Mid-term oncologic outcome of a novel approach for locally advanced colon cancer with neoadjuvant chemotherapy and surgery

Evaluation of colon cancer prognostic factors by CT and MRI: an up-to-date review

Colorectal cancer (CRC) is a significant global health concern. Prognostication of CRC traditionally relies on the Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) TNM staging classifications, yet clinical outcomes often vary independently of stage. Despite similarities, rectal and colon cancers are distinct in their diagnostic methodologies and treatments, with MRI and CT scans primarily used for staging rectal and colon cancers, respectively. This paper examines the challenges in accurately assessing prognostic factors of colon cancer such as primary tumor extramural extension, retroperitoneal surgical margin (RSM) involvement, extramural vessel invasion (EMVI), and lymph node metastases through preoperative CT and MRI. It highlights the importance of these factors in risk stratification, treatment decisions, and surgical planning for colon cancer patients. Advancements in imaging techniques are crucial for improving clinical management and optimizing patient outcomes, underscoring the necessity for ongoing research to refine diagnostic methods and incorporate novel findings into practice.

Sigmoid colon cancer presenting as a large abdominal mass accompanied by abscess and rupture: a case report and literature review

Introduction and Importance

Colon cancer presenting as a large abdominal mass accompanied by abscess and rupture is rare and prone to be misdiagnosed and delayed. In addition, the treatment plan is not clear when combined with abdominal wall metastasis.

Case Presentation

A 79-year-old woman presented with a large abdominal mass accompanied by abscess and rupture. It was misdiagnosed as a soft tissue infection in a local hospital, and after a comprehensive examination, it was diagnosed as sigmoid colon cancer with abdominal wall metastasis and abscess formation. The patient underwent a one-stage surgery, including en bloc resection of the tumor and invaded abdominal wall, as well as autologous tissue abdominal wall reconstruction, with a good clinical prognosis.

Clinical Discussion

For the diagnosis of large abdominal masses, abdominal CT, and pus culture are more valuable than ultrasound. For colon cancer with abdominal wall metastasis, one-stage surgery to completely remove the tumor and full-thickness of the abdominal wall, and the use of autologous tissue abdominal wall reconstruction technology to repair defects is feasible.

Conclusion

This case highlights the importance of using colon cancer as one of the differential diagnoses for the diagnosis for large abdominal mass accompanied by abscess and rupture in elderly patients, as well as the possibility of one-stage surgical resection of the tumor and invasion of the abdominal wall and reconstruction of the abdominal wall with autologous tissue when there is abdominal wall metastasis.

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 value of preoperative diagnosis of colorectal adenocarcinoma pathological T staging based on dual-layer spectral-detector computed tomography extracellular volume fraction: a preliminary study

PURPOSE

To investigate the value of preoperative diagnosis of colorectal adenocarcinoma (CRAC) pathological T staging based on dual-layer spectral-detector computed tomography (DLCT) extracellular volume fraction (ECV) of CRAC lesions.

METHODS

We prospectively collected clinical and DLCT imaging data from 165 patients with CRAC who attended two hospitals from June 2022 to April 2023. The enrolled patients were divided into a training group (n = 110, from Hospital 1) and an external validation group (n = 55, from Hospital 2). Measuring and calculating DLCT parameters of lesions, including CT values of 40 and 100 keV virtual mono-energetic images (VMI), iodine concentration (IC) and effective atomic number (Eff-Z) in the arterial phases (AP) and venous phases (VP), and ECV in the delayed phase (DP). The differences in clinical characteristics and DLCT parameters were compared between different pT subgroups. The correlation between DLCT parameters and pT stages were evaluated by Spearman correlation analysis. A multifactorial binary logistic stepwise forward regression analysis was performed to obtain independent influences associated with pT stage. Receiver operating characteristic curves (ROCs) were used to assess diagnostic efficacy and were expressed as area under the curve (AUC).

RESULTS

Each DLCT parameter was higher in pT3 stage tumors than in pT1-2 stage tumors (all P < 0.05). The highest correlation was found between ECV and pT stage (r = 0.637). ECV were independent influences associated with pT stage. ECV had excellent diagnostic efficacy for CRAC pT staging in both the training and external validation groups (AUC = 0.919 and 0.892).

CONCLUSION

ECV based on DLCT measurement can be used for preoperative noninvasive diagnosis of CRAC pT staging with excellent diagnostic efficacy. It can provide a new imaging marker for the preoperative evaluation of CRAC and help clinicians formulate individualized treatment earlier. However, it needs to be confirmed with a larger sample size.

Small arteriole sign: an imaging feature for staging T4a colon cancer

OBJECTIVES

By analyzing the distribution of existing and newly proposed staging imaging features in pT1-3 and pT4a tumors, we searched for a salient feature and validated its diagnostic performance.

METHODS

Preoperative multiphase contrast-enhanced CT images of the training cohort were retrospectively collected at three centers from January 2016 to December 2017. We used the chi-square test to analyze the distribution of several stage-related imaging features in pT1-3 and pT4a tumors, including small arteriole sign (SAS), outer edge of the intestine, tumor invasion range, and peritumoral adipose tissue. Preoperative multiphase contrast-enhanced CT images of the validation cohort were retrospectively collected at Beijing Cancer Hospital from January 2018 to December 2018. The diagnostic performance of the selected imaging feature, including accuracy, sensitivity, and specificity, was validated and compared with the conventional clinical tumor stage (cT) by the McNemar test.

RESULTS

In the training cohort, a total of 268 patients were enrolled, and only SAS was significantly different between pT1-3 and pT4a tumors. The accuracy, sensitivity, and specificity of the SAS and conventional cT in differentiating T1-3 and T4a tumors were 94.4%, 81.6%, and 97.3% and 53.7%, 32.7%, and 58.4%, respectively (all p < 0.001). In the validation cohort, a total of 135 patients were collected. The accuracy, sensitivity, and specificity of the SAS and the conventional cT were 93.3%, 76.2%, and 96.5% and 62.2%, 38.1%, and 66.7%, respectively (p < 0.001, p = 0.021, p < 0.001).

CONCLUSION

Small arteriole sign positivity, an indirect imaging feature of serosa invasion, may improve the accuracy of identifying T4a colon cancer.

CLINICAL RELEVANCE STATEMENT

Small arteriole sign helps to distinguish T1-3 and T4a colon cancer and further improves the accuracy of preoperative CT staging of colon cancer.

KEY POINTS

• The accuracy of preoperative CT staging of colon cancer is not ideal, especially for T4a tumors. • Small arteriole sign (SAS) is a newly defined imaging feature that shows the appearance of tumor-supplying arterioles at the site where they penetrate the intestine wall. • SAS is an indirect imaging marker of tumor invasion into the serosa with a great value in distinguishing between T1-3 and T4a colon cancer.

Short-term Outcomes of Elective Surgery Following Self-Expandable Metallic Stent and Neoadjuvant Chemotherapy in Patients With Left-Sided Colon Cancer Obstruction

BACKGROUND

Colonic stenting reduces morbidity and stoma formation for left-sided colon cancer obstruction, and a prolonged interval between stenting and surgery with neoadjuvant chemotherapy administered might result in a lower stoma rate and tumor reduction.

OBJECTIVE

The study aimed to evaluate the short-term outcomes of elective surgery following colonic stenting compared with elective surgery following colonic stenting and neoadjuvant chemotherapy in patients with left-sided colon cancer obstruction.

DESIGN

This is a prospective multicenter cohort study.

SETTINGS

This study was conducted at 5 medical centers.

PATIENTS

Patients ( n = 100) with acute left-sided colon cancer obstruction undergoing colonic stenting between December 2015 and December 2019 were included.

INTERVENTIONS

Patients were assigned to the stenting-alone or chemotherapy group.

MAIN OUTCOME MEASURES

The primary outcomes measured were laparoscopic surgery and stoma rate.

RESULTS

Of the 100 patients who underwent colonic stenting, 52 were assigned to the stenting group and 48 were assigned to the chemotherapy group. No statistically significant differences were detected in stent-related complications. The adverse events associated with neoadjuvant chemotherapy were well tolerated. The level of hemoglobin (117.2 vs 107.6 g/L; p = 0.008), albumin (34.2 vs 31.5 g/L; p < 0.001), and prealbumin (0.19 vs 0.16 g/L; p = 0.001) was significantly increased, and the bowel wall thickness (1.09 vs 2.04 mm; p < 0.001) was significantly decreased preoperatively in the chemotherapy group compared with the stenting group. The number of mean harvested lymph nodes was greater in the chemotherapy group than in the stenting group (25.6 vs 21.8; p = 0.04). Laparoscopic surgery was performed more frequently (77.1% vs 40.4%; p < 0.001) and a stoma was created less frequently (10.4% vs 28.8%; p = 0.02) in the chemotherapy group than in the stenting group.

LIMITATIONS

This trial was limited by the nonrandomized design and a short follow-up period.

CONCLUSIONS

This study suggests that elective surgery following neoadjuvant chemotherapy and colonic stenting is a safe, effective, and well-tolerated treatment approach with a high laparoscopic resection rate and a low stoma rate. See Video Abstract at http://links.lww.com/DCR/B980 .

RESULTADOS A CORTO PLAZO DE LA CIRUGA ELECTIVA SEGUIDO DE STENT METLICO AUTOEXPANDIBLE Y QUIMIOTERAPIA NEOADYUVANTE EN PACIENTES CON OBSTRUCCIN POR CNCER DE COLON IZQUIERDO

ANTECEDENTES:La colocación de stents colónicos reduce la morbilidad y la formación de estomas por obstrucción por cáncer de colon izquierdo, y el intervalo prolongado entre la colocación de stents y la cirugía con quimioterapia neoadyuvante administrada podría resultar en una menor tasa de estomas y reducción del tumor.OBJETIVO:Evaluar los resultados a corto plazo de la cirugía electiva después de la colocación de stent en el colon en comparación con la cirugía electiva después de la colocación de stent en el colon y la quimioterapia neoadyuvante en pacientes con obstrucción por cáncer de colon izquierdo.DISEÑO:Estudio prospectivo de cohorte multicéntrico.ENTORNO CLINICO:Este estudio se realizó en 5 centros médicos.PACIENTES:Se incluyeron pacientes (n=100) con obstrucción aguda por cáncer de colon izquierdo que se sometieron a colocación de stent colónico entre diciembre de 2015 y diciembre de 2019.INTERVENCIONES:Los pacientes fueron asignados al grupo de stent solo o quimioterapia.MEDIDAS DE RESULTADO PRINCIPALES:Los resultados primarios medidos fueron la cirugía laparoscópica y la tasa de ostomía.RESULTADOS:De los 100 pacientes que se sometieron a la colocación de stent colónico, 52 fueron asignados al grupo de colocación de stent y 48 al grupo de quimioterapia. No se detectaron diferencias estadísticamente significativas en las complicaciones relacionadas con el stent. Los eventos adversos asociados con la quimioterapia neoadyuvante fueron bien tolerados. Hemoglobina (117,2 g/l vs. 107,6 g/l; p = 0,008), albúmina (34,2 g/l vs. 31,5 g/l; p < 0,001) y prealbúmina (0,19 g/l vs. 0,16 g/l; p = 0,001) aumentaron significativamente y el grosor de la pared intestinal (1,09 mm vs. 2,04 mm; p < 0,001) disminuyó significativamente antes de la operación en el grupo de quimioterapia en comparación con el grupo de colocación de stent. El número medio de ganglios linfáticos extraídos fue mayor en el grupo de quimioterapia que en el grupo de stent (25,6 vs. 21,8; p = 0,04). La cirugía laparoscópica se realizó con mayor frecuencia (77,1 % vs. 40,4 %; p < 0,001) y se creó un estoma con menos frecuencia (10,4 % vs. 28,8 % ; p = 0,02) en el grupo de quimioterapia que en el grupo de colocación de stent.LIMITACIONES:Este ensayo estuvo limitado por el diseño no aleatorio y el corto período de seguimiento.CONCLUSIONES:Este estudio sugiere que la cirugía electiva después de la quimioterapia neoadyuvante y la colocación de stent colónico es un tratamiento seguro, efectivo y bien tolerado, con una alta tasa de resección laparoscópica y una baja tasa de estoma. Consulte Video Resumen en http://links.lww.com/DCR/B980 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Current Controversies in the Management of Locally Advanced Colon Cancer

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Current and emerging therapeutic approaches for colorectal cancer: A comprehensive review

Colorectal cancer (CRC) affects 1 in 23 males and 1 in 25 females, making it the third most common cancer. With roughly 608000 deaths worldwide, CRC accounts for 8% of all cancer-related deaths, making it the second most common cause of death due to cancer. Standard and conventional CRC treatments include surgical expurgation for resectable CRC and radiotherapy, chemotherapy, immunotherapy, and their combinational regimen for non-resectable CRC. Despite these tactics, nearly half of patients develop incurable recurring CRC. Cancer cells resist the effects of chemotherapeutic drugs in a variety of ways, including drug inactivation, drug influx and efflux modifications, and ATP-binding cassette transporter overexpression. These constraints necessitate the development of new target-specific therapeutic strategies. Emerging therapeutic approaches, such as targeted immune boosting therapies, non-coding RNA-based therapies, probiotics, natural products, oncolytic viral therapies, and biomarker-driven therapies, have shown promising results in preclinical and clinical studies. We tethered the entire evolutionary trends in the development of CRC treatments in this review and discussed the potential of new therapies and how they might be used in conjunction with conventional treatments as well as their advantages and drawbacks as future medicines.

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.

Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects

Approximately 7%-29% of patients with colorectal cancer present with colonic obstruction. The concept of self-expandable metal stent (SEMS) insertion as a bridge to surgery (BTS) is appealing. However, concerns on colonic stenting possibly impairing oncologic outcomes have been raised. This study aimed to review current evidence on the short- and long-term oncologic outcomes of SEMS insertion as BTS for left-sided malignant colonic obstruction. For short-term outcomes, colonic stenting facilitates a laparoscopic approach, increases the likelihood of primary anastomosis without a stoma, and may decrease postoperative morbidity. However, SEMS-related perforation also increases local recurrence and impairs overall survival. Moreover, colonic stenting may cause negative oncologic outcomes even without perforation. SEMS can induce shear forces on the tumor, leading to increased circulating cancer cells and aggressive pathological characteristics, including perineural and lymphovascular invasion. The conflicting evidence has led to discordant guidelines. Well-designed collaborative studies that integrate both oncologic outcomes and data on basic research (e.g., alteration of circulating tumors) are needed to clarify the actual benefit of colonic stenting as BTS.

Efficacy and Safety of Neoadjuvant Chemotherapy Combined with Adjuvant Chemotherapy for Locally Advanced Colon Cancer: A Propensity Score-Matching Analysis

Background and Objectives: Increasing evidence supports the use of neoadjuvant chemotherapy (NAC) for locally advanced colon cancer (LACC). However, its effectiveness remains controversial. This study explored the safety and efficacy of NAC combined with laparoscopic radical colorectal cancer surgery and adjuvant chemotherapy (AC) for LACC. Materials and Methods: We retrospectively analyzed 444 patients diagnosed with LACC (cT4 or cT3, with ≥5 mm invasion beyond the muscularis propria) in our hospital between 2012 and 2015. Propensity score matching (PSM; 1:2) was performed to compare patients treated with NAC and those treated with adjuvant chemotherapy (AC). Results: Overall, 42 patients treated with NAC were compared with 402 patients who received only AC. After PSM, 42 patients in the NAC group were compared with 84 patients in the control group, with no significant differences in the baseline characteristics between groups. The pathological tumor sizes in the NAC group were significantly smaller than those in the AC group (3.1 ± 2.1 cm vs. 5.8 ± 2.5 cm). Patients in the NAC group had a significantly lower T stage than those in the AC group (p < 0.001). After neoadjuvant chemotherapy, a significant response was observed in four (9.6%) patients, with two (4.8%) showing a complete response. The 5-year overall survival rates (88.1% vs. 77.8%, p = 0.206) and 5-year disease-free survival rates (75.1% vs. 64.2%, p = 0.111) did not differ between the groups. However, the 5-year cumulative rate of distant recurrence was significantly lower in the NAC than in the AC group (9.6% vs. 29.9%, p = 0.022). Conclusions: NAC, combined with AC, could downstage primary tumors of LACC and seems safe and acceptable for patients with LACC, with a similar long-term survival between the two treatments.

Estimation of colon cancer grade and metastatic lymph node involvement using DWI/ADC sequences

BACKGROUND

The potential benefit of neoadjuvant chemotherapy (NAC) in colon cancer is under evaluation. There is a need to improve preoperative non-invasive diagnostics using techniques that provide more accurate staging information in assessing patient eligibility for NAC.

PURPOSE

To investigate the link between the tumor grade (pathohistological confirmed) and the N status (corresponding to lymph node involvement) with apparent diffusion coefficient (ADC) values.

MATERIAL AND METHODS

A total of 17 patients planned for surgical resection had a biopsy confirming colon carcinoma and participated in the study. Abdominal magnetic resonance imaging with diffusion-weighted imaging/ADC sequence was recorded before surgery. The tumor and all visible lymph nodes were manually delineated directly on a grayscale ADC map for every single slice and detected to access the total tumor and summarized lymph node volume. The mean ADC value was further calculated for the mean tumor and mean lymph node values.

RESULTS

Low-grade tumors had a mean ADC equivalent to 1225 ± 170×10^-6 mm²/s, and the coefficient of high-grade tumors was 1444 ± 69×10^-6 mm²/s. The group of patients with positive lymph nodes in operative tissue samples (N+) exhibited lower mean ADC values (1023 ± 142×10^-6 mm²/s) as opposed to the group without metastatic lymph nodes (N-) with ADC values of 1260 ± 231×10^-6 mm²/s.

CONCLUSION

The mean whole-tumor ADC is associated with the histological tumor grade, and the mean ADC value of whole-volume abdominal lymph nodes could assume real nodal infiltration.

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.

Oncologic outcomes of pathologic T4 and T3 colon cancer patients diagnosed with clinical T4 stage disease using preoperative computed tomography scan

BACKGROUND

The diagnostic accuracy of computed tomography (CT) for colon cancer is low, and the preoperative risk factors for locally advanced colon cancer are unknown. This study aimed to evaluate the correlation between preoperative CT scan findings and oncologic outcomes and to identify risk factors associated with locally advanced colon cancer.

MATERIALS AND METHODS

Patients diagnosed with clinical stage (cT) 4 colon cancer based on preoperative CT scan findings who underwent curative surgery between January 2005 and December 2015 were retrospectively studied. Patients were divided according to pathologic stage (pT) into pT3 (n = 114) and pT4 (n = 102).

RESULTS

The disease-free survival rate was significantly different between the pT3 and pT4 groups (88.6% vs. 68.6%, p < 0.001). The overall survival rate of the pT3 group was significantly higher than that of the pT4 group (91.2% vs. 76.5%, p = 0.002). Perineural invasion and tumor budding were identified as preoperative risk factors predisposing to pT4 staging (p = 0.044, p = 0.001).

CONCLUSION

The survival rate of pT3 patients was significantly higher than that of pT4 patients with a preoperative cT4 diagnosis. This suggests that when planning for neoadjuvant chemotherapy in locally advanced colon cancer, preoperative CT scan findings may overestimate clinical staging and lead to inappropriate treatment. Thus, there is a need for a new modality to evaluate local advancement in colon cancer.

Ongoing and evolving clinical trials enhancing future colorectal cancer treatment strategies

INTRODUCTION

Molecular profiling has led to significantly longer survival in metastatic colorectal cancer (CRC) patients. Clinical guidelines recommend testing for KRAS/NRAS, BRAF and MSI status and over the last few years several promising new biomarkers have also been identified. Circulating tumor DNA has reshaped the prognosis of localized CRC. These genomic findings can guide treatment management to improve clinical outcomes.

AREAS COVERED

Preclinical and clinical data over the last decade were reviewed for known and novel biomarkers with clinical implications in refractory and metastatic CRC. In the localized stage, al clinical trials involving new approaches such as liquid biopsy or neoadjuvant immunotherapy are also discussed. Molecular alterations and targeted agents are described, and data from completed and ongoing studies with targeted therapy and immunotherapies are presented.

EXPERT OPINION

The implementation of liquid biopsies in the localized CRC setting has reshaped management of this disease. The expanded use of biomarkers to guide the treatment of patients with CRC has revealed a level of complexity arising from interactions between different biomarkers. Prevalence of most established targetable biomarkers is low, however the number of identified biomarkers in CRC is increasing. Thus, metastatic CRC may ultimately be considered an umbrella diagnosis encompassing numerous rare disease subtypes.

Accurate staging of non-metastatic colon cancer with CT: the importance of training and practice for experienced radiologists and analysis of incorrectly staged cases

PURPOSE

To investigate whether locoregional staging of colon cancer by experienced radiologists can be improved by training and feedback to minimize the risk of over-staging into the context of patient selection for neoadjuvant therapy and to identify potential pitfalls of CT staging by characterizing pathologic traits of tumors that remain challenging for radiologists.

METHODS

Forty-five cases of stage I-III colon cancer were included in this retrospective study. Five experienced radiologists evaluated the CTs; 5 baseline scans followed by 4 sequential batches of 10 scans. All radiologists were trained after baseline scoring and 2 radiologists received feedback. The learning curve, diagnostic performance, reader confidence, and reading time were evaluated with pathologic staging as reference. Pathology reports and H&E slides of challenging cases were reviewed to identify potential pitfalls.

RESULTS

Diagnostic performance in distinguishing T1-2 vs. T3-4 improved significantly after training and with increasing number of reviewed cases. Inaccurate staging was more frequently related to under-staging rather than over-staging. Risk of over-staging was minimized to 7% in batch 3-4. N-staging remained unreliable with an overall accuracy of 61%. Pathologic review identified two tumor characteristics causing under-staging for T-stage in 5/7 cases: (1) very limited invasive part beyond the muscularis propria and (2) mucinous composition of the invading part.

CONCLUSION

The high accuracy and specificity of T-staging reached in our study indicate that sufficient training and practice of experienced radiologists can ensure high validity for CT staging in colon cancer to safely use neoadjuvant therapy without significant risk of over-treatment, while N-staging remained unreliable.

Management of obstructive colon cancer: Current status, obstacles, and future directions

Approximately 10%–18% of patients with colon cancer present with obstruction at the initial diagnosis. Despite active screening efforts, the incidence of obstructive colon cancer remains stable. Traditionally, emergency surgery has been indicated to treat patients with obstructive colon cancer. However, compared to patients undergoing elective surgery, the morbidity and mortality rates of patients requiring emergency surgery for obstructive colon cancer are high. With the advancement of colonoscopic techniques and equipment, a self-expandable metal stent (SEMS) was introduced to relieve obstructive symptoms, allowing the patient’s general condition to be restored and for them undergo elective surgery. As the use of SEMS placement is growing, controversies about its application in potentially curable diseases have been raised. In this review, the short- and long-term outcomes of different treatment strategies, particularly emergency surgery vs SEMS placement followed by elective surgery in resectable, locally advanced obstructive colon cancer, are described based on the location of the obstructive cancer lesion. Controversies regarding each treatment strategy are discussed. To overcome current obstacles, a potential diagnostic method using circulating tumor DNA and further research directions incorporating neoadjuvant chemotherapy are introduced.

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.

Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review and meta-analysis

BACKGROUND

There is increasing evidence to support the use of neoadjuvant chemotherapy (NAC) in locally advanced colon cancer (LACC). However, its safety, efficacy and side effect profile is yet to be completely elucidated. This review aims to assess NAC regimens, duration, compare completion rates, intra-operative and post-operative complication profiles and oncological outcomes, in order to provide guidance for clinical practice and further research.

METHODS

PubMed, EMBASE and MEDLINE were searched for a systematic review of the literature from 2000 to 2020. Eight eligible studies were included, with a total of 1213 patients, 752 (62%) of whom received NAC. Of the eight studies analysed, two were randomised controlled trials comparing neoadjuvant chemotherapy followed by oncological resection to upfront surgery and adjuvant chemotherapy, three were prospective single-arm phase II trials analysing neoadjuvant chemotherapy followed by surgery only, one was a retrospective study comparing neoadjuvant chemotherapy followed by surgery versus surgery first followed by adjuvant chemotherapy and the remaining two were single-arm retrospective studies of neoadjuvant chemotherapy followed by surgery.

RESULTS

All cases of LACC were determined and staged by computed tomography; majority of the studies defined LACC as T3 with extramural depth of 5 mm or more, T4 and/or nodal positivity. NAC administered was either folinic acid, fluorouracil and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (XELOX) with the exception of one study which utilised 5-fluorouracil and mitomycin. Most studies had NAC completion rates of above 83% with two notable exceptions being Zhou et al. and The Colorectal Cancer Chemotherapy Study Group of Japan who both recorded a completion rate of 52%. Time to surgery from completion of NAC ranged on average from 16 to 31 days. The anastomotic leak rate in the NAC group ranged from 0 to 4.5%, with no cases of postoperative mortality. The R0 resection rate in the NAC group was 96.1%. Meta-analysis of both RCTs included in this study showed that neoadjuvant chemotherapy increased the likelihood of a negative resection margin T3/4 advanced colon cancer (pooled relative risk of 0.47 with a 95% confidence interval) with no increase in adverse consequence of anastomotic leak, wound infection or return to theatre.

CONCLUSIONS

Our systematic review and meta-analysis show that NAC is safe with an acceptable side effect profile in the management of LACC. The current data supports an oncological benefit for tumour downstaging and increased in R0 resection rate.

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.

Conversion to Open Surgery in Laparoscopic Colorectal Cancer Resection: Predictive Factors and its Impact on Long-Term Outcomes. A Case Series Study

BACKGROUND

Laparoscopic resection is the treatment of choice for colorectal cancer. Rates of conversion to open surgery range between 7% and 30% and controversy exists as to the effect of this on oncologic outcomes. The objective of this study was to analyze what factors are predictive of conversion and what effect they have on oncologic outcomes.

METHODS

From a prospective database of patients undergoing laparoscopic surgery between 2000 and 2018 a univariate and multivariate analyses were made of demographic, pathologic, and surgical variables together with complementary treatments comparing purely laparoscopic resection with conversions to open surgery. Overall and disease-free survival were compared using the Kaplan-Meier method.

RESULTS

Of a total of 829 patients, 43 (5.18%) converted to open surgery. In the univariate analysis, 12 variables were significantly associated with conversion, of which left-sided resection [odds ratio (OR): 2.908; P=0.02], resection of the rectum (OR: 4.749, P=0.014), and local invasion of the tumor (OR: 6.905, P<0.01) were independently predictive factors in the multiple logistic regression. Female sex was associated with fewer conversions (OR: 0.375, P=0.012). The incidence and pattern of relapses were similar in both groups and there were no significant differences between overall and disease-free survival.

CONCLUSIONS

Left-sided resections, resections of the rectum and tumor invasion of neighboring structures are associated with higher rates of conversion. Female sex is associated with fewer conversions. Conversion to open surgery does not compromise oncologic outcomes at 5 and 10 years.

Interventions and Outcomes for Neoadjuvant Treatment of T4 Colon Cancer: A Scoping Review

While adjuvant treatment of colon cancers that penetrate the serosa (T4) have been well-established, neoadjuvant strategies have yet to be formally evaluated. Our objective was to perform a scoping review of eligibility criteria, treatment regimens, and primary outcomes for neoadjuvant approaches to T4 colon cancer. A librarian-led, systematic search of MEDLINE, Embase, Cochrane Library, Web of Science, and CINAHL up to 11 February 2020 was performed. Primary research evaluating neoadjuvant treatment in T4 colon cancer were included. Screening and data abstraction were performed in duplicate; analyses were descriptive or thematic. A total of twenty studies were included, most of which were single-arm, single-center, and retrospective. The primary objectives of the literature to date has been to evaluate treatment feasibility, tumor response, disease-free survival, and overall survival in healthy patients. Conventional XELOX and FOLFOX chemotherapy were the most commonly administered interventions. Rationale for selecting a specific regimen and for treatment eligibility criteria were poorly documented across studies. The current literature on neoadjuvant strategies for T4 colon cancer is overrepresented by single-center, retrospective studies that evaluate treatment feasibility and efficacy in healthy patients. Future studies should prioritize evaluating clear selection criteria and rationale for specific neoadjuvant strategies. Validation of outcomes in multi-center, randomized trials for XELOX and FOLFOX have the most to contribute to the growing evidence for this poorly managed disease.

Preoperative multidisciplinary team assessment is associated with improved survival in patients with locally advanced colon cancer; a nationwide cohort study in 3157 patients

INTRODUCTION

Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer.

MATERIAL AND METHODS

All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT.

RESULTS

MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI).

CONCLUSION

Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

The Role of Neoadjuvant Chemotherapy in Locally Advanced Colon Cancer

Neoadjuvant systemic therapy has many potential advantages over up-front surgery, including tumor downstaging, early treatment of micrometastatic disease, and providing an in vivo test of tumor biology. Due to these advantages, neoadjuvant therapy is becoming the standard of care for an increasing number of tumor types. Currently, colon cancer patients are still routinely treated with up-front surgery, and neoadjuvant systemic therapy is not yet standard. Limitations to widespread use of neoadjuvant therapy have included inaccurate radiological staging, concerns about tumor progression while undergoing preoperative treatment rendering a patient incurable, and a lack of randomized data demonstrating benefit. However, there is great interest in neoadjuvant chemotherapy, and a number of trials are under way. Early follow up of the first phase III trial of neoadjuvant chemotherapy for colon cancer demonstrated tumor downstaging and suggested an improvement in disease-free survival with neoadjuvant chemotherapy, and it is hoped that this will translate into longer-term overall survival benefit. Clinicians should closely watch this developing field, consider the option of neoadjuvant chemotherapy for colon cancer patients, and actively seek out opportunities for their patients to participate in ongoing clinical trials to further inform this field in future.

Pluronic F127-Modified Electrospun Fibrous Meshes for Synergistic Combination Chemotherapy of Colon Cancer

Colon cancer ranks as the third most common malignancy in the world. Combination chemotherapy, resorting to electrospun fibrous technology, has been considered as a promising strategy to exert synergistic effects in colon cancer treatment. Herein, we manufactured various pluronic F127 (PF127)-modified electrospun fibrous meshes with different weight ratios of camptothecin (CPT) and curcumin (CUR). The fluorescence characterization of the obtained PF127-CPT-meshes, PF127-CUR-meshes, and PF127-CPT/CUR-meshes (2:1) showed that CPT and CUR were evenly distributed within individual fibers of these meshes. Drug release experiments revealed that both types of drugs could be released from fibrous meshes simultaneously and sustainably. Importantly, these meshes exhibited strong in vitro anti-colon cancer activities, compared with the control meshes without drugs. Moreover, the combination index values of the PF127-CPT/CUR-meshes (CPT/CUR weight ratio = 5:1, 3:1, or 2:1) were <0.5 after incubation for respective 24 and 36 h, indicating the synergistic anti-colon cancer effects of CPT and CUR in fibrous meshes. Collectively, these results demonstrate that PF127-CPT/CUR-meshes can be developed as an efficient implantable system for effective synergistic treatment of colon cancer.

Clinical Significance of has_circ_0055625 in Colon Cancer Patients Undergoing FOLFOX Chemotherapy Treatment

Objective

Colon cancer is a leading global cancer-related cause of morbidity and mortality. The oxaliplatin, 5-fluorouracil (5-FU), and leucovorin (FOLFOX) regimen is a standard chemotherapeutic approach used to treat colon cancer. However, chemoresistant tumor cells typically lead to the emergence of recurrent FOLFOX-resistant tumors after initial treatment. As such, it is vital that novel approaches to identifying and eliminating such chemoresistant tumors be developed in an effort to improve patient chemotherapy outcomes.

Materials and Methods

In total, 100 samples of serum were obtained between April 2014 and April 2019 from patients who had been pathologically diagnosed with colon cancer from the Xiamen Haicang Hospital, and after these patients received FOLFOX chemotherapy treatment, serum samples were collected again. The expression of has_circ_0055625 in these serum samples was assessed via qPCR. Additionally, 5-FU IC50 values were detected via CCK-8 assay.

Results

We found has_circ_0055625 to be significantly upregulated in colon cancer patient serum. After FOLFOX treatment, chemotherapy-resistance was associated with the upregulation of has_circ_0055625.

Conclusion

In summary, these data may provide a foundation for future studies of chemotherapeutic resistance in patients undergoing FOLFOX treatment, potentially guiding treatment adjustment strategies. However, further work will be necessary to expand upon these findings.

Sophocarpine can enhance the inhibiting effect of oxaliplatin on colon cancer liver metastasis-in vitro and in vivo

To determine whether sophocarpine (SC) can enhance the inhibiting effect of oxaliplatin on colorectal cancer (CRC) liver metastasis (CRCLM)-in vitro and in vivo. The inhibitory effect of SC and/or oxaliplatin on the proliferation, invasion, and migration of CRC cells was determined by CCK-8, MTT, wound healing migration, and transwell assay. Western blot and immunohistochemistry were used to evaluate the inhibitory effect of SC and/or oxaliplatin on the epithelial-mesenchymal transition (EMT) process. Nude mouse models of human CRCLM were established to test the anti-metastasis effect of SC and oxaliplatin in the single or combined form. SC exerted an inhibitory effect on the proliferation, invasion, and migration of CRC cells both in vitro and in vivo. The combination index of SC and oxaliplatin was 0.58. In addition, the inhibitory effect of SC in combination with oxaliplatin was found to be significantly stronger compared with that mediated by either SC or oxaliplatin alone, suggesting that SC can effectively enhance the inhibitory effect of oxaliplatin on CRCLM both in vitro and in vivo. SC was also revealed to reverse EMT process in cell lines and tissues, as reflected by the observed downregulation of N-cadherin and vimentin expression and the upregulation of E-cadherin expression. Taken together, data from the present study suggest that SC administration can inhibit CRC cell proliferation, invasion, migration, and EMT, while enhancing the inhibitory effects of oxaliplatin both in vitro and in vivo. These findings indicate (that) SC to be a promising anti-metastasis agent for CRCLM.

Neoadjuvant therapy in locally advanced colon cancer: a meta-analysis and systematic review

Background

The role of perioperative or neoadjuvant chemotherapy for locally advanced colon cancer is unclear. Emerging evidence such as the FOXTROT trial is challenging the conventional norm of upfront operation for these patients. However, these trials have yet to reach statistical significance.

Methods

MEDLINE, Embase, Cochrane Library, China Knowledge Resource Integrated Database (CNKI) and ClinicalTrials.gov were searched. Randomized controlled trials (RCTs) and observational studies of patients with locally advanced colon cancer were included. The intervention arm was neoadjuvant chemotherapies while the comparator arm was adjuvant chemotherapies. Studies which reported outcomes of interests included overall survival, disease-free survival, R0 resection rate, perioperative complications and adverse effects of chemotherapy were chosen.

Results

We identified five eligible randomized trials and two observational studies, including 29,504 patients. Neoadjuvant therapies exhibited statistically significant improvement in overall survival [hazard ratio (HR) =0.76, 95% confidence interval (CI): 0.65-0.89, P=0.0005], and disease-free survival (HR =0.74, 95% CI: 0.58-0.95, P=0.02). R0 resection rate fell slightly short of significance [odds ratio (OR) =1.86, 95% CI: 0.95-3.62, P=0.07]. Risk of peri-operative complications did not differ between groups when examining abdominal infection [risk ratio (RR) =1.14, 95% CI: 0.59-2.18, P=0.70] and anastomotic leakage (RR =0.83, 95% CI: 0.53-1.31, P=0.42). No statistical differences in complications from chemotherapy were reported.

Conclusions

This meta-analysis highlights the potential survival benefit of neoadjuvant chemotherapy compared to adjuvant chemotherapy for locally advanced colon cancer, without an increase in surgical morbidity. Neoadjuvant or perioperative approaches may be considered an alternative to upfront surgery followed by chemotherapy for locally advanced colon cancer.

Neoadjuvant Chemotherapy without Radiation in Colorectal Cancer

In colon cancer, primary surgery followed by postoperative chemotherapy represents the standard of care. In rectal cancer, the standard of care is preoperative radiotherapy or chemoradiation, which significantly reduces local recurrence but has no impact on subsequent metastatic disease or overall survival. The administration of neoadjuvant chemotherapy (NACT) before surgery can increase the chance of a curative resection and improves long-term outcomes in patients with liver metastases. Hence, NACT is being explored in both primary rectal and colon cancers as an alternative strategy to shrink the tumor, facilitate a curative resection, and simultaneously counter the risk of metastases. Yet, this lack of clarity regarding the precise aims of NACT (downstaging, maximizing response, or improving survival) is hindering progress. The appropriate cytotoxic agents, the optimal regimen, the number of cycles, or duration of NACT prior to surgery or in the postoperative setting remains undefined. Several potential strategies for integrating NACT are discussed with their advantages and disadvantages.

Identification of Novel Transcriptome Signature as a Potential Prognostic Biomarker for Anti-Angiogenic Therapy in Glioblastoma Multiforme

Simple Summary

Neoadjuvant chemotherapy is commonly used in several solid tumor malignancies, but remains understudied in the setting of locally advanced colon cancer. Advantages of this strategy extrapolated from other disease sites include early treatment of micro-metastatic disease, the ability to decrease local disease burden potentially leading to more effective resections and improved treatment tolerability. Approaches for accurate staging and safe administration of systemic treatment are being investigated in large, randomized clinical trials, but available data are either not mature enough or have not demonstrated a convincing argument for adoption into standard practice warranting further investigation.

Abstract

Early stage colon cancer is typically managed with surgical resection, although not all patients experience a durable remission. Adjuvant chemotherapy with a fluoropyrimidine, with or without oxaliplatin, is commonly utilized to increase the chance of cure, but its efficacy in the neoadjuvant setting is not well established. Preoperative chemotherapy has demonstrated safety and efficacy in other gastrointestinal malignancies, but there is a paucity of data from large, prospective randomized trials, although multiple are ongoing. In this review, we will discuss the theoretical risks and benefits, logistical difficulties, and available safety and efficacy data pertaining to the use of chemotherapy in locally advanced colon cancer.

Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review

BACKGROUND

Preoperative or neoadjuvant chemotherapy (NAC) has emerged as a novel alternative to treat locally advanced colon cancer (LACC), as in other gastrointestinal malignancies. However, evidence of its efficacy and safety has not yet been gathered in the literature. The aim of the present study was to perform an extensive review of the scientific evidence for NAC in patients with LACC.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane Library were searched for a systematic review of the literature from 2010 to 2019. Six eligible studies were included, with a total of 27,937 patients, 1232 of them (4.4%) treated with NAC. There were only one randomized controlled trial, three phase II non-randomized single arm studies and two retrospective studies.

RESULTS

The baseline computed tomography scan showed that most of patients had a T3 tumor. The completion rate of the planned neoadjuvant treatment ranged from 52.5 to 93.8%. Between 97.2 and 100% of patients had the scheduled surgery. The median tumor volume reduction after NAC ranged from 62.5 to 63.7%. The anastomotic leak rate in the NAC group ranged from 0 to 7%, with no cases of postoperative mortality. There was major pathological tumor regression in 4-34.7% of cases. Between 84 and 100% of NAC patients had R0-surgery. Survival after NAC seems to be encouraging although significant improvement has only been proven in T4b tumours.

CONCLUSIONS

According to our systematic review, the NAC may be a safe and effective emerging therapeutic alternative for treating LACC. This approach, which is still being tested, increases the reliance on accurate radiological staging.

A pathological complete response after neoadjuvant triplet chemotherapy for locally advanced transverse colon cancer

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Perioperative chemotherapy could improve oncological outcome for colon cancer.

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The effectiveness of triplet chemotherapy as neoadjuvant setting is still unknown.

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A pathological complete response after neoadjuvant triplet chemotherapy was described.

Introduction

Perioperative chemotherapy could improve oncological outcomes for patients with advanced colon cancer. However, the effectiveness of triplet chemotherapy in the neoadjuvant setting is still unknown.

Presentation of case

A 61-year-old man was referred to our hospital due to abdominal distention. Abdominal computed tomography showed a huge, 18-cm mass in the right upper abdomen. Biopsy showed well-differentiated adenocarcinoma. Locally advanced transverse colon cancer T4b N2a M0 Stage IIIC was diagnosed. Considering the extensive invasion to surrounding organs and difficulties in achieving margin-negative surgery, an emergency ileostomy was performed first. Then, neoadjuvant chemotherapy (NAC) consisting of a combination of 5-fluorouracil (5-FU), oxaliplatin, irinotecan, and leucovorin (FOLFOXIRI) was planned, followed by primary tumor resection. After 6 courses of treatment, the primary tumor shrank remarkably. Finally, laparoscopic radical extended right hemi-colectomy was performed. There were no residual tumor cells in resected specimens, including the primary tumor and surrounding lymph nodes. The pathological diagnosis was complete response.

Conclusion

A case of pathological complete response after neoadjuvant treatment followed by radical resection was reported. Further research is needed to confirm the appropriate indications for neoadjuvant FOLFOXIRI therapy for patients with LACC.

Efficacy and safety of self-expanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing left-sided colonic cancer

Background

This study aimed to evaluate the safety and feasibility of self-expanding metallic stent (SEMS) followed by neoadjuvant chemotherapy prior to elective surgery for obstructing left-sided colon cancer.

Methods

Eleven consecutive patients with obstructing left-sided colon cancer between May 2014 and November 2015 were included retrospectively. All patients received SEMS followed by neoadjuvant chemotherapy. The primary outcome measure was stoma and laparoscopic surgery.

Results

Chemotherapy was with two cycles of CAPOX (54.5%) or three cycles mFOLFOX6 (45.5%). Median serum albumin and hemoglobin levels before surgery were significantly higher than before neoadjuvant chemotherapy (p = 0.01 and p = 0.008 respectively) and before SEMS (p = 0.01 and p = 0.003 respectively). Median bowel wall thickness proximal to the upper edge of tumor was significantly more before neoadjuvant chemotherapy than before stent (p = 0.003), and significantly less before surgery than before neoadjuvant chemotherapy (p = 0.003). No patient underwent stoma creation. Laparoscopic surgery was performed in nine (81.8%) patients. No local recurrence or metastases developed over median cancer-specific follow-up of 44 months (range, 37–55 months).

Conclusion

SEMS followed by neoadjuvant chemotherapy prior to elective surgery appears to be safe and well tolerated in patients with obstructing left-sided colon cancer.

[Selection criteria for neoadjuvant chemoradiotherapy of rectal cancer : Neoadjuvant therapy even for locally advanced colon cancer?]

During the last two decades a neoadjuvant treatment concept has been established for an increasing number of malignant tumors of the gastrointestinal tract; however, these concepts are still subject to a constant change concerning the indications and type of treatment. A prime example for this is rectal cancer. The rate of local recurrence in particular was significantly reduced by neoadjuvant therapy but until now it has not been possible to validly show an improvement in overall or disease-free survival. At the beginning of the millennium it was recommended to treat every rectal carcinoma in UICC stages II and III with neoadjuvant therapy, independent of the height localization. In the meantime this has increasingly been relativized and only locally advanced tumors of the middle and lower thirds of the rectum should be pretreated, whereas tumors of the upper third of the rectum should basically be treated in the same way as colon cancer. It is to be expected that there will be further differentiation concerning the indications in this context in the future mainly based on a preoperative magnetic resonance imaging (MRI) examination. At the same time, initial studies for colon cancer show that neoadjuvant chemotherapy can be beneficial and that an optimized computed tomography (CT) scan can be a worthwhile tool with respect to pretherapeutic stratification of patients.

Dehydrogenase/reductase SDR family member 2 silencing sensitizes an oxaliplatin‑resistant cell line to oxaliplatin by inhibiting excision repair cross‑complementing group 1 protein expression

Oxaliplatin (Oxa)-based chemotherapy is widely used as the first-line treatment for colorectal cancer (CRC). However, Oxa-resistance is common for many postoperative CRC patients. To explore drug resistance in CRC, an Oxa-resistant cell line, HCT116/Oxa, was established from parental HCT116 cells. These Oxa-resistant cells exhibited characteristics of epithelial-mesenchymal transition (EMT) and a higher migratory capacity than parental cells. Protein profiles of HCT116/Oxa and HCT116 cells were compared using a tandem mass tag-based quantitative proteomics technique. The protein dehydrogenase/reductase SDR family member 2 (DHRS2) was revealed to be highly expressed in HCT116/Oxa cells. Silencing of DHRS2 in HCT116/Oxa cells effectively restored Oxa-sensitivity by suppressing the expression of excision repair cross-complementing group 1 protein via a p53-dependent pathway, and reversed the EMT phenotype. Overall, the suppression of DHRS2 expression may be a promising strategy for the prevention of Oxa-resistance in CRC.

Highly specific colon-targeted transformable capsules containing indomethacin immediate-release pellets for colon cancers therapy

Generally, definite intestine targeting and immediate drug releasing are both important for the treatment of colon cancer via oral administration of anti-cancer drugs. We developed a highly specific oral colon-targeted pulsatile capsule, based on the effective enzyme-responsive 'pulse plug', which can be degraded under mannanase abundant in colon. Indomethacin (IN) solid dispersion immediate-release pellets were filled in an insoluble capsule body, a guar gum-lactose-hydroxypropyl methylcellulose (HPMC) composed tablet was embedded on the top of capsule as the 'pulse plug', and then covered by enteric soluble cap. In this study, the influence of the proportion of guar gum/lactose/HPMC, the viscosity of HPMC, and the tablet weight on the degradation behaviour of the plug tablet was investigated. The drug-releasing profiles of those pulsatile capsules in different simulated colon medium verified the 'pulse plug' could realise the colon-targeted pulsatile drug-releasing. Furthermore, the rabbit pharmacokinetic experiments showed that the in vivo time lag of drug loaded pulsatile capsules was significantly extended to 5.61 ± 0.08 h (p<.01), compared with that (0.33 ± 0.47 h) of the marketed tablets (YUNPENG^®). These results indicated that colon-targeted pulsatile capsules would be effective oral delivering system for colon cancers therapy.

Efficacy of Neoadjuvant Chemotherapy with Capecitabine plus Oxaliplatin in the Treatment of Locally Advanced Sigmoid Colon Cancer Invading the Urinary Bladder: A Report of Three Cases

Introduction

We herein present three cases of locally advanced colon cancer (LACC) invading the urinary bladder, in whom combined neoadjuvant chemotherapy with surgical intervention was effective in disease control and preserving urinary function.

Case Presentation

Before neoadjuvant chemotherapy, all three cases underwent loop transverse colostomy for symptomatic colonic obstruction. Case 1: after 6 courses of capecitabine plus oxaliplatin (CAPOX), we performed sigmoid colectomy and partial resection of the bladder. The histological examination revealed pathological complete response (pCR). The final diagnosis was ypStage 0 (ypT0ypN0M0). Case 2: after 13 courses of CAPOX plus bevacizumab, we performed Hartmann's operation with partial resection of the bladder. The histological examination revealed pCR. The final diagnosis was ypStage 0 (ypT0ypN0M0). Case 3: after 6 courses of chemotherapy with CAPOX plus bevacizumab, we performed sigmoid colectomy and partial resection of the bladder. The pathological response was grade 1a according to the Japanese Classification of Colorectal Carcinoma. The final diagnosis was ypStage IIC (ypT4bypN0M0). All three cases underwent capecitabine-based adjuvant chemotherapy after radical surgery and patients are alive without recurrence.

Conclusion

Neoadjuvant chemotherapy with CAPOX with or without bevacizumab followed by radical surgery could be an effective treatment option for LACC invading the urinary bladder.

CapeOX perioperative chemotherapy versus postoperative chemotherapy for locally advanced resectable colon cancer: protocol for a two-period randomised controlled phase III trial

INTRODUCTION

Adjuvant chemotherapy with the CapeOX regimen is now widely used for treating colorectal cancer. However, prior studies have demonstrated better efficacy of pre-operative/neoadjuvant chemotherapy without increase of safety risks.

METHODS AND ANALYSIS

This multicentre, open-label, parallel-group, randomised, controlled, phase III study aims to compare the efficacy and safety of perioperative CapeOX chemotherapy with the postoperative one for treating patients with locally advanced R0 resectable colon cancers in China. In total 1370 eligible patients will be randomised to: the test group, up to four cycles (every 3 weeks is a cycle, Q3W) of chemotherapy plus radical surgery plus up to four cycles of post-operative chemotherapy; or the control group, radical surgery first, then up to eight cycles of chemotherapy. In each cycle, oxaliplatin will be given at a dose of 130 mg/m² through continuous IV infusion for 2 hours on the first day. From day 1 to day 14, capecitabine will be taken orally every morning and evening at a dose of 1000mg/m²/d. The primary outcome measure is the 3-year disease free survival. The objective response rate, R0 resection rate, overall survival, as well as the adverse events will also be measured as second endpoints. The study may include two periods. If results of period 1 are not favourable, period 2 will be initiated, recruiting genetically sensitive patients and repeating the same process with period 1.

ETHICS AND DISSEMINATION

Informed consent will be required from, and provided, by all subjects. The study protocol has been approved by the independent ethics committee of Shanghai Fudan University Cancer Centre. This study will clearly demonstrate the potential benefit of perioperative chemotherapy with the CapeOX regimen. Results will be shared among all the participating centres, and with policymakers and the academic community to promote the clinical management of colon cancer.

TRIAL REGISTRATION NUMBER

NCT03125980.

A qualitative signature for predicting pathological response to neoadjuvant chemoradiation in locally advanced rectal cancers

BACKGROUND AND PURPOSE

The standard therapy for locally advanced rectal cancers (LARCs) is neoadjuvant chemoradiation (nCRT) followed by surgical resection. Pathological response to nCRT varies among patients, and it remains a challenge to predict pathological response to nCRT in LARCs.

MATERIAL AND METHODS

Using 42 samples as the training cohort, we searched a signature by screening the gene pairs whose within-sample relative expression orderings are significantly correlated with the pathological response. The signature was validated in both a public cohort of 46 samples and a cohort of 33 samples measured at our laboratory.

RESULTS

A signature consisting of 27 gene pairs was identified in the training cohort with an accuracy of 92.86% and an area under the receiver operating characteristic curve (AUC) of 0.95. The accuracy was 89.13% for the public test cohort and 90.91% for the private test cohort, with AUC being 0.95 and 0.91, respectively. Furthermore, the signature was used to predict disease-free survival benefits from 5Fu-based chemotherapy in 285 locally advanced colorectal cancers.

CONCLUSIONS

The signature consisting of 27 gene pairs can robustly predict clinical response of LARCs to nCRT.

Assessing tumor angiogenesis in colorectal cancer by quantitative contrast-enhanced endoscopic ultrasound and molecular and immunohistochemical analysis

Background and Objectives

Data on contrast-enhanced endoscopic ultrasound (CE-EUS) for colorectal cancer (CRC) evaluation are scarce. Therefore, we aimed to assess the vascular perfusion pattern in CRC by quantitative CE-EUS and compare it to immunohistochemical and genetic markers of angiogenesis.

Patients and Methods

We performed a retrospective analysis of CE-EUS examinations of 42 CRC patients, before any therapy. CE-EUS movies were processed using a dedicated software. Ten parameters were automatically generated from the time-intensity curve (TIC) analysis: peak enhancement (PE), rise time (RT), mean transit time, time to peak (TTP), wash-in area under the curve (WiAUC), wash-in rate (WiR), wash-in perfusion index (WiPI), wash-out AUC (WoAUC), and wash-in and wash-out AUC (WiWoAUC). The expression levels of the vascular endothelial growth factor receptor 1 (VEGFR1) and VEGFR2 genes were assessed from biopsy samples harvested during colonoscopy. Microvascular density and vascular area were calculated after CD31 and CD105 immunostaining.

Results

Forty-two CE-EUS video sequences were analyzed. We found positive correlations between the parameters PE, WiAUC, WiR, WiPI, WoAUC, WiWoAUC, and N staging (Spearman r = 0.437, r = 0.336, r = 0.462, r = 0.437, r = 0.358, and r = 0.378, respectively, P < 0.05), and also between RT and TTP and CD31 vascular area (r = 0.415, and r = 0.421, respectively, P < 0.05). VEGFR1 and VEGFR2 expression did not correlate with any of the TIC parameters.

Conclusions

CE-EUS with TIC analysis enables minimally invasive assessment of CRC angiogenesis and may provide information regarding the lymph nodes invasion. However, further studies are needed for defining its role in the evaluation of CRC patients.

MicroRNAs and their role for T stage determination and lymph node metastasis in early colon carcinoma

Worldwide, colon cancer is among the most common cancer entities. Understanding the molecular background is the key to enable accurate stage determination, which is crucial to assess optimal therapy options. The search for preoperative biomarkers is ongoing. In recent years, several studies have proposed a diagnostic and prognostic role for miRNAs in cancer. Aim of this study was to evaluate miRNA expression patterns correlating with tumor stage, especially lymph node metastasis, in primary colon carcinoma tissue. Screening was accomplished using GeneChip^® miRNA v3.0 arrays (Thermo Fisher Scientific, Waltham, MA, USA) and validated via TaqMan^® qPCR assays (Thermo Fisher Scientific, Waltham, MA, USA) to investigate miRNA expressions in 168 FFPE and 83 fresh frozen colon carcinoma samples. Regarding lymph node status, analyses displayed no significantly differential miRNA expression. Interestingly, divergent expression of miR-18a-5p, miR-20a-5p, miR-21-5p, miR-152-3p and miR-1973 was detected in stage pT1. Although miRNAs might not represent reliable biomarkers regarding lymph node metastasis status, they could support risk assessment in stage T1 tumors.

ZEB1 Promotes Oxaliplatin Resistance through the Induction of Epithelial - Mesenchymal Transition in Colon Cancer Cells

Background: Oxaliplatin (OXA) chemotherapy is widely used in the clinical treatment of colon cancer. However, chemo-resistance is still a barrier to effective chemotherapy in cases of colon cancer. Accumulated evidence suggests that the epithelial mesenchymal transition (EMT) may be a critical factor in chemo-sensitivity. The present study investigated the effects of Zinc finger E-box binding homeobox 1 (ZEB1) on OXA-sensitivity in colon cancer cells.

Method: ZEB1expression and its correlation with clinicopathological characteristics were analyzed using tumor tissue from an independent cohort consisting of 118 colon cancer (CC) patients who receiving OXA-based chemotherapy. ZEB1 modulation of OXA-sensitivity in colon cancer cells was investigated in a OXA-resistant subline of HCT116/OXA cells and the parental colon cancer cell line: HCT116. A CCK8 assay was carried out to determine OXA-sensitivity. qRT-PCR, Western blot, Scratch wound healing and transwell assays were used to determine EMT phenotype of colon cells. ZEB1 knockdown using small interfering RNA (siRNA) was used to determine the ZEB1 contribution to OXA-sensitivity in vitro and in vivo (in a nude mice xenograft model).

Result: ZEB1 expression was significantly increased in colon tumor tissue, and was correlated with lymph node metastasis and the depth of invasion. Compared with the parental colon cancer cells (HCT116), HCT116/OXA cells exhibited an EMT phenotype characterized by up-regulated expression of ZEB1, Vimentin, MMP2 and MMP9, but down-regulated expression of E-cadherin. Transfection of Si-ZEB1 into HCT116/OXA cells significantly reversed the EMT phenotype and enhanced OXA-sensitivity in vitro and in vivo.

Conclusion: HCT116/OXA cells acquired an EMT phenotype. ZEB1 knockdown effectively restored OXA-sensitivity by reversing EMT. ZEB1 is a potential therapeutic target for the prevention of OXA-resistance in colon cancer.

Local staging of sigmoid colon cancer using MRI

Background

An accurate radiological staging of colon cancer is crucial to select patients who may benefit from neoadjuvant chemotherapy.

Purpose

To evaluate the diagnostic accuracy of preoperative magnetic resonance imaging (MRI) in identifying locally advanced sigmoid colon cancer, poor prognostic factors, and the inter-observer variation of the tumor apparent diffusion coefficient (ADC) values of diffusion-weighted imaging (DWI).

Material and Methods

Using 1.5 T MRI with high resolution T2-weighted (T2W) imaging, DWI, and no contrast enhancement, 35 patients with sigmoid colon cancer were assessed. T-stage, N-stage, extramural vascular invasion (EMVI), and ADC values of the tumors were assessed and blindly compared by two observers using postoperative histopathological examination as the gold standard. Early tumors were defined as T1 to T3ab, and advanced tumors as T3cd or T4.

Results

The accuracy of the two radiologists in staging early versus advanced tumors, N-stage, and identification of EMVI was 94%/89%, 60%/66%, and 77%/60% with an inter-observer agreement of к = 0.86 (95% confidence interval [CI] = 0.67–1.00), к = 0.64 (95% CI = 0.39–0.90), and к = 0.52 (95% CI = 0.23–0.80). All the measured mean ADC values were below 1.0 × 10⁻³ mm²/s with an intra-class correlation coefficient in T3cd–T4 tumors of 0.85.

Conclusion

Preoperative MRI can identify locally advanced sigmoid colon cancer and has potential as the imaging of choice to select patients for neoadjuvant chemotherapy. Initial experience with ADC measurement was achieved with an excellent inter-observer agreement in advanced tumors.

IMP3 expression in biopsy specimens as a diagnostic biomarker for colorectal cancer

No single biological marker is used in routine diagnosis of colorectal cancer (CRC) in endoscopic biopsies. IMP3 is a good independent prognostic biomarker for CRC. However, the expression of IMP3 in hyperplastic polyp (HP) and adenoma has not yet been studied. Moreover, no studies have established the diagnostic value of IMP3 in biopsies. This study aims to assess IMP3 expression in HP, adenoma, and CRC in resection specimens and to investigate its value in diagnosis of CRC in biopsies. A total of 1328 specimens (633 of polypectomy, 395 surgical resections, 300 biopsies) were retrospectively analyzed. IMP3 expression was observed in 0 of 197 (0%) normal tissues, 0 of 130 (0%) HPs, 14 of 504 (2.8%) adenomas, and 139 of 197 (70.6%) CRCs. IMP3 was found to be overexpressed in CRC compared with adenoma (P<.001). Among the 300 biopsies, 56 were diagnosed as adenoma, and 244 were CRCs. Of the 56 adenoma cases, 22 (39.3%) were confirmed, whereas 34 (60.7%) were diagnosed as CRC in resection specimens. All 244 CRC biopsies were confirmed by resection specimens. IMP3-positive expression was observed in 204 of 300 (68.0%) biopsies, including in 22 of 56 (39.3%) adenomas and 182 of 244 (74.6%) CRCs. All IMP3-positive expressions in the biopsies were finally diagnosed as CRC. Our findings demonstrated that IMP3 is a reliable marker for the diagnosis of CRC in endoscopic biopsies.

Neoadjuvant FOLFOX chemotherapy combined with radiotherapy followed by radical resection in patients with locally advanced colon cancer

Background

Patients with locally advanced colon cancer (LACC) have a relatively poor prognosis despite radical resection and adjuvant chemotherapy. This study investigated the treatment efficacy and toxicity of neoadjuvant chemoradiotherapy in patients with LACC.

Methods

We retrospectively reviewed 36 patients with LACC preoperatively treated with chemotherapy and radiotherapy. Patients were administered chemoradiotherapy, which comprised radiotherapy and neoadjuvant chemotherapy involving a 5-fluorouracil, leucovorin, and oxaliplatin regimen every 2 weeks.

Results

Median age was 64 years (45–86 years) and median follow-up period was 23.5 months (5.0–49.1 months). Seven (19.4%) patients developed grade 3 or 4 adverse events during neoadjuvant concurrent chemoradiotherapy. Pathologic responses were not evaluated in two patients who did not undergo radical resection. Of the 34 patients who underwent surgery, nine (26.4%) achieved a pathologic complete response (pCR). The 2-year estimated overall survival and disease-free survival rates were 88.7% and 73.6%, respectively.

Conclusions

Our results demonstrated that neoadjuvant chemoradiotherapy is feasible and safe. A prominent pCR rate with an acceptable toxicity profile suggests that the multimodality therapy might be a treatment option for patients with LACC.