Factors that influence treatment strategies in advanced colorectal cancer

Long non-coding RNA NKILA serves as a biomarker in the early diagnosis and prognosis of patients with colorectal cancer

Colorectal cancer (CRC) is one of the leading causes of cancer-associated mortality worldwide. The prognosis of patients with CRC at an advanced stage is poor. Biomarkers currently used in clinical practice, including carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9, lack sufficient sensitivity and specificity for early diagnosis and prediction, therefore there remains a requirement to improve the prognosis of patients with CRC. Long non-coding RNAs (lncRNAs) have been revealed to serve fundamental roles in various pathophysiological processes, including cancer initiation and progression. The present study investigated the expression and clinical significance of the lncRNA nuclear factor-κB interacting long non-coding RNA (NKILA) in CRC. It was identified that NKILA was downregulated in six CRC cell lines and tissues (n=173). Low NKILA expression was significantly associated with a poor differentiation grade, larger tumor size and advanced Tumor-Node-Metastases stages. Further statistical analyses revealed that low NKILA expression predicted poor overall survival (OS) rate and progression-free survival (PFS) rate. In addition, low NKILA expression was determined as an independent risk factor for poor OS and PFS. Furthermore, NKILA exhibited a relatively high sensitivity and specificity compared with CEA and CA19-9 in the early diagnosis of CRC. The serum level of NKILA was positively correlated with the level in tissues. In addition, a decreased NKILA level in serum was revealed to be partially restored post-operatively. In conclusion, low NKILA expression has been demonstrated to accelerate CRC progression and NKILA may be a potential novel biomarker in early diagnosis and prognosis of patients with CRC.

Historical perspective: Two decades of progress in treating metastatic colorectal cancer

Colorectal cancer is the third most commonly diagnosed cancer in the United States. While screening methods strive to improve rates of early stage detection, 25% of patients have metastatic disease at the time of diagnosis, with the most common sites being the liver, lung, and peritoneum. While once perceived as hopeless, the last two decades have seen substantial strides in the medical, surgical, and regional therapies to treat metastatic disease offering significant improvements in survival.

Safety and advantages of combined resection and microwave ablation in patients with bilobar hepatic malignancies

BACKGROUND

The multimodality approach has significantly improved outcomes for hepatic malignancies. Microwave ablation is often used in isolation or succession, and seldom in combination with resection. Potential benefits and pitfalls from combined resection and ablation therapy in patients with complex and extensive bilobar hepatic disease have not been well defined.

METHODS

A review of the University of Louisville prospective Hepato-Pancreatico-Biliary Patients database was performed with multi-focal bilobar disease that underwent microwave ablation with resection or microwave only included.

RESULTS

One hundred and eight were treated with microwave only (MWA, n = 108) or combined resection and ablation (CRA, n = 84) and were compared with similar disease-burden patients undergoing resection only (n = 84). The groups were comparable except that the MWA group was older (p = .02) and with higher co-morbidities (diabetes, hepatitis). The resection group had larger tumours (4 vs. 3.2 and 3 cm) but the CRA group had more numerous lesions (4 vs. 3 and 2, p = .002). Short-term outcomes including morbidity (47.6% vs. 43%, p = .0715) were similar between the CRA and resection only groups. Longer operative time (164 vs. 126 min, p = .003) and need for blood transfusion (p = .001) were independent predictors of complications. Survival analyses for colorectal metastasis patients (n = 158) demonstrated better overall survival (OS) (43.9 vs. 37.6 and 30.5 months, p = .035), disease-free survival (DFS) (38 vs. 26.6 and 16.9 months, p = .028) and local recurrence-free survival (LRFS) (55.4 vs. 17 and 22.9 months, p < .001) with resection only.

CONCLUSION

The use of microwave ablation in addition to surgical resection did not significantly increase the morbidities or short-term outcomes. In combination with systemic and other local forms of therapy, combined resection and ablation is a safe and effective procedure.

Large variation in the utilization of liver resections in stage IV colorectal cancer patients with metastases confined to the liver

BACKGROUND

Surgical resection of both the primary tumor and all metastases is considered the only chance of cure for patients with stage IV colorectal cancer. The aim of this study was to investigate change over time in the utilization of liver resections, as well as possible institutional variations.

PATIENTS AND METHODS

All patients diagnosed with stage IV colorectal cancer with metastases confined to the liver (n = 1617) between 2004 and 2012 were selected from the population-based Eindhoven Cancer Registry. The proportion of patients undergoing liver resection was investigated. Institutional variation in the period 2010-2012 was analyzed using logistic regression. Kaplan-Meier and Cox regression analyses were used to analyze overall survival.

RESULTS

The proportion of patients undergoing liver metastasectomy increased over time from 8% in 2004 to approximately 24% in 2012. There was a wide inter-hospital variation in the proportion of patients that underwent a liver resection (range: 14-34%) in the period 2010-2012. Liver resection was more often performed in younger patients and in rectal cancer patients. Median overall survival in patients undergoing liver resection was 55 months. Adjusted for potential confounders, resection of liver metastases was strongly associated with improved overall survival (HR 0.32, 95%CI 0.25-0.40).

DISCUSSION

This study shows that despite the excellent long-term prognosis for patients with stage IV colorectal cancer after liver resection, there is still a large institutional variation in the utilization of this potentially curative therapy.

Thermal ablation of colorectal liver metastases: a position paper by an international panel of ablation experts, The Interventional Oncology Sans Frontières meeting 2013

Objectives

Previous attempts at meta-analysis and systematic review have not provided clear recommendations for the clinical application of thermal ablation in metastatic colorectal cancer. Many authors believe that the probability of gathering randomised controlled trial (RCT) data is low. Our aim is to provide a consensus document making recommendations on the appropriate application of thermal ablation in patients with colorectal liver metastases.

Methods

This consensus paper was discussed by an expert panel at The Interventional Oncology Sans Frontières 2013. A literature review was presented. Tumour characteristics, ablation technique and different clinical applications were considered and the level of consensus was documented.

Results

Specific recommendations are made with regard to metastasis size, number, and location and ablation technique. Mean 31 % 5-year survival post-ablation in selected patients has resulted in acceptance of this therapy for those with technically inoperable but limited liver disease and those with limited liver reserve or co-morbidities that render them inoperable.

Conclusions

In the absence of RCT data, it is our aim that this consensus document will facilitate judicious selection of the patients most likely to benefit from thermal ablation and provide a unified interventional oncological perspective for the use of this technology.

Key Points

• Best results require due consideration of tumour size, number, volume and location.

• Ablation technology, imaging guidance and intra-procedural imaging assessment must be optimised.

• Accepted applications include inoperable disease due to tumour distribution or inadequate liver reserve.

• Other current indications include concurrent co-morbidity, patient choice and the test-of-time approach.

• Future applications may include resectable disease, e.g. for small solitary tumours.

Outcome analysis of a decade-long experience of isolated hepatic perfusion for unresectable liver metastases at a single institution

OBJECTIVE

To evaluate outcomes of isolated hepatic perfusion (IHP) on isolated liver metastases (LMs).

BACKGROUND

Isolated unresectable LMs are often the main determinant of overall survival (OS) for colorectal cancer (CRC) and other solid malignancies. We hypothesized that IHP can be performed safely and yield impressive responses for a variety of solid tumor pathology, using different perfusion agents.

METHODS

Retrospective review of a prospectively collected database of patients undergoing IHP for unresectable solid tumor LM.

RESULTS

Between 2003 and 2012, IHP was completed in 91 patients. Primary tumor pathology was CRC = 54, non-CRC = 37 (ocular/cutaneous melanoma = 32, cholangiocarcinoma = 3, appendiceal = 1, and breast = 1). IHP employed Melphalan (n = 69) (CRC = 32, non-CRC = 37), Oxaliplatin (n = 10) (CRC), or Oxaliplatin + 5FU (n = 12) (CRC). Hepatic arterial infusion (HAI) pumps were placed in all CRC patients. There were 3(3.3%) perioperative deaths. Response rates for CRC, melanoma, and cholangiocarcinoma were 68.2%, 57.1%, and 100% respectively. Response rates for CRC patients using 5FU + Oxaliplatin, Oxaliplatin, or Melphalan were 83.3%, 66.7%, and 60.9%, respectively. Median OS for the CRC patients (from IHP date) was 23 months (95% confidence interval: 15-28 months). On univariate analysis, receipt of HAI-FUDR (floxuridine) within 1 year of IHP was the only factor associated with improved OS (P = 0.043) in CRC patients.

CONCLUSIONS

IHP results in excellent response rates for patients with unresectable liver metastasis from solid tumors. Improved local control for CRC patients undergoing IHP-HAI may improve survival.

Computed tomographic colonography in preoperative evaluation of colorectal tumors: a prospective study

Background

This study aimed to assess the usefulness of computed tomographic colonography (CTC) in preoperative evaluation of colorectal tumors and the entire bowel including endoscopically inaccessible regions.

Methods

Colonoscopy and CTC were performed for 49 patients. The tumor and the entire colon were assessed, and the results were compared with colonoscopy. The extraluminal findings of CTC were compared with contrast-enhanced computed tomography (CT) of the abdomen and the pelvis in 33 patients. All these patients had undergone surgery. A comparison of results for tumor node metastasis classification between CTC, CT, and histopathology was performed.

Results

Exploration of the entire colon was possible for 89.8% of the patients using CTC and 49.0% of the patients using colonoscopy. Bowel cleansing was assessed as worse with CTC. In the evaluation of tumor location and morphologic type, CTC was congruent with colonoscopy. Colonoscopy enabled approximate tumor size and volume to be evaluated for only 59.2% (29/49) and 30.6% (15/49) of patients, respectively, whereas CTC enabled evaluation of all 48 (100.0%) visualized tumors. Wall thickening, outer contour, and suspected infiltration of surrounding tissues and organs are impossible to determine with colonoscopy but can be determined with CTC. Using CTC, two additional tumors were found proximate to occlusive masses in endoscopically inaccessible regions.

Conclusion

Computed tomographic colonography is a useful method for diagnosing colorectal tumors. It allows the clinician to diagnose tumor, determine local tumor progression, and detect synchronous lesions in the large bowel including endoscopically inaccessible regions.

Comparison of CT colonography vs. conventional colonoscopy in mapping the segmental location of colon cancer before surgery

Once presence of a colorectal cancer has been diagnosed, a key factor for patient's prognosis in view of surgical intervention is the correct segmental localization and resection of the tumor. The aim of this work was to compare the accuracy of the current gold standard technique, conventional colonoscopy (CC), to computed tomography colonography (CTC) in the segmental localization of tumor. Sixty-five patients (mean age 64; 45 female and 19 male) with colorectal cancer diagnosed at colonoscopy underwent CTC before surgery. In 45 out of 65 cases (69%), patients were referred to CTC after incomplete CC. Reasons were patient intolerance to CC or presence of stenosing cancer, with consistent difficulties in crossing the tract of the colon involved by the lesion. CTC allowed the complete colonic examination in 63/65 cases, since in 2 patients with an obstructing lesion of the sigmoid colon, pneumocolon could not be obtained. However, per patient and per lesion sensitivity of CTC was 100%. Difference from colonoscopy was statistically significant (P < 0.05). In terms of segmental localization of masses, CTC located precisely all lesions, while colonoscopy failed in 16/67 (24%) lesions, though six were missed for incomplete colonoscopy (9%). In the remaining 10/67 (15%) lesions, detected by colonoscopy but incorrectly located, the mismatch occurred in the rectum (n = 3), sigmoid (n = 2), descending (n = 1), transverse (n = 2), ascending colon, and cecum. Agreement between CTC and CC was fair (k value 0.62). Sensitivity, specificity, positive predictive value and negative predictive value of CTC in determining the precise location of colonic masses were respectively 100%, 96%, 85%, and 100%. CT detected hepatic (6/65 patients) and lung metastases (3/65 patients). CT colonography has better performance in the identification of colonic masses (diameter > 3 cm), in the completion of colonic evaluation and in the segmental localization of tumor. CTC should replace colonoscopy for preoperative staging of colorectal cancer.

A phase I study of hyperthermic isolated hepatic perfusion with oxaliplatin in the treatment of unresectable liver metastases from colorectal cancer

Isolated hepatic perfusion (IHP) is a proven approach for regional delivery of chemotherapy in patients with unresectable primary and metastatic tumors of the liver. Most trials of IHP have utilized melphalan as the active drug in the perfusate. We performed a phase I trial to evaluate the efficacy, safety, and maximum tolerated dose (MTD) of oxaliplatin delivered by hyperthermic isolated hepatic perfusion. A phase I dose-escalation trial of hyperthermic IHP with oxaliplatin in patients with unresectable metastatic colorectal cancer scheduled to undergo placement of a hepatic arterial infusion (HAI) pump was carried out. Thirteen patients were enrolled between November 2003 and September 2006. Dose-limiting veno-occlusive disease was observed at 60 mg/m(2). At the MTD of 40 mg/m(2) only minor transient liver dysfunction was observed. Ultrafilterable platinum area under the curve and maximum concentration delivered by IHP increased nonlinearly with dose as did platinum concentrations in liver biopsies obtained at the end of the 60 min IHP. Seventy-seven percent of patients had a >50% decrease in serum carcinoembryonic antigen (CEA) after IHP. The overall response rate to the combined IHP and HAI therapy was 66%. One patient had a durable complete response (>4 years). We conclude that hyperthermic IHP with oxaliplatin was safe and feasible at a dose of 40 mg/m(2). The ability to obtain complete vascular isolation with open IHP was confirmed. The response rate in this small phase I study was encouraging.