Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review

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.

The ELECLA trial: A multicentre randomised control trial on outcomes of neoadjuvant treatment on locally advanced colon cancer

BACKGROUND

Colon cancer (CC) is a public health concern with increasing incidence in younger populations. Treatment for locally advanced CC (LACC) involves oncological surgery and adjuvant chemotherapy (AC) to reduce recurrence and improve overall survival (OS). Neoadjuvant chemotherapy (NAC) is a novel approach for the treatment of LACC, and research is underway to explore its potential benefit in terms of survival. This trial will assess the efficacy of NAC in LACC.

METHODS

This is a multicentre randomised, parallel-group, open label controlled clinical trial. Participants will be selected based on homogenous inclusion criteria and randomly assigned to two treatment groups: NAC, surgery, and AC or surgery followed by AC. The primary aim of this study is to evaluate the 2-year progression-free survival (PFS), with secondary outcomes including 5-year PFS, 2- and 5-year OS, toxicity, radiological and pathological response, morbidity, and mortality.

DISCUSSION

The results of this study will determine whether NAC induces a clinical and histological tumour response in patients with CCLA and if this treatment sequence improves survival without increasing morbidity and mortality.

REGISTRATION NUMBER

NCT04188158.

Effects of neoadjuvant chemotherapy for patients with obstructive colon cancer: A multicenter propensity score-matched analysis (YCOG2101)

Aim

Obstructive colon cancer is locally advanced colon cancer with poor prognosis. However, the effect of neoadjuvant chemotherapy (NAC) on obstructive colon cancer remains unclear. Therefore, this study aimed to investigate the safety and efficacy of NAC in patients with obstructive colon cancer.

Methods

From January 2012 to December 2017, we collected patient data for clinical stage II/III obstructive colon cancer at seven Yokohama Clinical Oncology Group (YCOG) institutions. The long-term outcomes of the NAC and non-NAC groups were analyzed retrospectively after adjusting for patients' background characteristics using propensity score matching.

Results

Among the 202 eligible patients, propensity score matching extracted 51 patients each for the NAC and non-NAC groups. After matching, the groups showed no marked differences in the background factors. All the patients in the NAC group underwent diverting stoma construction. Nineteen patients (37.3%) experienced grade 3-4 adverse events during NAC. The incidence of postoperative complications was similar between groups. The 5-year progression-free survival rates were 75.8% in the NAC group and 63.0% in the non-NAC group (p = 0.22, log-rank test). The 5-year overall survival rates were 88.5% in the NAC group and 78.8% in the non-NAC group (p = 0.09, log-rank test).

Conclusion

Although NAC was feasible for obstructive colon cancer after diverting stoma construction, its effects on long-term outcomes could not be proven.

The diagnostic accuracy of local staging in colon cancer based on computed tomography (CT): evaluating the role of extramural venous invasion and tumour deposits

PURPOSE

The shift from adjuvant to neoadjuvant treatment in colon cancer demands the radiological selection of patients for systemic therapy. The aim of this study was to evaluate the accuracy of the CT-based TNM stage and high-risk features, including extramural venous invasion (EMVI) and tumour deposits, in the identification of patients with histopathological advanced disease, currently considered for neoadjuvant treatment (T3-4 disease).

METHODS

All consecutive patients surgically treated for non-metastatic colon cancer between January 2018 and January 2020 in a referral centre for colorectal cancer were identified retrospectively. All tumours were staged on CT according to the TNM classification system. Additionally, the presence of EMVI and tumour deposits on CT was evaluated. The histopathological TNM classification was used as reference standard.

RESULTS

A total of 176 patients were included. Histopathological T3-4 colon cancer was present in 85.0% of the patients with CT-detected T3-4 disease. Histopathological T3-4 colon cancer was present in 96.4% of the patients with CT-detected T3-4 colon cancer in the presence of both CT-detected EMVI and CT-detected tumour deposits. Histopathological T0-2 colon cancer was present in 50.8% of the patients with CT-detected T0-2 disease, and in 32.4% of the patients without CT-detected EMVI and tumour deposits.

CONCLUSION

The diagnostic accuracy of CT-based staging was comparable with previous studies. The presence of high-risk features on CT increased the probability of histopathological T3-4 colon cancer. However, a substantial part of the patients without CT-detected EMVI and tumour deposits was diagnosed with histopathological T3-4 disease. Hence, more accurate selection criteria are required to correctly identify patients with locally advanced disease.

Colonic stent as a bridge to surgery versus emergency rection for malignant left-sided colorectal obstruction: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The role of self-expanding metal stent (SEMS) implantation as a bridge to surgery in malignant left-sided colorectal obstruction (MLCO) remains controversial.

OBJECTIVE

To evaluate the safety of SEMS implantation versus emergency surgery (ER) in the treatment of MLCO.

METHODS

Four major literature databases (Cochrane Library, Embase, PubMed, and Web of Science) were searched to collect articles published before April 20, 2023. After determining random or fixed-effect models based on heterogeneity tests, odds ratios (RR) or standardized mean differences (SMD) with their respective 95% confidence intervals (CI) were calculated.

RESULTS

Nineteen randomized controlled studies were included. The main outcomes included overall tumor recurrence rate, 30-day mortality rate, and overall incidence of complications. Secondary outcomes included mortality-related indicators, tumor recurrence-related indicators, surgery-related indicators, and other relevant indicators. The study found that there was no significant difference in the 30-day mortality rate between the SEMS group and the er group. However, the SEMS group had a lower overall incidence of complications (RR = 0.787, P = .004), lower incision infection rate (RR = 0.472, P = .003), shorter operation time (SMD = -0.591, P = .000), lower intraoperative blood loss (SMD = -1.046, P = .000), lower intraoperative transfusion rate (RR = 0.624, P = .021), lower permanent stoma rate (RR = 0.499, P = .000), lower overall stoma rate (RR = 0.520,P = .000), shorter hospital stay (SMD = -0.643, P = .014), and more lymph node dissections during surgery (SMD = 0.222, 95% CI: 0.021-0.423, P = .031), as well as a higher primary anastomosis rate (RR = 0.472, 95% CI: 0.286-0.7 77, P = .003), among other advantages. However, the SEMS group had a higher overall tumor recurrence rate (RR = 1.339, P = .048).

CONCLUSION

SEMS has significant advantages over er in relieving clinical symptoms and facilitating postoperative recovery in MLCO, but does not reduce the tumor recurrence rate. Neoadjuvant chemotherapy combined with SEMS may provide a new approach to the treatment of MLCO.

A locally advanced colon cancer patient with Muir-Torre syndrome obtains durable response to neoadjuvant and adjuvant immunotherapy

INTRODUCTION

Muir-Torre syndrome, presenting with cutaneous tumors and visceral malignancies, is a variant of Lynch syndrome. The development of immune checkpoint inhibitors provided novel effective treatment options for metastatic colorectal cancer patients with microsatellite instability and deficient mismatch repair. However, the use of immune checkpoint inhibitors in neoadjuvant and adjuvant settings for patients with locally advanced colorectal cancer remains undefined because of limited follow-ups in current studies.

CASE PRESENTATION

In the present study, we reported a 33-year-old Muri-Torre syndrome patient with stage ⅢC (c.T4N2M0) colorectal cancer and keratoacanthoma. Microsatellite instability / deficient mismatch repair, high tumor mutation burden, and MSH2 germline mutation were identified by next-generation sequencing. Pembrolizumab monotherapy was used as neoadjuvant treatment and the patient achieved a major pathological response. After surgical resection, pembrolizumab was continuously used in an adjuvant setting for 12 months. The patient remained disease-free with a durable disease-free survival for 44 months. To our knowledge, this is the first and longest follow-up study reporting pembrolizumab as a single-agent neoadjuvant therapy for locally advanced colon cancer.

CONCLUSIONS

The results demonstrate promising performance in neoadjuvant and adjuvant settings. Further studies are needed to confirm its potential usefulness as an outcome measure in clinical practice.

Is There a Role for Neoadjuvant Systemic Therapy for cT4bM0 Colon Cancer? A Propensity Score-Matched Analysis of the National Cancer Database

BACKGROUND

Nonmetastatic T4b colon cancer has been traditionally treated with upfront surgery, often requiring technically challenging multiorgan resection. Neoadjuvant chemotherapy can potentially downsize these tumors and improve their resectability.

OBJECTIVE

This study aimed to explore trends and outcomes of neoadjuvant chemotherapy use compared to upfront surgery in patients with nonmetastatic T4b colon cancer. This study also sought to determine factors associated with increased neoadjuvant chemotherapy use and with overall survival.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted using the National Cancer Database.

PATIENTS

Patients with nonmetastatic T4b colon cancer who underwent colectomy (2006-2016) were included in the study. Patients receiving neoadjuvant chemotherapy were propensity-matched (1:2) to those who underwent upfront surgery in either clinically node-negative or node-positive disease.

MAIN OUTCOME MEASURES

Postoperative outcomes (length of stay, 30-d readmission, 30/90-d mortality), oncologic resection adequacy (R0 rate, number of resected/positive nodes), and overall survival were the main outcome measures.

RESULTS

Neoadjuvant chemotherapy was used in 7.7% of the patients. Neoadjuvant chemotherapy use increased over the study period from 4% to 16% in the entire cohort, from 3% to 21% in patients with clinically node-positive disease, and from 6% to 12% in patients with clinically node-negative disease. Factors associated with increased use of neoadjuvant chemotherapy included younger age (OR 0.97; 95% CI, 0.96-0.98; p < 0.001), male sex (OR 1.35; 95% CI, 1.11-1.64; p = 0.002), recent diagnosis year (OR 1.16; 95% CI, 1.12-1.20; p < 0.001), academic centers (OR 2.65; 95% CI, 2.19-3.22; p < 0.001), clinically node-positive (OR 1.23; 95% CI, 1.01-1.49; p = 0.037), and tumor located in the sigmoid colon (OR 2.44; 95% CI, 1.97-3.02; p < 0.001). Patients who received neoadjuvant chemotherapy had significantly higher R0 resection compared with upfront surgery (87% vs 77%; p < 0.001). On multivariable analysis, neoadjuvant chemotherapy was associated with higher overall survival (HR 0.76; 95% CI, 0.64-0.91; p = 0.002). On propensity-matched analyses, neoadjuvant chemotherapy was associated with a higher 5-year overall survival compared to upfront surgery in patients with clinically node-positive disease (57% vs 43%; p = 0.003) but not in patients with clinically node-negative disease (61% vs 56%; p = 0.090).

LIMITATIONS

Retrospective design.

CONCLUSION

Neoadjuvant chemotherapy use for nonmetastatic T4b has increased significantly on the national level, more so in patients with clinically node-positive disease. Patients with node-positive disease treated with neoadjuvant chemotherapy had higher overall survival compared to those who underwent upfront surgery. See Video Abstract at http://links.lww.com/DCR/C228 .

EXISTE LUGAR PARA LA TERAPIA SISTMICA NEOADYUVANTE PARA EL CNCER DE COLON CTBM UN ANLISIS EMPAREJADO DE PUNTAJE DE PROPENSIN DE LA BASE DE DATOS NACIONAL DEL CNCER

ANTECEDENTES:El cáncer de colon T4b no metastásico se ha tratado tradicionalmente con cirugía inicial, que frecuentemente requiere de una resección multiorgánica técnicamente desafiante. La quimioterapia neoadyuvante puede potencialmente reducir el tamaño y mejorar la resecabilidad de esos tumores.OBJETIVO:Explorar las tendencias y los resultados del uso de quimioterapia neoadyuvante en pacientes con cáncer de colon T4b no metastásico, en comparación con la cirugía inicial. Determinar los factores asociados con el aumento del uso de quimioterapia neoadyuvante y con la supervivencia general.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Utilizando de la Base de Datos Nacional del Cáncer.PACIENTES:Pacientes con cáncer de colon T4b no metastásico sometidos a colectomía (2006-2016). Los pacientes que recibieron quimioterapia neoadyuvante fueron emparejados por propensión (1:2) con aquellos sometidos a cirugía inicial, ya sea en enfermedad clínica con ganglios negativos o ganglios positivos.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios (duración de la hospitalización, reingreso a los 30 días, mortalidad a los 30/90 días), adecuación de la resección oncológica (tasa R0, número de ganglios resecados/positivos) y supervivencia general.RESULTADOS:La quimioterapia neoadyuvante se utilizó en el 7,7% de los pacientes. El uso de quimioterapia neoadyuvante aumentó durante el período de estudio del 4% al 16% en toda la cohorte; del 3% al 21% en pacientes con enfermedad clínica y ganglios positivos; y del 6% al 12% en pacientes con enfermedad clínica y ganglios negativos. Los factores asociados con un mayor uso de quimioterapia neoadyuvante incluyeron, edad más joven (OR 0,97, IC del 95 %: 0,96-0,98, p < 0,001), sexo masculino (OR 1,35, IC del 95 %: 1,11-1,64, p = 0,002), año de diagnóstico mas reciente (OR 1,16, 95% IC: 1,12-1,20, p < 0,001), centros académicos (OR 2,65, 95% IC: 2,19-3,22, p < 0,001), enfermedad clínica con ganglios positivos (OR 1,23, 95% IC: 1,01-1,49, p = 0,037), y tumor localizado en colon sigmoide (OR 2,44, 95% IC: 1,97-3,02, p < 0,001). Los pacientes que recibieron quimioterapia neoadyuvante tuvieron una resección R0 significativamente mayor en comparación con la cirugía inicial (87 % frente a 77 %, p < 0,001). En análisis multivariable, la quimioterapia neoadyuvante se asoció con una mayor supervivencia global (HR 0,76, IC del 95%: 0,64-0,91, p = 0,002). En los análisis de propensión pareada, la quimioterapia neoadyuvante se asoció con una mayor supervivencia general a los 5 años en comparación con la cirugía inicial en pacientes con enfermedad clínica con ganglios positivos (57% frente a 43%, p = 0,003), pero no en pacientes con enfermedad clínica y ganglios negativos (61% vs 56%, p = 0,090).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:El uso de quimioterapia neoadyuvante para T4b no metastásico ha aumentado significativamente a nivel nacional, más aún en pacientes con enfermedad clínica y ganglios positivos. Los pacientes con enfermedad y ganglios positivos tratados con quimioterapia neoadyuvante tuvieron una mayor supervivencia general en comparación con la cirugía inicial. Consulte Video Resumen en http://links.lww.com/DCR/C228 . (Traducción-Dr. Fidel Ruiz Healy ).

Nationwide practice in CT-based preoperative staging of colon cancer and concordance with definitive pathology

INTRODUCTION

In an era of exploring patient-tailored treatment options for colon cancer, preoperative staging is increasingly important. This study aimed to evaluate completeness and reliability of CT-based preoperative locoregional colon cancer staging in Dutch hospitals.

MATERIALS AND METHODS

Patients who underwent elective oncological resection of colon cancer without neoadjuvant treatment in 77 Dutch hospitals were evaluated between 2011 and 2021. Completeness of T-stage was calculated for individual hospitals and stratified based on a 60% cut-off. Concordance between routine CT-based preoperative locoregional staging (cTN) and definitive pathological staging (pTN) was examined.

RESULTS

A total of 59,558 patients were included with an average completeness of 43.4% and 53.4% for T and N-stage, respectively. Completeness of T-stage improved from 4.9% in 2011-2014 to 74.4% in 2019-2021. Median completeness for individual hospitals was 53.9% (IQR 27.3-80.5%) and were not significantly different between low and high-volume hospitals. Sensitivity and specificity for T3-4 tumours were relatively low: 75.1% and 76.0%, respectively. cT1-2 tumours were frequently understaged based on a low negative predictive value of 56.8%. Distinction of cT4 and cN2 disease had a high specificity (>95%), but a very low sensitivity (<50%). Positive predictive values of <60% indicated that cT4 and cN1-2 were often overstaged. Completeness and time period did not influence reliability of staging.

CONCLUSION

Completeness of locoregional staging of colon cancer improved during recent years and varied between hospitals independently from case volume. Discriminating cT1-2 from cT3-4 tumours resulted in substantial understaging and overstaging, additionally cT4 and cN1-2 were overstaged in >40% of cases.

Relationship between histopathological therapeutic effect and prognosis in oral cancer patients after preoperative S-1 chemotherapy followed by surgery

OBJECTIVES

Preoperative S-1 chemotherapy is administered to prevent tumor proliferation before surgery in oral squamous cell carcinoma (OSCC). The aim of this study was to investigate the relationship between the histological therapeutic effect and prognosis in patients with OSCC after pre-operative S-1 chemotherapy.

MATERIALS AND METHODS

Among 461 OSCC cases, 281 patients who received preoperative S-1 chemotherapy were compared with 180 patients that did not receive chemotherapy to determine the histological therapeutic effect in the resected specimens and the differences in relapse-free survival.

RESULTS

The histological chemotherapeutic effect was well correlated with the subsequent prognosis. In an examination of the combined effect of treatment and ypStage, the groups with good S-1 treatment effects had extremely good prognoses, even if the postoperative resection specimens were within the same ypStage. In a stratified search of patients who received S-1 for more than 7 days and who had a significantly better prognosis than those who did not receive S-1, it was found that the prognosis was significantly better for patients with tongue cancer according to site; furthermore, tongue cancer, age under 70 years of age, male sex, and clinical stage I were factors associated with a significantly better prognosis.

CONCLUSIONS

Even if the postoperative resection specimens were within the same ypStage, the groups that responded to S-1 treatment were considered to have extremely good prognoses.

CLINICAL RELEVANCE

A good adaptation for S-1 was tongue cancer, and especially tongue cancer with cStage I, male sex, and age less than 70 years old.

E2F3 accelerates the stemness of colon cancer cells by activating the STAT3 pathway

Introduction

Colon cancer is one of the most prevalent malignancies and causes of cancer-related deaths worldwide. Thus, further research is required to explicate the latent molecular mechanisms and look for novel biomarkers. E2F3 has been confirmed to be an oncogene in a variety of cancers. However, the particular regulation of E2F3 in colon cancer needs further investigation.

Methods

The self-renewal ability was detected through a sphere formation assay. The tumorigenic ability was measured through nude mice in vivo assay. The protein expression of genes was examined through a Western blot. The expression of E2F3 in tumor tissues was detected through an IHC assay. The resistance to cisplatin was assessed through the CCK-8 assay. The cell migration and invasion abilities were measured after upregulating or suppressing E2F3 through the Transwell assay.

Results

Results uncovered that E2F3 was upregulated in spheroid cells. In addition, E2F3 facilitates stemness in colon cancer. Moreover, E2F3 facilitated colon cancer cell migration and invasion. Finally, it was revealed that E2F3 affected the STAT3 pathway to modulate stemness in colon cancer. E2F3 served as a promoter regulator in colon cancer, aggravating tumorigenesis and stemness in colon cancer progression through the STAT3 pathway.

Conclusion

E2F3 may be a useful biomarker for anticancer treatment in colon cancer.

Recurrence After Colectomy for Locally Advanced Colon Cancer: Experience from a Developing Country

Risk factors for disease recurrence following curative resection for locally advanced colon cancer (LACC) remain unclear as conflicting results have been reported in the literature. The aim of this study was to examine these factors in the setting of developing country's health care system affected by limited accessibility to the multimodal cancer treatment. Patients who had undergone curative colon resection for LACC between 2004 and 2018 were included. Data were obtained from a prospectively maintained database. Factors associated with disease recurrence, types of recurrence and recurrence-free survival were studied. A total of 118 patients with LACC were operated within the study period. Median follow-up was 36 (2-147) months. Adjuvant therapy was used in 41 (34.7%) patients and 62 (52.5%) were diagnosed with recurrence. In the multivariable analysis, disease recurrence was associated with tumor and nodal stages, as well as with the lymph node yield. Local recurrence, distant metastases, and peritoneal carcinomatosis were observed in 8 (6.8%), 30 (25.4%), and 24 (20.3%) patients, respectively. Early recurrence was diagnosed in 27 (22.9%) cases with peritoneal carcinomatosis being its most common type. Preoperative serum CA 19-9 levels, tumor, and nodal stages were linked to recurrence-free survival in the univariable analysis. Only tumor stage remained such in the multivariable model. Our findings suggest that lymph node yield, tumor, and nodal stages are associated with recurrence following curative resection for LACC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01672-x.

Current Controversies in the Management of Locally Advanced Colon Cancer

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Pathological response and safety of FOLFOXIRI for neoadjuvant treatment of high-risk relapsed locally advanced colon cancer: study protocol for a single-arm, open-label phase II trial

INTRODUCTION

Neoadjuvant chemotherapy (NAC) has been demonstrated effective in several tumours, but its benefit has not yet been elucidated in colorectal cancer, especially locally advanced colorectal cancer (LACRC).

METHODS AND ANALYSIS

This is a single-arm, open-label, prospective phase II exploratory clinical trial. Patients with LACRC will receive four cycles of NAC with 5-fluorouracil, oxaliplatin and irinotecan (FOLFOXIRI), followed by operation and then adjuvant chemotherapy with capecitabine and oxaliplatin for two to five cycles or single-agent capecitabine for five cycles, or observation. The primary endpoint is the rate of tumour regression grade (TRG) 0-2 in the resected tumour tissue, which is evaluated by experienced pathologists according to the Ryan R TRG grading system. Secondary endpoints include objective response rate, pathologic complete response, microscopically complete resection rate, progression-free survival, distant metastasis-free survival, overall survival, toxicity and compliance to study treatment, molecular markers, quality of life to study treatment and the number of patients with 30-day postoperative mortality. The objective of this study is to analyse the efficacy and safety of FOLFOXIRI as the NAC regimen in patients with LACRC and to identify a promising treatment strategy in this setting.

ETHICS AND DISSEMINATION

Written informed consent will be required from and provided by all patients enrolled. The study protocol has been approved by the independent ethics committee of West China Hospital, Sichuan University (approval number: 2021403). This study will demonstrate the potential benefit of NAC with the FOLFOXIRI regimen. Results will be shared with policymakers and the academic community to promote the clinical management of colon cancer.

TRIAL REGISTRATION NUMBER

NCT05018182.

Baicalin-Loaded Lipid-Polymer Hybrid Nanoparticles Inhibiting the Proliferation of Human Colon Cancer: Pharmacokinetics and In Vivo Evaluation

This research work is focused on pharmacokinetic and biochemical experiments to assess baicalin-loaded lipid-polymer hybrid nanoparticles (LPHNPs) with colon-targeting specificity. The nanoprecipitation method was used to develop the LPHNPs, and the characterized formulation revealed the 184.3 nm particle size, PDI of 0.177, spherical shape, and zeta potential of -19.8 mV. The baicalin LPHNPs are said to be poorly absorbed in the stomach and small intestine, and in vitro drug release tests have shown that the drug is released mostly in the caecal fluid. Additionally, the LPHNPs showed stability and nonsignificant drug loss at 25 °C for 3 months. The least viable population of baicalin-loaded LPHNPs was detected at a lower IC₅₀ value after 48 h, and no cytotoxicity was observed by blank suspension and blank LPHNPs up to the concentration of 100 µg/mL. Apart from this, the pharmacokinetics study showed that baicalin from LPHNPs is much less absorbed and least available in the blood plasma and maximum available in the colon. Concurrently, organ distribution studies demonstrated that baicalin-loaded LPHNPs were distributed more widely in the colon compared to baicalin suspension. Moreover, baicalin-loaded LPHNPs were found to be superior to a baicalin suspension in reducing elevated liver enzyme levels. In a nutshell, baicalin-loaded LPHNPs show superior efficacy and can be maximally localized into the colon rectal cancer along with systemic availability of the drug.

Prognostic value of the ascites characteristics in pseudomyxoma peritonei originating from the appendix

Background

Pseudomyxoma peritonei (PMP) is a rare disease, with the overall survival (OS) influenced by many factors. To date, no ascites characteristics have been reported to predict OS of patients with PMP. The present study therefore aims to describe the ascites characteristics for PMP and identify prognostic factors for survival.

Methods

Between June 2010 and June 2020, 473 PMP patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were included in a retrospective study. Survival analysis was performed with the Kaplan-Meier method by the log-rank test and a Cox proportional hazards model. Associations between categorical variables were analyzed using the chi-squared test.

Results

Among all included patients, 61% were women. The median OS was 47 months (range, 4-124 months) at the last follow-up in December 2020. Ascites characteristics can be divided into light blood ascites, "Jelly" mucus ascites, and faint yellow and clear ascites. Multivariate Cox analysis showed that the degree of radical surgery, ascites characteristics, and pathological grade were independently associated with OS in PMP patients. The chi-squared test documented that faint yellow "Jelly" ascites were related to low-grade PMP and light blood ascites were associated with high-grade PMP (P < 0.01).

Conclusions

Light blood ascites, incomplete cytoreduction surgery, and high-grade histopathology may predict poor OS in appendix-derived PMP.

Surgical treatment of locally advanced right colon cancer invading neighboring organs

Purpose

Invasion of the pancreas and/or duodenum with/without neighboring organs by locally advanced right colon cancer (LARCC) is a very rare clinical phenomenon that is difficult to manage. The purpose of this review is to suggest the most reasonable surgical approach for primary right colon cancer invading neighboring organs such as the pancreas and/or duodenum.

Methods

An extensive systematic research was conducted in PubMed, Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) using the MeSH terms and keywords. Data were extracted from the patients who underwent en bloc resection and local resection with right hemicolectomy (RHC), the analysis was performed with the survival rate as the outcome parameters.

Results

As a result of the analysis of 117 patient data with locally advanced colon cancer (LACC) (73 for males, 39 for females) aged 25-85 years old from 11 articles between 2008 and 2021, the survival rate of en bloc resection was 72% with invasion of the duodenum, 71.43% with invasion of the pancreas, 55.56% with simultaneous invasion of the duodenum and pancreas, and 57.9% with invasion of neighboring organs with/without invasion of duodenum and/or pancreas. These survival results were higher than with local resection of the affected organ plus RHC.

Conclusion

When the LARCC has invaded neighboring organs, particularly when duodenum or pancreas are invaded simultaneously or individually, en bloc resection is a reasonable option to increase patient survival after surgery.

Post-operative anastomotic leakage and collagen changes in patients with rectal cancer undergoing neoadjuvant chemotherapy vs chemoradiotherapy

Background

A significant difference in the anastomotic leakage (AL) rate has been observed between patients with locally advanced rectal cancer who have undergone preoperative chemotherapy and those undergoing preoperative chemoradiotherapy. This study aimed to quantitatively analyse collagen structural changes caused by preoperative chemoradiotherapy and illuminate the relationship between collagen changes and AL.

Methods

Anastomotic distal and proximal "doughnut" specimens from the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) were quantitatively assessed for collagen structural changes between patients with and without preoperative radiotherapy using multiphoton imaging. Then, patients treated with preoperative chemoradiotherapy were used as a training cohort to construct an AL-SVM classifier by the Mann-Whitney U test and support vector machine (SVM). An independent test cohort from the Fujian Province Cancer Hospital (Fuzhou, China) was used to validate the AL-SVM classifier.

Results

A total of 207 patients were included from the Sixth Affiliated Hospital of Sun Yat-sen University. The AL rate in the preoperative chemoradiotherapy group (n = 107) was significantly higher than that in the preoperative chemotherapy group (n = 100) (21.5% vs 7.0%, P = 0.003). A fully quantitative analysis showed notable morphological and spatial distribution feature changes in collagen in the preoperative chemoradiotherapy group. Then, the patients who received preoperative chemoradiotherapy were used as a training cohort to construct the AL-SVM classifier based on five collagen features and the tumor distance from the anus. The AL-SVM classifier showed satisfactory discrimination and calibration with areas under the curve of 0.907 and 0.856 in the training and test cohorts, respectively.

Conclusions

The collagen structure may be notably altered by preoperative radiotherapy. The AL-SVM classifier was useful for the individualized prediction of AL in rectal cancer patients undergoing preoperative chemoradiotherapy.

Polyphyllin I Promotes Autophagic Cell Death and Apoptosis of Colon Cancer Cells via the ROS-Inhibited AKT/mTOR Pathway

Colon cancer is a common malignant tumor of the digestive tract, and it is considered among the biggest killers. Scientific and reasonable treatments can effectively improve the survival rate of patients if performed in the early stages. Polyphyllin I (PPI), a pennogenyl saponin isolated from Paris polyphylla var. yunnanensis, has exhibited strong anti-cancer activities in previous studies. Here, we report that PPI exhibits a cytotoxic effect on colon cancer cells. PPI suppressed cell viability and induced autophagic cell death in SW480 cells after 12 and 24 h, with the IC50 values 4.9 ± 0.1 μmol/L and 3.5 ± 0.2 μmol/L, respectively. Furthermore, we found PPI induced time-concentration-dependent autophagy and apoptosis in SW480 cells. In addition, down-regulated AKT/mTOR activity was found in PPI-treated SW480 cells. Increased levels of ROS might link to autophagy and apoptosis because reducing the level of ROS by antioxidant N-acetylcysteine (NAC) treatment mitigated PPI-induced autophagy and apoptosis. Although we did not know the molecular mechanism of how PPI induced ROS production, this is the first study to show that PPI induces ROS production and down-regulates the AKT/mTOR pathway, which subsequently promotes the autophagic cell death and apoptosis of colon cancer cells. This present study reports PPI as a potential therapeutic agent for colon cancer and reveals its underlying mechanisms of action.

Safety and feasibility of neoadjuvant chemotherapy as a surgical bridge for acute left-sided malignant colorectal obstruction: a retrospective study

BACKGROUND

For colorectal cancer, preoperative (neoadjuvant) chemotherapy is more effective than postoperative chemotherapy because it not only eradicates micrometastases more effectively but also reduces the risk of incomplete intraoperative resection and tumor cell shedding. For the treatment of acute left-sided malignant colorectal obstruction, colorectal stents as well as stoma are being used to relieve the obstructive colorectal cancer, and as a bridge to surgery, allowing easy mobilization and resection of the colon. Neoadjuvant chemotherapy combined with self-expandable metal stents (SEMS) or neoadjuvant chemotherapy combined with decompressing stoma (DS) can be used as a bridge to elective surgery (BTS) as an alternative to emergency surgery in patients with acute left-sided malignant colorectal obstruction, but its benefit is uncertain. The purpose of this study was to evaluate the safety and feasibility of neoadjuvant chemotherapy as a bridge to surgery in the treatment of acute left-sided malignant colorectal obstruction.

METHODS

Data from patients who were admitted with acute left-sided malignant colorectal obstruction between January 2012 and December 2020 were retrospectively reviewed, and patients with gastrointestinal perforation or peritonitis were excluded. We performed one-to-two propensity score matching to compare the stoma requirement, postoperative complications, and other short-term oncological outcomes between the neoadjuvant chemotherapy group and surgery group.

RESULTS

There were no differences in intraoperative blood loss, operative time, one-year postoperative mortality, and postoperative tumor markers between the two groups. The 1-year recurrence-free survival (RFS) rates of neoadjuvant chemotherapy group and surgery group were 96.8 and 91.3% (p = 0.562). The neoadjuvant chemotherapy group was able to reduce stoma rate 1 year after surgery (p = 0.047). Besides, the neoadjuvant group significantly reduced postoperative bowel function time (p < 0.001), postoperative hospital stay (p < 0.001), total hospital stay (p = 0.002), postoperative complications (p = 0.017), reduction in need to stay in the intensive care unit (ICU) (p = 0.042).

CONCLUSIONS

Neoadjuvant chemotherapy as a bridge to elective surgery in patients with acute left-sided malignant colorectal obstruction is safe and has many advantages. Prospective multicenter studies with large samples are needed to further evaluate the feasibility of neoadjuvant chemotherapy.

Comprehensive Analysis of Necroptosis-Related Long Noncoding RNA Immune Infiltration and Prediction of Prognosis in Patients With Colon Cancer

Colon cancer (CC) is one of the most frequent malignancies in the world, with a high rate of morbidity and death. In CC, necroptosis and long noncoding RNA (lncRNAs) are crucial, but the mechanism is not completely clear. The goal of this study was to create a new signature that might predict patient survival and tumor immunity in patients with CC. Expression profiles of necroptosis-related lncRNAs in 473 patients with CC were retrieved from the TCGA database. A consensus clustering analysis based on differentially expressed (DE) genes and a prognostic model based on least absolute shrinkage and selection operator (LASSO) regression analysis were conducted. Clinicopathological correlation analysis, expression difference analysis, PCA, TMB, GO analysis, KEGG enrichment analysis, survival analysis, immune correlation analysis, prediction of clinical therapeutic compounds, and qRT–PCR were also conducted. Fifty-six necroptosis-related lncRNAs were found to be linked to the prognosis, and consensus clustering analysis was performed. There were substantial variations in survival, immune checkpoint expression, clinicopathological correlations, and tumor immunity among the different subgroups. Six lncRNAs were discovered, and patients were split into high-risk and low-risk groups based on a risk score generated using these six lncRNAs. The survival time of low-risk patients was considerably longer than that of high-risk patients, indicating that these lncRNAs are directly associated with survival. The risk score was associated with the tumor stage, infiltration depth, lymph node metastasis, and distant metastasis. After univariate and multivariate Cox regression analysis, the risk score and tumor stage remained significant. Cancer- and metabolism-related pathways were enriched by KEGG analyses. Immune infiltration was shown to differ significantly between high- and low-risk patients in a tumor immunoassay. Eight compounds were screened out, and qRT–PCR confirmed the differential expression of the six lncRNAs. Overall, in CC, necroptosis-related lncRNAs have an important function, and the prognosis of patients with CC can be predicted by these six necroptosis-related lncRNAs. They may be useful in the future for customized cancer therapy.

Comprehensive Analysis of Pyroptosis-Related Long Noncoding RNA Immune Infiltration and Prediction of Prognosis in Patients with Colon Cancer

Colon cancer (CC) is one of the most prevalent malignant tumours of the alimentary canal. It is unclear whether pyroptosis-related lncRNA expression is correlated with CC prognosis. We discovered 20 pyroptosis-related lncRNAs that were expressed differently in CC and normal colon tissues in our investigation. Based on differentially expressed genes (DEGs), we grouped all CC patients into two categories (Clusters 1 and 2). Cluster 1 was shown to be connected with a higher overall survival rate, upregulated expression of immune checkpoints, higher immunoscores, higher estimated scores, and immune cell infiltration. Using data from the Cancer Genome Atlas (TCGA), to create a multigene signature, the predictive significance of each lncRNA linked with pyroptosis for survival was assessed. A 9-lncRNA signature was established using the least absolute shrinkage and selection operator (LASSO) Cox regression method, and all CC patients in the TCGA cohort were classified into low-risk or high-risk groups. The low-risk CC patients had a much greater chance of survival than those in the high-risk group. The risk score is an independent prognostic indicator for predicting survival. In addition, risk characteristics are linked to immune characteristics. In summary, pyroptosis-related lncRNAs can be used to predict CC prognosis and participate in tumour immunity.

Critical reappraisal of neoadjuvant concurrent chemoradiotherapy for treatment of locally advanced colon cancer

BACKGROUND

Locally advanced colon cancer (LACC) is associated with surgical challenges during R0 resection, increased postoperative complications, and unfavorable treatment outcomes. Neoadjuvant concurrent chemoradiotherapy followed by surgical resection is an effective treatment strategy that can increase the complete surgical resection rate and improve the patient survival rate. This study investigated the efficacy and toxicity of concurrent chemoradiotherapy in patients with LACC as well as the prognosis and long-term clinical outcomes of these patients.

MATERIALS

From January 2012 to July 2020, we retrospectively reviewed the real-world data of 75 patients with LACC who received neoadjuvant concurrent chemoradiotherapy. The chemotherapy regimen consisted of folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX). The following data were obtained from medical records: patients' characteristics, pathologic results, toxicity, and long-term oncologic outcome.

RESULTS

Of the 75 patients, 13 (17.3%) had pathologic complete responses. Hematologic adverse effects were the most common (grade 1 anemia: 80.0% and leukopenia: 82.7%). Conversely, grade 2 or 3 adverse effects were relatively uncommon (<10%). Pathologic N downstaging, ypT0, and pathologic complete responses were significant prognostic factors for patient survival. Multivariate analysis revealed that pathologic N downstaging was an independent predictor of patients' overall survival (P = 0.019). The estimated 5-year overall and disease-free survival rates were 68.6% and 50.6%, and the medians of overall and disease-free survival periods were 72.3 and 58.7 months, respectively. Moreover, patients with pathologic complete responses had improved overall survival (P = 0.039) and an improved local recurrence control rate (P = 0.042) but an unfavorable distant metastasis control rate (P = 0.666) in the long-term follow-up.

CONCLUSION

The long-term oncologic outcome of patients with LACC following concurrent chemoradiotherapy is acceptable, and the adverse effects seem to be tolerable. Pathologic N downstaging was an independent prognostic factor for patients' overall survival. However, a large prospective, randomized control study is required to confirm the current results.

Changes and Prognostic Value of lncRNA CASC9 in Patients with Advanced Colon Cancer after Chemotherapy

Objective

Colon cancer (CC) shows a gradual increasing incidence in recent years, and chemotherapy is a frequently adopted treatment for patients with middle or advanced colon cancer (ACC), but it lacks prognostic markers after CC.

Methods

The changes of lncRNA CASC9 in 58 patients with CC were determined using a real-time quantitative PCR (qRT-PCR) assay before and after chemotherapy, and the correlation of serum lncRNA CASC9 with efficacy of FOLFOX4 regimen (oxaliplatin + calcium folinate + fluorouracil) was analyzed. The patients were followed up to understand the association of lncRNA CASC9 with overall survival (OS) and progression-free survival (PFS).

Results

Patients with CC showed notably higher lncRNA CASC9 expression than controls, and lncRNA CASC9 presented an association with the clinical stage of the patients. In addition, lncRNA CASC9 demonstrated a clinical value in predicting efficacy on patients and acted as one independent prognostic factor for PFS in patients with ACC.

Conclusions

With increased expression of serum lncRNA CASC9, patients with ACC suffered an unfavorable chemotherapy effect. In addition, serum lncRNA CASC9 is a promising sensitive indicator for prediction of ACC and is related to the clinical efficacy and prognosis of patients.

Emergency resection or diverting stoma followed by elective resection in patients with colonic obstruction due to locally advanced cancer: a national cohort study

AIM

The aim was to assess long-term prognosis after emergency resection versus primary diverting stoma followed by elective tumour resection.

METHOD

A national-register-based cohort study with retrospective analysis of prospectively collected data was performed. All Swedish patients with non-metastatic obstructive locally advanced colon cancer treated with emergency resection or diverting stoma, followed by an elective resection, between 2007 and 2017 were included. The Kaplan-Meier method and Cox proportional hazards model were used to compare all-cause mortality between patients with emergency resection and elective right- and left-sided resection. The multivariable model was adjusted for year of diagnosis, age at diagnosis, sex, Charlson Comorbidity Index, American Society of Anesthesiologists class, tumour location and pN stage.

RESULTS

In all, 751 patients with a tumour in the right colon and 700 patients with a tumour in the left colon were included. Emergency resection was more common in patients with right-sided colon tumours (681/751) than in patients with left-sided colon tumours (483/700). The 5-year overall survival in patients with right-sided tumours was 25% after emergency resection and 46% after diverting stoma followed by elective resection (log-rank test P = 0.001). The corresponding numbers for patients with left-sided colon tumours were 40% and 64% (P < 0.001). Emergency resection was independently associated with increased all-cause mortality in patients with left-sided tumour (hazard ratio 1.63, 95% CI 1.21-2.19) but not in patients with right-sided tumour (hazard ratio 1.21, 95% CI 0.80-1.81).

CONCLUSION

Diverting stoma followed by elective resection is associated with improved survival compared with emergency resection in patients with left-sided colonic obstruction due to locally advanced tumours.

Efficacy of Xiang-Sha-Liu-Jun-Zi on chemotherapy-induced nausea and vomiting: A protocol for systematic review and meta-analysis

BACKGROUND

Cancer is the main cause of death worldwide, and chemotherapy is the basic method of treating cancer. However, chemotherapy-induced nausea and vomiting (CINV) is the most common side effect of chemotherapy, and conventional antiemetics for the treatment of CINV also have side effects. At present, a large number of randomized controlled trials have shown that Xiang-Sha-Liu-Jun-Zi (XSLJZ) can effectively treat CINV, but there is no systematic review. Therefore, this systematic review aims to discuss the effectiveness of XSLJZ in the treatment of CINV.

METHODS

Search for relevant documents in the Chinese and English databases, and the search time is limited to March 2021. Databases include Embase, Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure, Chongqing VIP Information Resource Integration Service Platform, Wanfang Data, Chinese Biomedical Literature, etc. We will search the international clinical trial registration platform and the Chinese clinical trial registration platform to find ongoing and unpublished clinical trials. Randomized controlled trial of the efficacy of XSLJZ in the treatment of CINV were collected. After screening the literature according to the inclusion and exclusion criteria, two researchers independently extracted the data. The effective rate of treatment is the main outcome indicator of this study. The secondary indicators of this study include the incidence of adverse reactions and the improvement rate of quality of life. RevMan 5.3.5 software was used for statistical analysis. Grades of Recommendation, Assessment, Development, and Evaluation system will be used to evaluate the quality evidence for each outcome.

RESULTS

This study will provide the latest evidence for the treatment of CINV by XSLJZ.

CONCLUSION

: To evaluate the efficacy of XSLJZ in the treatment of CINV.

UNIQUE INPLASY NUMBER

INPLASY202140079.

Outcomes of Partial or Total Cystectomy in Advanced Colon Cancer with Suspected Bladder Invasion-Our 8-Year Experience and Literature Review

PURPOSE

Advanced colon cancers with bladder invasion pose a heavy burden and challenge towards patients and surgeons. Herein, we report our series with regards to operative and oncological outcomes in our 8 years of experience.

METHODS

All patients with advanced colonic tumours and suspected bladder invasion being operated from 2012 to 2020 were included. The histological findings, clinical and oncological outcomes were evaluated.

RESULTS

Twenty-two patients were included. Partial cystectomy was performed in 17 of them (77%). No neoadjuvant treatment was prescribed. All preoperative computed tomography (CT) scan showed bladder invasion or colovesical fistula. True tumour invasion to bladder (T4b disease) was confirmed in 17 patients (77%) by histopathology. The 3-year overall survival and recurrence rates were 82% and 9%, respectively.

CONCLUSION

En bloc resection of colonic tumour with adherent bladder in advanced colon cancers can achieve a good operative and oncological outcome without neoadjuvant therapy. The relatively low concordance rate between preoperative CT scan and final histopathology may limit the benefit of routine administration of neoadjuvant therapy as it may overtreat and delay subsequent oncological treatment of our patients with possible added morbidity.