Colorectal Cancer Trends of 2018 in Romania-an Important Geographical Variation Between Northern and Southern Lands and High Mortality Versus European Averages

Colorectal Cancer Risk Prediction Using the rs4939827 Polymorphism of the SMAD7 Gene in the Romanian Population

Colorectal cancer (CRC) is globally recognized as a prevalent malignancy known for its significant mortality rate. Recent years have witnessed a rising incidence trend in colorectal cancer, emphasizing the necessity for early diagnosis. Our study focused on examining the impact of the SMAD7 gene variant rs4939827 on the risk of colorectal cancer occurrence. The composition of our study group included 340 individuals, comprising 170 CRC diagnosed patients and 170 healthy controls. We performed genotyping of all biological samples using the TaqMan assay on the ABI 7500 Real-Time PCR System (Applied Biosystems, Waltham, MA, USA). This investigation focused on the rs4939827 gene variant, assessing its association with CRC risk and clinicopathological characteristics. Genotyping results for the SMAD7 gene variant rs4939827 revealed a 42.6% prevalence of the C allele in CRC patients (p = 0.245) and a 22.8% prevalence of the T allele in control subjects (p = 0.109). This study concluded that there was an elevated risk of CRC in the dominant model for CC/CT+TT, with a p-value of 0.113 and an odds ratio (OR) of 2.781, within a 95% confidence interval (CI) of 0.998 to 3.456. The findings of our research indicate a correlation between variants of the SMAD7 gene and the likelihood of developing colorectal cancer in our study population. Consequently, these results could be instrumental in facilitating early diagnosis of colorectal cancer utilizing information on single-nucleotide polymorphism (SNP) and genetic susceptibility to the disease.

Long-term trends in the burden of colorectal cancer in Europe over three decades: a joinpoint regression and age-period-cohort analysis

Background

The burden of colorectal cancer (CRC) in Europe is at a high level, but the epidemiological features have not yet been systematically studied. This study aimed to provide a timely and reliable assessment of the burden and trends of CRC in Europe to provide a scientific basis for its prevention and treatment.

Methods

We analyzed data on CRC in 44 European countries between 1990 and 2019 from the Global Burden of Disease study (GBD) 2019. In addition, the joinpoint regression model was applied to reflect temporal trends. The age-period-cohort model was constructed to explore age, period, and birth cohort effects that influence the risk of morbidity and mortality.

Results

In Europe, new cases, disability-adjusted life years (DALYs) and deaths of CRC rose by 70.01%, 22.88% and 38.04% from 1990 to 2019, respectively. The age-standardized incidence rate (ASIR) has increased, while age-standardized DALY rate and age-standardized mortality rate (ASMR) have declined. We found that men experienced a significantly higher CRC burden than women. Age-period-cohort analysis showed that the risk of incidence and mortality increased with age and time; and it was lower in the later-born cohort than the earlier-born cohort.

Conclusion

ASIR for CRC in Europe generally trended upwards from 1990 to 2019, stabilizing in recent years but still at a high level. CRC burden varied considerably in different countries. There was a pronounced gender difference in CRC burden, and middle-aged and older men should be a priority population for CRC prevention and treatment.

Clinical, Pathological and Molecular Insights on KRAS, NRAS, BRAF, PIK3CA and TP53 Mutations in Metastatic Colorectal Cancer Patients from Northeastern Romania

Mutations in RAS, BRAF, PIK3CA, and TP53 are well-established genetic abnormalities in metastatic colorectal cancer (mCRC). However, limited information is available for patients from Eastern Europe, including Romania. In this retrospective analysis, we investigated 104 mCRC patients from the Northeastern region of Romania to determine the frequency, distribution, coexistence, and clinicopathological and molecular correlations of these mutations. TP53 was the most frequently mutated gene (73.1%), followed by KRAS (45.2%) and PIK3CA (6.7%). Patients with KRAS mutant tumors and wild-type TP53 genotype were found to have no personal history of gastrointestinal cancer (p = 0.02, p = 0.007). KRAS mutations in exon 3 were associated with the female gender (p = 0.02) and the absence of lymph node invasion (p = 0.02). PIK3CA mutations were linked to the absence of lymph node invasion (p = 0.006). TP53 mutations were associated with KRAS mutations in exon 2 (p = 0.006), ulcerated histopathologic type (p = 0.04), and G2 differentiation (p = 0.01). It provides novel insights into genetic variations specific to the population from Northeastern Romania, which has been underrepresented in previous studies within Eastern Europe. Furthermore, our findings enable the development of genetic profiles in a developing country with limited access to specialized genetic tests and facilitate comparisons with other populations.

Clinicopathological Analysis of Complicated Colorectal Cancer: A Five-Year Retrospective Study from a Single Surgery Unit

Patients with primary colorectal cancer can present with obstructions, tumor bleeding, or perforations, which represent acute complications. This paper aimed to analyze and compare the clinical and pathological profiles of two patient groups: one with colorectal cancer and a related complication and another without any specific complication. We performed a five-year retrospective study on colorectal cancer patients admitted to a surgery unit and comparatively explored the main clinical and pathological features of the tumors belonging to the two groups. A total of 250 patients with colorectal cancer were included in the analysis. Of these, 117 (46.8%) had presented a type of complication. The comparative analysis that examined several clinical and pathological parameters showed a statistically significant difference for unfavorable prognosis factors in the group with complications. This was evident for features such as vascular and perineural invasion, lymph node involvement, pathological primary tumor stage, and TNM stage. Colorectal cancers with a related complication belonged to a group of tumors with a more aggressive histopathologic profile and more advanced stages. Furthermore, the comparable incidence of cases in the two groups of patients warrants further efforts to be made in terms of early detection and prognosis prediction of colorectal cancer.

New Regional Dynamic Cancer Model across the European Union

BACKGROUND

Can increasing levels of economic wealth significantly influence changes in cancer incidence and mortality rates?

METHODS

We investigated this issue by means of regression analyses based on the study of incidence and mortality indicators for lip, oral cavity, and pharyngeal; colon; pancreatic; lung; leukaemia; brain and central nervous system cancers in correlation with the levels of economic welfare and financial allocations to health at the level of the European Union member states, with the exception of Luxembourg and Cyprus for which there are no official statistical data reported.

RESULTS

The results of the study showed that there were significant disparities both regionally and by gender, requiring corrective public policy measures that were formulated in this study.

CONCLUSIONS

The conclusions highlight the main findings of the study in terms of the evolution of the disease, present the significant aspects that characterise the evolution of each type of cancer during the period analysed (1993-2021), and highlight the novelty and limitations of the study and future directions of research. As a result, increasing economic welfare is a potential factor in halting the effects of cancer incidence and mortality at the population level, while the financial allocations to health of EU member countries' budgets are a drawback due to large regional disparities.

Bevacizumab Treatment for Metastatic Colorectal Cancer in Real-World Clinical Practice

Background and Objectives: Colorectal cancer (CRC) is a leading cause of cancer-related mortality and morbidity worldwide. Bevacizumab was approved for the treatment of metastatic colorectal cancer (mCRC) based on favorable benefit-risk assessments from randomized controlled trials, but evidence on its use in the real-world setting is limited. The aim of the current study is to evaluate the outcomes and safety profile of bevacizumab in mCRC in a real-world setting in Romania. Patients and Methods: This was an observational, retrospective, multicentric, cohort study conducted in Romania that included patients with mCRC treated with bevacizumab as part of routine clinical practice. Study endpoints were progression-free survival, overall survival, adverse events, and patterns of bevacizumab use. Results: A total of 554 patients were included in the study between January 2008 and December 2018. A total of 392 patients (71%) received bevacizumab in the first line and 162 patients (29%) in the second line. Bevacizumab was mostly combined with a capecitabine/oxaliplatin chemotherapy regimen (31.6%). The median PFS for patients treated with bevacizumab was 8.4 months (interquartile range [IQR], 4.7-15.1 months) in the first line and 6.6 months (IQR, 3.8-12.3 months) in the second line. The median OS was 17.7 months (IQR, 9.3-30.6 months) in the first line and 13.5 months (IQR, 6.7-25.2 months) in the second line. Primary tumor resection was associated with a longer PFS and OS. The safety profile of bevacizumab combined with chemotherapy was similar to other observational studies in mCRC. Conclusions: The safety profile of bevacizumab was generally as expected. Although the PFS was generally similar to that reported in other studies, the OS was shorter, probably due to the less frequent use of bevacizumab after disease progression and the baseline patient characteristics. Patients with mCRC treated with bevacizumab who underwent resection of the primary tumor had a higher OS compared to patients with an unresected primary tumor.

Diabetes Mellitus and Other Predictors for the Successful Treatment of Metastatic Colorectal Cancer: A Retrospective Study

Background and Objectives: In the last decades there has been an increasing body of research identifying the positive correlation between diabetes mellitus (DM) and solid malignancies, moreover, having shown DM as an independent risk factor for colorectal cancer (CRC). The aim of the present study was to assess the impact of DM on metastatic CRC (mCRC), and to identify possible predictive factors in the successful treatment of mCRC. Materials and Methods: 468 patients with mCRC were included in this retrospective, observational study. A total of 8669 oncological treatment cycles related to 988 distinct chemotherapy lines were analyzed. Data regarding lines of treatment and blood panel values were obtained from the Oncohelp Hospital database. Results: The presence of DM in male patients >70 years was a negative predictor (RR = 1.66 and a p = 0.05). DM seemed to have a detrimental effect in patients whose treatment included bevacizumab (median time to treatment failure -TTF- 94 days for DM+ cases compared to 114 days for DM-patients, p = 0.07). Analysis of treatments including bevacizumab based on DM status revealed lower values of mean TTF in DM+ female patients versus DM-(81.08 days versus 193.09 days, p < 0.001). It was also observed that DM+ patients had a higher mean TTF when undergoing anti-EGFR (epidermal growth factor) therapy (median TTF 143 days for DM+ patients versus 97.5 days for those without DM, p = 0.06). Conclusions: The favorable predictive factors identified were the inclusion of antiangiogenic agents, a higher hemoglobin value, a higher lymphocyte count, the inclusion of anti-EGFR treatment for DM+ patients, a higher creatinine, and a higher lymphocyte count in treatment lines that included anti-EGFR treatment. Unfavorable predictive factors were represented by the presence of DM in female patients undergoing antiangiogenic treatment, neutropenia in male patients, the association of oxaliplatin and antiangiogenic agents, and a higher monocyte count in the aforementioned treatment lines.

Extended Lymphadenectomy for Proximal Transverse Colon Cancer: Is There a Place for Standardization?

Background and Objectives: Complete mesocolon excision and high vascular ligation have become a standard procedure in the treatment of colon cancer. The transverse colon has certain embryological and anatomical particularities which require special attention in case of oncological surgeries. Proximal transverse colon cancer (TCC) can metastasize to the lymph nodes in the gastrocolic ligament. The aim of this study is to assess the tumor involvement of these lymph nodes and to determine the applicability of gastrocolic ligament lymph nodes dissection as the standard approach for proximal transverse colon cancer. Materials and Methods: this study analyzes the cases of patients admitted to the Surgery Department, diagnosed with proximal transverse colon cancer, with tumor invasion ≥ T2 and for which complete mesocolon excision with high vascular ligation and lymphadenectomy of the gastrocolic ligament (No. 204, 206, 214v) were performed. Results: A total of 43 cases operated during 2015−2020 were included in the study. The median total number of retrieved central lymph nodes was 23 (range, 12−38), that had tumor involvement in 22 cases (51.2%). Gastrocolic ligament tumor involvement was found in 5 cases (11.6%). The median operation time was 180 min, while the median blood loss was 115 mL (range 0−210). The median time of hospitalization was 6 days (range, 5−11). Grade IIIA in the Clavien-Dindo classification was noticed in 3 patients, with no mortality. Upon Kaplan−Meier analysis, tumors > T3 (p < 0.016) and lymph node ratio < 0.05 (p < 0.025) were statistically significant. Conclusions: lymph node dissection of the gastrocolic ligament in patients with advanced proximal transverse colon cancer may improve the oncological outcome in T3/T4 tumors, and therefore standardization could be feasible

Oxaliplatin-induced neuropathy and colo-rectal cancer patient’s quality of life: Practical lessons from a prospective cross-sectional, real-world study

BACKGROUND

Colon cancer is one the most common forms of cancer in both sexes. Due to important progress in the field of early detection and effective treatment, colon and rectal cancer survivors currently account for 10% of cancer survivors worldwide. However, the effects of anti-cancer treatments, especially oxaliplatin-based chemotherapy, on the quality of life (QoL) have been less evaluated. Although the incidence of severe chemotherapy-induced neuropathy (CIPN) in clinical studies is below 20%, data from real-world studies is scarce, and CIPN is probably under-reported due to patient selection and the patients’ fear that reporting side-effects might lead to treatment cessation.

AIM

To determine the impact of CIPN on QoL in colorectal cancer patients with a recent history of oxaliplatin-based chemotherapy.

METHODS

We performed a prospective cross-sectional study in two major Romanian oncology tertiary hospitals—the Regional Institute of Oncology Iași (Iasi, Romania) and the Fundeni Clinical Oncology Institute (Bucharest, Romania). All consecutive patients with colon or rectal cancer, undergoing Oxaliplatin-based chemotherapy that consented to enroll in the study, were assessed by means of two questionnaires—the EORTC QQ-CR29 (quality of life in colon and rectal cancer patients) and the QLQ-CIPN20 (assessment of neuropathy). Several demographical, social, clinical and treatment data were also collected. Statistical analysis was performed by means of SPSS v20. The student t test was used to assess the relationship between the QLQ-CIPN20 and QLQ-CR29 results. Kaplan Meyer-curves were used to report 3-year progression-free survival (PFS) in patients that discontinued chemotherapy vs those that completed the recommended course.

RESULTS

Of the 267 patients that fulfilled the inclusion criteria in the pre-specified time frame, 101 (37.8%) agreed to participate in the clinical study. At the time of the enrolment in the study, over 50% of the patients had recently interrupted their oxaliplatin-based chemotherapy, most often due to neuropathy. Almost 85% of the responders reported having tingling or numbness in their fingers or hands, symptoms that were associated with pain in over 20% of the cases. When comparing the scores in the two questionnaires, a statistically significant relationship (P < 0.001) was found between the presence of neuropathic symptoms and a decreased quality of life. This correlation was consistent when the patients were stratified by sex, disease stage, comorbidities and the presence of stoma or treatment type, suggesting that neuropathy in itself may be a reason for a decreased quality of life. At the 3 year final assessment, median recurrence-free survival in stage III patients was 26.88 mo. When stratified by completion of chemotherapy, median recurrence free-survival of stage III patients that completed chemotherapy was 28.27 mo vs 24.33 mo in patients that discontinued chemotherapy due to toxicity, a difference that did not reach statistical significance.

CONCLUSION

CIPN significantly impacts QoL in colorectal cancer patients. CIPN is also the most frequent reason for treatment discontinuation. Physicians should actively assess for CIPN in order to prevent chronic neuropathy.

Opportunistic Colonoscopy Cancer Screening Pays off in Romania-A Single-Centre Study

Colorectal cancer (CRC) is the third most diagnosed cancer in men (after prostate and lung cancers) and in women (after breast and lung cancer). It is the second cause of cancer death in men (after lung cancer) and the third one in women (after breast and lung cancers). It is estimated that, in EU-27 countries in 2020, colorectal cancer accounted for 12.7% of all new cancer diagnoses and 12.4% of all deaths due to cancer. Our study aims to assess the opportunistic colorectal cancer screening by colonoscopy in a private hospital. A secondary objective of this study is to analyse the adenoma detection rate (ADR), polyp detection rate (PDR), and colorectal cancer (CRC) detection rate. We designed a retrospective single-centre study in the Gastroenterology Department of Saint Mary Hospital. The study population includes all individuals who performed colonoscopies in 2 years, January 2019–December 2020, addressed to our department by their family physician or came by themselves for a colonoscopy. One thousand seven hundred seventy-eight asymptomatic subjects underwent a colonoscopy for the first time. The mean age was 59.0 ± 10.9, 59.5% female. Eight hundred seventy-three polyps were found in 525 patients. Five hundred and twenty-five had at least one polyp, 185 patients had two polyps, 87 had three polyps, and 40 patients had more than three polyps. The PDR was 49.1%, ADR 39.0%, advanced adenomas in 7.9%, and carcinomas were found in 5.4% of patients. In a country without any colorectal cancer screening policy, polyps were found in almost half of the 1778 asymptomatic patients evaluated in a single private center, 39% of cases adenomas, and 5.4% colorectal cancer. Our study suggests starting screening colonoscopy at the age of 45. A poor bowel preparation significantly impacted the adenoma detection rate.

Right-sided colon cancer with invasion of the duodenum or pancreas: A glimpse into our experience

Duodenal or pancreatic invasion in locally advanced right colon cancer (LARCC) is a challenging situation that can pose difficulties in its management. When the duodenum alone is invaded, the surgeon may undertake right hemicolectomy (RH) en bloc with the affected patch of duodenum. The duodenal defect can be reconstructed using several techniques. When invasion of the pancreas is present, RH en bloc with duodenopancreatectomy (DP) is the treatment of choice. We present our experience regarding the treatment and prognostic results of this rare colon cancer form. We retrospectively reviewed the data of patients who underwent surgery for right-sided colon cancer with duodenal and/or pancreatic invasion between January 2004 and March 2020. Among the 110 patients with LARCC, pancreas and/or duodenum invasion was encountered in 22 patients, with a mean age of 49.5 years. From the 22 patients, 5 patients underwent palliative procedures, with a maximal survival of 15 months. Three patients underwent RH alone, with lethal outcome in the first year in 66% of the cases. RH en bloc with antrectomy was performed in 2 patients. Eight patients underwent RH with DP, with a 1-year survival of 75% (6/8) and a 5-year survival of 50% (3/6). Thirty-day mortality post-DP was noted in 25% (2/8) of the cases. Four patients underwent RH with limited duodenal resection, with no recurrence of disease at 11 to 39 months postoperatively. Among the duodenal defect restoration, simple duodenal suture was practiced in 2 patients, duodenojejunostomy in one patient and pedicled ileal flap in 1 case. In conclusion, although postoperative mortality can be significant, en bloc resection for LARCC invading the duodenum and/or pancreas offers prolonged survival in a considerable number of patients.

Abilities of Pre-Treatment Inflammation Ratios as Classification or Prediction Models for Patients with Colorectal Cancer

Background: Systemic inflammatory status is known as an important factor of colorectal cancer prognosis. Our study aimed to evaluate the performances of inflammation biomarker ratios as classification models of seven outcomes in patients with colorectal cancer. Methods: A retrospective cohort study was conducted on subjects with colorectal cancer over five years at a single center in Transylvania, Romania. Seven derived ratios were calculated based on laboratory data: neutrophil-to-lymphocyte (NLR), derived neutrophil-to-lymphocyte (dNLR), platelet-to-lymphocyte (PLR), lymphocyte-to-monocyte (LMR) and albumin-to-globulin (AGR) ratios, Systemic Immune Inflammation Index (SII) and Prognostic Nutritional Index (PNI). The utility of these ratios as predictors for seven outcomes was further evaluated in multivariable regression models. Results: Our study shows that the evaluated ratios exhibit specific performances for individual outcomes, proving a fair ability as screening tools (NLR and dNLR for survival, T stage and M stage; NLR and SII for T stage; and PLR for M stage). A dNLR over 3.1 (OR = 2.48, 95% CI (1.421 to 4.331)) shows predictive value for survival. A value of NLR over 3.10 (OR = 1.389, 95% CI (1.061 to 1.817)) is positively associated with an advanced T stage, while LMR is negatively related to the T stage (OR = 0.919, 95% CI (0.867 to 0.975)). NLR over 4.25 (OR = 2.647, 95% CI (2.128 to 3.360)) is positively associated with, while PNI is negatively related (OR = 0.970, 95% CI (0.947 to 0.993)) to, the M stage. Conclusion: Each of the evaluated ratios possesses prognostic value for certain outcomes considered, but the reported models need external validation to recommend their clinical practice utilization.