (n = 13,860) and the validation cohort (n = 5936). Patients' age at diagnosis; gender; race; tumor site; tumor grade; T and N stage; brain, lung, bone, and liver metastasis status; marital status; and therapy were associated with survival in the multivariate models. All these factors were incorporated to construct a nomogram. Additionally, we divide all 19,796 patients into high-risk group and low-risk group according to our nomogram, and plotted Kaplan-Meier curve. The result indicated that patients with higher risk had worse survival outcomes.

CONCLUSIONS

Our predictive model has the potential to provide an individualized risk estimate of survival in CRC patients with M1 stage.

Long-term survival after adrenal metastasectomy from colorectal cancer: a report of two cases

Background

Solitary adrenal metastasis from colorectal cancer is rare. Adrenal metastasis is usually detected with synchronous multiple metastases in other organs and is, therefore, considered to be unsuitable for surgical resection. The long-term outcomes of patients with solitary adrenal metastasectomy from colorectal cancer have been reported; however, the survival advantage has not been established. We herein report two cases of curative adrenal resection in patients with solitary adrenal metastasis from colorectal cancer who achieved long-term survival of > 9 years without recurrence after surgical resection.

Case presentation

The first case involved a 71-year-old man who underwent abdominoperineal rectal resection for rectal cancer. Preoperative CT revealed a mass in the right adrenal, which was growing after surgery. After chemotherapy the adrenal mass decreased in size, and adrenalectomy was performed at 8 months after the first surgery. A pathological examination confirmed metastasis from rectal cancer. The patient received adjuvant chemotherapy and is currently alive without recurrence at 9 years after the adrenalectomy. The second case involved a 53-year-old man who underwent sigmoidectomy for sigmoid colon cancer. Four years later, lobectomy was performed for isolated lung metastasis. Twenty months later, PET-CT revealed solitary metastasis in the left adrenal gland and adrenalectomy was performed. A histopathological examination revealed metastatic adenocarcinoma of sigmoid cancer. Postoperative chemotherapy was administered after adrenalectomy and the patient is currently alive and apparently disease-free at more than 9 years after undergoing adrenal metastasectomy.

Conclusion

Curative resection for solitary adrenal metastasis from colorectal cancer may be beneficial for survival.

Prognostic Significance of Peritoneal Metastasis in Stage IV Colorectal Cancer Patients With R0 Resection: A Multicenter, Retrospective Study

BACKGROUND

Stage IV colorectal cancer encompasses various clinical conditions. The differences in prognosis after surgery between different metastatic organs have not been fully investigated.

OBJECTIVE

This study aimed to assess prognostic significance in peritoneal metastasis in R0 resected stage IV colorectal cancer.

DESIGN

We conducted a multicenter retrospective study of patients with R0 resected stage IV colorectal cancer; they were categorized into 3 groups according to the number and location of metastatic organs, including single-organ metastasis in the peritoneum, single-organ metastasis at sites except the peritoneum, and multiple-organ metastases.

SETTINGS

This study used data accumulated by the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer.

PATIENTS

A total of 1133 patients with R0 resected stage IV colorectal cancer were registered retrospectively between 1997 and 2007 in 20 referral hospitals.

MAIN OUTCOME MEASURES

Cancer-specific survival rates between the groups were measured.

RESULTS

The median cancer-specific survival of the single-organ metastasis in the peritoneum group was considerably shorter than that of the single-organ metastasis at a site other than the peritoneum group and was almost comparable to that of the multiple-organ metastases group (3.41 years, 6.20 years, and 2.99 years). In a multivariate analysis of cancer-specific survival, peritoneal dissemination was confirmed as an independent prognostic factor of survival. The median postrecurrence survival of single-organ metastasis in the peritoneum group was considerably shorter than that of the single-organ metastasis at a site other than the peritoneum group. Approximately half of the patients who experienced recurrence of single-organ metastasis in the peritoneum experienced peritoneal recurrence.

LIMITATIONS

This was a retrospective, population-based study that requires a prospective design to validate its conclusions.

CONCLUSIONS

Peritoneal metastasis of colorectal cancer frequently recurred in the peritoneum even after R0 resection. The cancer-specific survival of the single-organ metastasis in the peritoneum group was as poor as that of the multiple-organ metastases group. See Video Abstract at http://links.lww.com/DCR/A398.

Influence of primary site on metastatic distribution and survival in stage IV colorectal cancer

BACKGROUND

To assess pattern distribution and prognosis of the three anatomical entities of metastatic colorectal cancer, and influence of treatment of metastases on survival.

METHODS

Patients presenting with stage IV colorectal cancer (synchronous group), or who developed metastatic recurrence (metachronous group) after initial curative treatment between January 2005 and August 2015 were reviewed. Right sided (cecum to transverse colon), left sided (splenic flexure to sigmoid colon) and rectal cancers were identified. Distribution of metastases were noted as hepatic, lung or peritoneal.

RESULTS

Of 374 patients, 276 were synchronous, 98 were metachronous. Metachronous group had a better 3-year survival (54%, 95% CI: 42-64 versus 33%, 95% CI: 27-39, log rank P = 0.0038). There were equal numbers of right (n = 119), left (n = 115) and rectal cancers (n = 140). Rectal cancers had a higher metastatic recurrence, yet demonstrated better 3-year survival (right colon 45%, 95% CI: 19-67, left colon 49%, 95% CI: 27-68, rectum 59%, 95% CI: 42-72, P = 0.39) due to higher proportions of metachronous patients undergoing treatment for metastases (40 versus 14%). Over half of all organ metastases spread to liver, with equal distribution from all three anatomical groups. Rectal cancers showed highest preponderance for lung metastases.

CONCLUSION

Rectal cancers have a higher chance of recurring, with a higher metastatic rate to the lung, yet demonstrate better survival outcomes in metastatic colorectal cancer, reflecting the benefit of intervention for metastases.

Neoadjuvant chemotherapy can improve outcome of colorectal cancer patients with unresectable metastasis

BACKGROUND

The prognosis for colorectal cancer (CRC) patients with unresectable metastases is dismal. This study compared outcomes of different metastatic treatments.

PATIENTS AND METHODS

We collected 653 CRC cases with unresectable metastases including 490 cases receiving primary tumor resection then chemotherapy (surgery group) and 163 patients receiving neoadjuvant chemotherapy then did or did not receive operations (chemotherapy (C/T) group) from 2004 to 2010. The statistical endpoint was overall survival from the date of diagnosis.

RESULTS

In the C/T group, 124 (76%) patients received an operation after 9.0 ± 6.2 months of chemotherapy, including 57 (34.9%) patients with curative surgery. The C/T group had a higher proportion of T4 lesions (37.4%) than the surgery group (26.9%). Survival of the C/T group was longer than that of the surgery group (28.8 ± 8.8 vs. 24.3 ± 7.5 months; p = 0.043). Survival of 57 patients receiving curative surgery was 36.0 ± 6.3 months, which was significantly better than that of the 67 patients receiving palliative resection (25.2 ± 5.6, p < 0.001). In the surgery group, 42 (8.6%) patients received curative metastasectomy after 8.5 ± 7.1 months of postoperative chemotherapy; survival was 30.8 ± 7.8 months, which was significantly better than that of patients who did not receive metastasectomy (22.4 ± 6.3 months). In multivariate analysis, poor differentiation, lymphovascular invasion, isolated cancer nodules, clinical risk score, and curative surgery were independent prognostic factors of overall patient survival.

CONCLUSIONS

Neoadjuvant chemotherapy can improve outcome of CRC patients with unresectable metastases.