A real-world, population-based study of the outcomes of patients with metastatic colorectal cancer to the peritoneum treated with or without cytoreductive surgery

Cytoreductive surgery without intra-peritoneal chemotherapy for metachronous colorectal peritoneal metastases

BACKGROUND

Cytoreductive surgery and chemotherapy reportedly improve the prognosis of patients with metachronous peritoneal metastases. However, the types of peritoneal metastases indicated for cytoreductive surgery remains unclear. Therefore, we aimed to clarify the category of cases for which cytoreductive surgery would be effective and report the prognosis associated with cytoreductive surgery for metachronous peritoneal metastases.

METHODS

This study included 52 consecutive patients who underwent cytoreductive surgery for metachronous peritoneal metastases caused by colorectal cancer between January 2005 and December 2018 and fulfilled the selection criteria. The median follow-up period was 54.9 months. Relapse-free survival was calculated as the time from cytoreductive surgery of metachronous peritoneal metastases to recurrence. Overall survival was defined as the time from cytoreductive surgery of metachronous peritoneal metastases to death or the end of the follow-up period.

RESULTS

The 5-year relapse-free survival rate was 30.0% and the 5-year overall survival rate was 72.3%. None of the patients underwent hyperthermic intraperitoneal chemotherapy. The analysis indicated no potential risk factors for 5-year relapse-free survival. However, for 5-year overall survival, the multivariate analysis revealed that time to diagnosis of metachronous peritoneal metastases of < 2 years after primary surgery (hazard ratio = 4.1, 95% confidence interval = 2.0-8.6, p = 0.0002) and number of metachronous peritoneal metastases ≥ 3 (hazard ratio = 9.8, 95% confidence interval = 2.3-42.3, p = 0.002) as independent factors associated with a poor prognosis.

CONCLUSIONS

Long intervals of more than 2 years after primary surgery and 2 or less metachronous peritoneal metastases were good selection criteria for cytoreductive surgery for metachronous peritoneal metastases from colorectal cancer.

Microsatellite instability should not determine candidacy for cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion in patients with peritoneal metastases from colorectal cancer

BACKGROUND

Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a multimodal therapeutic option for the management of peritoneal metastases (PM). Treatment outcomes for patients with colorectal cancer (CRC) PM undergoing CRS+HIPEC with microsatellite instability (MSI) remain unknown. We examined the patient characteristics and outcomes in patients with MSI CRC after CRS+HIPEC.

METHODS

This was a retrospective cohort study of a prospectively maintained database of all patients with CRC PM undergoing CRS+HIPEC (2010-2020). Categorical and continuous variables were analyzed using the chi-square test and independent samples t test, respectively. Survival was evaluated with the Kaplan-Meier analysis.

RESULTS

There were 324 patients diagnosed as having CRC PM undergoing CRS+HIPEC (MSI, n = 23; microsatellite stable [MSS], n = 301). There was no statistically significant difference in patient demographics, tumor characteristics, or perioperative factors between the 2 groups. There was a trend toward improved survival in the MSI group with a median overall survival (OS) of 96.7 month compared with patients with MSS disease (median OS, 51.4 months; P = .10). Patients with MSI demonstrated median progression-free survival (PFS) 8.5 months compared with 11.4 months in the MSS cohort (P = .28).

CONCLUSION

Patients with CRC PM, regardless of MSI or MSS status, demonstrate similar OS and PFS after CRS+HIPEC. MSI status should not change a patient's candidacy for CRS+HIPEC.

A radiomics-boosted deep-learning for risk assessment of synchronous peritoneal metastasis in colorectal cancer

OBJECTIVES

Synchronous colorectal cancer peritoneal metastasis (CRPM) has a poor prognosis. This study aimed to create a radiomics-boosted deep learning model by PET/CT image for risk assessment of synchronous CRPM.

METHODS

A total of 220 colorectal cancer (CRC) cases were enrolled in this study. We mapped the feature maps (Radiomic feature maps (RFMs)) of radiomic features across CT and PET image patches by a 2D sliding kernel. Based on ResNet50, a radiomics-boosted deep learning model was trained using PET/CT image patches and RFMs. Besides that, we explored whether the peritumoral region contributes to the assessment of CRPM. In this study, the performance of each model was evaluated by the area under the curves (AUC).

RESULTS

The AUCs of the radiomics-boosted deep learning model in the training, internal, external, and all validation datasets were 0.926 (95% confidence interval (CI): 0.874-0.978), 0.897 (95% CI: 0.801-0.994), 0.885 (95% CI: 0.795-0.975), and 0.889 (95% CI: 0.823-0.954), respectively. This model exhibited consistency in the calibration curve, the Delong test and IDI identified it as the most predictive model.

CONCLUSIONS

The radiomics-boosted deep learning model showed superior estimated performance in preoperative prediction of synchronous CRPM from pre-treatment PET/CT, offering potential assistance in the development of more personalized treatment methods and follow-up plans.

CRITICAL RELEVANCE STATEMENT

The onset of synchronous colorectal CRPM is insidious, and using a radiomics-boosted deep learning model to assess the risk of CRPM before treatment can help make personalized clinical treatment decisions or choose more sensitive follow-up plans.

KEY POINTS

Prognosis for patients with CRPM is bleak, and early detection poses challenges. The synergy between radiomics and deep learning proves advantageous in evaluating CRPM. The radiomics-boosted deep-learning model proves valuable in tailoring treatment approaches for CRC patients.

Colorectal cancer: a comprehensive review of carcinogenesis, diagnosis, and novel strategies for classified treatments

Colorectal cancer is the third most common and the second deadliest cancer worldwide. To date, colorectal cancer becomes one of the most important challenges of the health system in many countries. Since the clinical symptoms of this cancer appear in the final stages of the disease and there is a significant golden time between the formation of polyps and the onset of cancer, early diagnosis can play a significant role in reducing mortality. Today, in addition to colonoscopy, minimally invasive methods such as liquid biopsy have received much attention. The treatment of this complex disease has been mostly based on traditional treatments including surgery, radiotherapy, and chemotherapy; the high mortality rate indicates a lack of success for current treatment methods. Moreover, disease recurrence is another problem of traditional treatments. Recently, new approaches such as targeted therapy, immunotherapy, and nanomedicine have opened new doors for cancer treatment, some of which have already entered the market, and many methods have shown promising results in clinical trials. The success of immunotherapy in the treatment of refractory disease, the introduction of these methods into neoadjuvant therapy, and the successful results in tumor shrinkage without surgery have made immunotherapy a tough competitor for conventional treatments. It seems that the combination of those methods with such targeted therapies will go through promising changes in the future of colorectal cancer treatment.

A novel risk model for predicting peritoneal metastasis in colorectal cancer based on the SEER database

BACKGROUND

Early detection and intervention could significantly improve the prognosis of patients with peritoneal metastasis (PM). Our main purpose was to develop a model to predict the risk of PM in patients with colorectal cancer (CRC).

METHODS

Patients from the Surveillance, Epidemiology, and End Results (SEER) database with CRC classified according to the AJCC 8th TNM staging system were selected for the study. After data pre-processing, the dataset was divided into a training set and a validation set. In the training set, univariate logistic analysis and stepwise multivariate logistic regression analysis were utilized to screen clinical features and construct a risk prediction model. Then, we validated the model using the confusion matrix, receiver operating characteristic (ROC) curves, decision curve analysis (DCA), and calibration curves to examine its performance.

RESULTS

The model constructed using stepwise multivariate logistic regression analysis incorporated the following eight clinical features: age, tumor location, histological type, T stage, carcinoembryonic antigen (CEA) level, tumor deposits (TDs), log odds (LODDS) of metastatic lymph nodes, and extraperitoneal metastasis (EM). The areas under the curve (AUCs) of the model in the training and validation sets were 0.924 and 0.912, respectively. The accuracy and the recall ratio were higher than 0.8 in both cohorts. DCA and the calibration curves also confirmed its excellent predictive power.

CONCLUSIONS

Our model can effectively predict the risk of PM in CRC patients, which is of great significance for the timely identification of patients at high risk of PM and further clinical decision-making.

First experience with 224Radium-labeled microparticles (Radspherin®) after CRS-HIPEC for peritoneal metastasis in colorectal cancer (a phase 1 study)

Background

Peritoneal metastasis (PM) from colorectal cancer carries a dismal prognosis despite extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). With a median time to recurrence of 11-12 months, there is a need for novel therapies. Radspherin® consists of the α-emitting radionuclide radium-224 (²²⁴Ra), which has a half-life of 3.6 days and is adsorbed to a suspension of biodegradable calcium carbonate microparticles that are designed to give short-range radiation to the serosal peritoneal surface linings, killing free-floating and/or tumor cell clusters that remain after CRS-HIPEC.

Methods

A first-in-human phase 1 study (EudraCT 2018-002803-33) was conducted at two specialized CRS-HIPEC centers. Radspherin® was administered intraperitoneally 2 days after CRS-HIPEC. Dose escalation at increasing activity dose levels of 1-2-4-7-MBq, a split-dose repeated injection, and expansion cohorts were used to evaluate the safety and tolerability of Radspherin®. The aim was to explore the recommended dose and biodistribution using gamma-camera imaging. The results from the planned safety interim analysis after the completion of the dose-limiting toxicity (DLT) period of 30 days are presented.

Results

Twenty-three patients were enrolled: 14 in the dose escalation cohort, three in the repeated cohort, and six in the expansion cohort. Of the 23 enrolled patients, seven were men and 16 were women with a median age of 64 years (28-78). Twelve patients had synchronous PM stage IV and 11 patients had metachronous PM [primary stage II; (6) and stage III; (5)], with a disease-free interval of 15 months (3-30). The peritoneal cancer index was median 7 (3-19), operation time was 395 min (194-515), and hospital stay was 12 days (7-37). A total of 68 grade 2 adverse events were reported for 17 patients during the first 30 days; most were considered related to CRS and/or HIPEC. Only six of the TEAEs were evaluated as related to Radspherin®. One TEAE, anastomotic leakage, was reported as grade 3. Accordion ≥3 grade events occurred in a total of four of the 23 patients: reoperation due to anastomotic leaks (two) and drained abscesses (two). No DLT was documented at the 7 MBq dose level that was then defined as the recommended dose. The biodistribution of Radspherin® showed a relatively even peritoneal distribution.

Conclusion

All dose levels of Radspherin® were well tolerated, and DLT was not reached. No deaths occurred, and no serious adverse events were considered related to Radspherin®.Clinical Trial Registration: Clinicaltrials.gov, NCT03732781.

Impact of KRAS, BRAF and microsatellite instability status after cytoreductive surgery and HIPEC in a national cohort of colorectal peritoneal metastasis patients

BACKGROUND

Patients with metastatic colorectal cancer (mCRC) carrying BRAF (mutBRAF) or KRAS mutation (mutKRAS) have an inferior prognosis after liver or lung surgery, whereas the prognostic role in the context of peritoneal metastasis (PM) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been less investigated.

METHODS

In total, 257 patients with non-appendiceal PM-CRC were included from the Norwegian National Unit for CRS-HIPEC.

RESULTS

In total, 180 patients received CRS-HIPEC with Mitomycin C, 77 patients received palliative surgery only. In the CRS-HIPEC group, mutBRAF was found in 24.7%, mutKRAS 33.9% and double wild-type 41.4% without differences in survival. MSI was found in 29.3% of mutBRAF cases. Patients with mutBRAF/MSI had superior 5-year survival compared to mutBRAF with MSS (58.3% vs 25.2%, P = 0.022), and better 3-year disease-free survival (DFS) compared to mutKRAS (48.6% vs 17.2%, P = 0.049). Peritoneal Cancer Index and the number of lymph node metastasis were prognostic for OS, and the same two, location and gender prognostic for DFS in multivariate analysis.

CONCLUSIONS

PM-CRC with CRS-HIPEC patients has a surprisingly high proportion of mutBRAF (24.7%). Survival was similar comparing mutBRAF, mutKRAS and double wild-type cases, whereas a small subgroup with mutBRAF and MSI had better survival. Patients with mutBRAF tumours and limited PM should be considered for CRS-HIPEC.

A real-world, population-based study for the outcomes of patients with metastatic colorectal cancer to the liver with distant lymph node metastases treated with metastasectomy

Aim: To assess the impact of metastasectomy on survival outcomes of patients with concurrent liver and distant nodal metastases. Materials & methods: Surveillance, Epidemiology, and End Results (SEER) database was accessed and patients with colorectal liver metastases (with or without distant lymph node involvement) were reviewed. Kaplan-Meier survival estimates were then used to assess the impact of the presence of distant lymph node metastases as well as the impact of metastasectomy on overall and cancer-specific survival. A propensity score matching was then conducted between patients with distant lymph node metastases who had surgery versus those who did not have surgery. Results: A total of 15,325 patients were included in the current analysis including 1603 patients who have liver and distant nodal metastases (10.5%) and 13,722 patients who have liver metastases only (89.5%). The following factors were associated with better overall survival (OS): younger age (hazard ratio [HR] with increasing age: 1.024; 95% CI: 1.022-1.025), white race (HR for African-American race vs white race: 1.233; 95% CI: 1.175-1.295), distal site of the primary (HR: 0.808; 95% CI: 0.778-0.840), absence of distant lymph nodes (HR: 0.697; 95% CI: 0.659-0.737), metastasectomy (HR for no metastasectomy vs metastasectomy: 1.954; 95% CI: 1.858-2.056). Within the postpropensity cohort, metastasectomy was associated with improved OS among patients with concurrent distant lymph node and liver metastases (median OS of 20 vs 11 months; p < 0.001). Conclusion: Metastasectomy seems to be associated with improved survival among patients with concurrent lymph node and liver metastases. It is unclear if improved survival is related to the surgical intervention or to the fact that surgically treated patients have a better baseline general condition and hence improved outcomes.

Quxie Capsule Modulating Gut Microbiome and Its Association With T cell Regulation in Patients With Metastatic Colorectal Cancer: Result From a Randomized Controlled Clinical Trial

Aim:

Quxie capsule(QX), a TCM compound, had shown benefit on survival outcomes for metastatic colorectal cancer(mCRC) patients and could inhibit tumor growth through immune regulation. This study aimed to evaluate whether such effect is associated with gut microbiome modulation.

Method:

We conducted a randomized double-blinded placebo controlled clinical trial in Xiyuan Hospital, China Academy of Chinese Medical Sciences. All patients were randomly assigned into QX or placebo control group. Before and after 1-month interventions, we collected patients’ stool samples for microbiome analysis by 16s rRNA sequencing approaches, as well as blood samples to analyze T lymphocyte subsets by flow cytometry methods. Microbiome analysis among groups was done through bioinformation analysis platform. The study had been proved by the ethics committee of Xiyuan Hospital (2016XLA122-1) had been registered on Chinese Clinical Trial Registry (registration number: ChiCTR2000029599). All patients consented before enrollment.

Results:

We randomly assigned 40 patients and 34 were finally analyzed. Among them, 29% were female, with an average age of 63 years old, and 74% had liver or lung metastasis. Both CD4 T(TH) cell and CD8 T(TC) cell counts increased after QX treatment, while TH cells were significantly more in QX than in control group (737 vs 449, P = .024). Microbiome community analysis on Class level showed that the proportion of Actinobacteria declined in the control group, but significantly increased after QX treatments (0.83% vs 4.7%, P = .017). LEfSe analysis showed that after treatments, samples from QX group were highly related with Oscillibacter, Eubacterium, and Lachnospiraceae. RDA analysis showed that after QX interventions, stool samples and microbiome species had relevance with TC/TH cells counts but were not statistically significant. Heatmap analysis on Genus level revealed that after QX treatments, higher amounts of TH cells were significantly associated with less abundance of g_Bifidobacterium (coef. −0.76, P = .002), Collinsella (coef.−0.61, P = .02), Ruminiclostridium_9 (coef. −0.64, P = .01).

Conclusion:

QX capsule could enhance TH cells level among mCRC patients and increase the abundance of gut anticancer bacteria such as Actinobacteria as well as butyrate-producing bacteria such as Lachnospiraceae. These results indicated that QX capsule might have the property of dual effects of antitumor and immunity enhancement, both mediated by the microbiome.

Development and Validation of a Prognostic Nomogram for Colorectal Cancer Patients With Synchronous Peritoneal Metastasis

Purpose

Synchronous peritoneal metastasis (S-PM) is considered a poor prognostic factor for colorectal cancer (CRC) and there is no nomogram to predict the survival of these patients. In this study, we aimed to use a multicenter data to identify the factors associated with S-PM of CRC to construct a nomogram for predicting the overall survival (OS) of these patients.

Methods

CRC patients with S-PM from two medical centers were enrolled between September 2007 and June 2017. Multivariate analysis was used to identify independent factors associated with OS for the nomogram to predict the 1-, 2-, and 3-year OS rates in the development group. The concordance index (C-index), calibration plot, relative operating characteristic (ROC) curve with area under the curve (AUC) were calculated to evaluate the performance of the nomogram in both the development and an external validation group.

Results

277 CRC patients with S-PM in the development group and 68 patients in the validation group were eligible for this study. In multivariate analysis of development group, age, carbohydrate antigen 19-9 (CA19-9), carbohydrate antigen 125 (CA125), cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), and chemotherapy were independent variables for OS, based on which the nomogram was built. The C-index of the nomogram in the development and validation group was 0.701 (95% Cl, 0.666–0.736) and 0.716 (95% Cl, 0.622–0.810); demonstrating good discriminative ability. The calibration plots showed satisfactory consistency between actual observation and nomogram-predicted OS probabilities in the development and external validation group. The nomogram showed good predictive accuracy for 1-, 2-, and 3-year OS rates in both groups with AUC >0.70. An online dynamic webserver was also developed for increasing the ease of the nomogram.

Conclusions

We developed and validated a predictive nomogram with good discriminative and high accuracy to predict the OS in CRC patients with S-PM.

Outcomes of small-cell versus large-cell gastroenteropancreatic neuroendocrine carcinomas: A population-based study

The recent World Health Organization classification for gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) classified poorly differentiated GEP-NENs into small cell and large cell categories. The present study aimed to assess the differences in outcomes between patients with both histological categories. The Surveillance, Epidemiology and End Results (SEER) database (1975-2016) was accessed and patients with small cell and large cell GEP-neuroendocrine carcinomas (NECs) were extracted. Differences in survival outcomes were explored through Kaplan-Meier survival estimates and multivariable Cox regression models. In total, 2204 patients with GEP-NEC were identified in the survival cohort, including 1698 patients with small cell NEC (77%) and 506 patients with large cell NEC (23%). Using Kaplan-Meier analysis/log-rank testing, large cell GEP-NEC was associated with better overall survival compared to small cell NEC (P < 0.01). Using multivariable Cox regression analysis, large cell GEP-NEC was associated with better overall survival (large cell GEP-NEC versus small cell GEP-NEC, hazard ratio = 0.77; 95% confidence interval = 0.68-0.86) and cancer-specific survival (large cell GEP-NEC versus small cell GEP-NEC, hazard ratio = 0.79; 95% 95% confidence interval = 0.69-0.91). Patients with small cell GEP-NEC have worse survival outcomes compared to those with large cell GEP-NEC. Further efforts are needed to identify biological differences and treatment sensitivities between both histological categories.

Factors Prognostic for Peritoneal Metastases from Colorectal Cancer Treated with Surgery

Purpose

To analysis factors prognostic for peritoneal metastases (PM) from colorectal cancer (CRC) treated with surgery using data from two sources and investigate the origin and effective treatment of ovarian metastases (OM).

Patients and Methods

Data from CRC patients with PM who had undergone surgery were collected from the Surveillance, Epidemiology, and End Results (SEER) database (n = 639) and a single Chinese institution (n = 60). Cumulative survival was evaluated by Kaplan–Meier analysis. Factors associated with overall survival (OS) and progression-free survival (PFS) prognosis were assessed using Cox’s proportional hazard regression models.

Results

Median OS values for patients who underwent surgery were 19 and 32 months in the SEER database and Chinese center, respectively. Age was an independent predictor of OS in both datasets. Signet-ring cell cancer and perineural invasion were independent predictors of inferior OS only in the SEER dataset, while completeness of cytoreduction (CC) and peritoneal carcinomatosis index were independent predictors for OS and PFS only in the Chinese center. Median OS was 24 months in CRC patients with PM alone and 36 months in those with both PM and OM (p = 0.181). Further, median PSF in patients with PM alone was 10 months, while that in individuals with both PM and OM was 20 months (p = 0.181).

Conclusion

Surgical treatment of the primary and metastatic sites is effective and safe for CRC patients with PM. CC-0 is recommended for improved prognosis. Moreover, OM should be recognized as a feature of PM, and cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy is beneficial for CRC patients with OM.

Impact of Surgical Resection on Metachronous Metastases of Colorectal Cancer According to Tumor Doubling Time

BACKGROUND/AIM

We aimed to elucidate the prognostic impact of tumor doubling time (DT) and radical surgery when classified by DT in patients with metachronous liver, lung, or peritoneal metastases of colorectal cancer (CRC).

PATIENTS AND METHODS

We reviewed the data of 1941 patients who underwent curative surgery for CRC and calculated DT for recurrences using computed tomography.

RESULTS

Short DT was an independent prognostic risk factor in liver (p<0.001) and peritoneal (p=0.03) metastases. Survival was significantly better in patients who underwent surgery than in those who did not, both in short and long DT groups in any metastatic organ (p<0.01). Patients with long DT gained significantly better prognostic benefit from surgery than those with short DT in liver (p=0.01) and peritoneal (p=0.04) metastases.

CONCLUSION

Surgery is recommended for resectable metastases, especially in patients with liver and peritoneal metastases with long DT.

Impact of cytoreductive surgery on outcomes of metastatic appendiceal carcinoma: a real-world, population-based study

Aim: To evaluate the impact of cytoreductive surgery on the outcomes of patients with metastatic appendiceal carcinoma. Methods: Surveillance, Epidemiology and End Results (SEER) database was accessed and patients with metastatic appendiceal carcinoma diagnosed (2010-2015) were reviewed. Kaplan-Meier survival estimates/log-rank testing were then used to assess overall survival outcomes according to cytoreductive surgery. Multivariable Cox regression analysis was then used to evaluate factors affecting cancer-specific survival. Factors included in this model were age, race, sex, stage and histology and cytoreductive surgery. Results: A total of 1339 patients with metastatic appendiceal carcinoma were included in the current study. Using Kaplan-Meier survival estimates to evaluate overall survival, patients with surgery for metastatic disease have better overall survival compared with patients without surgery for metastatic disease (p < 0.001). Stratifying survival analysis according to histology, the overall survival benefit from surgery for the metastases seems to be limited to patients with mucinous adenocarcinoma (p = 0.002) rather than patients with nonmucinous adenocarcinoma (p = 0.401). Multivariable Cox regression analysis was then conducted to evaluate factors predicting cancer-specific survival. The following factors were associated with worse cancer-specific survival: African-American race (hazard ratio [HR]: 1.356; 95% CI: 1.036-1.774; p = 0.026), more advanced stage (HR: 3.910; 95% CI: 2.735-5.588; p < 0.001), nonmucinous adenocarcinoma (HR for signet ring carcinoma vs mucinous adenocarcinoma: 2.119; 95% CI: 1.674-2.683; p < 0.001) and no surgical resection of metastatic disease (HR: 1.273; 95% CI: 1.067-1.519; p < 0.001). Conclusion: The current study suggests that among patients with metastatic appendiceal carcinoma, surgical cytoreduction of metastatic disease is associated with improved outcomes for patients with mucinous adenocarcinoma but not in patients with nonmucinous adenocarcinoma.