Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery

Predictive factors of surgery in metastatic colorectal cancer: a retrospective cohort study

INTRODUCTION

Current management of metastatic colorectal cancer is based on neoadjuvant chemotherapy. Few studies have reported on surgery procedures in patients with metastatic colorectal cancer. The objective of this study was to describe our institutional experience with emergency surgery performed in patients with metastatic colorectal cancer during chemotherapy.

PATIENTS AND METHODS

This was a retrospective cohort study including adult patients of ≤80 years with a metastatic colorectal cancer between 2017 and 2020 and undergoing surgery during chemotherapy. Statistical analyses were based on Kaplan-Meier's curve and Cox proportional hazard model. The surgery statistical risk during chemotherapy was studied through all tumor and patient's characteristics. Multivariable logistic regression models were used to identify predictive factors of emergency surgery in these patients.

RESULTS

Seventy-two cases were identified and 60% patients undergone an emergency surgery. By Kaplan-Meier's analyses, intestinal surgery was much more frequent and early in patients who have severe stenosis (either blocking or only permeable using a gastroscope) at the time of diagnosis. Patients with severe malignant stenosis presented a 6.28 time higher surgery risk (p < .0001). The median time between admission and surgery was 54 days in patients with severe stenosis who were operated.

CONCLUSION

The degree of colorectal tumor stenosis measured by endoscopy was a risk factor for emergency surgery in patients with metastatic colorectal cancer during neoadjuvant chemotherapy. In this group of patients presenting low survival outcomes, further studies are needed to define the place of preventive surgery, avoiding emergency surgery and morbidity in such fragile patients.

Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes.

METHODS

CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC.

RESULTS

The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

CONCLUSIONS

The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Recent progress of targeted nanocarriers in diagnostic, therapeutic, and theranostic applications in colorectal cancer

Cancer at the lower end of the digestive tract, colorectal cancer (CRC), starts with asymptomatic polyps, which can be diagnosed as cancer at a later stage. It is the fourth leading cause of malignancy-associated mortality worldwide. Despite progress in conventional treatment strategies, the possibility to overcome the mortality and morbidity issues with the enhancement of the lifespan of CRC patients is limited. With the advent of nanocarrier-based drug delivery systems, a promising revolution has been made in diagnosis, treatment, and theranostic purposes for cancer management. Herein, we reviewed the progress of miniaturized nanocarriers, such as liposomes, niosomes, solid lipid nanoparticles, micelles, and polymeric nanoparticles, employed in passive and active targeting and their role in theranostic applications in CRC. With this novel scope, the diagnosis and treatment of CRC have proceeded to the forefront of innovation, where specific characteristics of the nanocarriers, such as processability, flexibility in developing precise architecture, improved circulation, site-specific delivery, and rapid response, facilitate the management of cancer patients. Furthermore, surface-engineered technologies for the nanocarriers could involve receptor-mediated deliveries towards the overexpressed receptors on the CRC microenvironment. Moreover, the potential of clinical translation of these targeted miniaturized formulations as well as the possible limitations and barriers that could impact this translation into clinical practice were highlighted. The advancement of these newest developments in clinical research and progress into the commercialization stage gives hope for a better tomorrow.

The mechanisms underlying the enrichment and action of glypican-1-positive exosomes in colorectal cancer cells

BACKGROUND

Glypican-1 (GPC1) is overexpressed in several tumors, and GPC1⁺ exosomes have shown the potential to predict early colorectal cancer (CRC). However, the mechanisms underlying the enrichment and action of GPC1⁺ exosomes in CRC remain unknown.

METHODS

The expression of slit guidance ligand 2 (SLIT2), hypoxia-inducible factor (HIF)-1α/2α, and GPC1 in clinical CRC tissues was detected using immunohistochemistry and western blot. Exosomes were isolated from the supernatants of CRC cell cultures. The effects of SLIT2, hypoxia, heparin, and phospholipase C (PLC) on exosomal GPC1 expression and GPC1⁺ exosome enrichment in CRC cells were analyzed with western blot and flow cytometry. CRC cell proliferation was assessed with MTT and colony formation assays. Co-immunoprecipitation was used to detect the binding of GPC1 and SLIT2 in SW480 cells. Nude mice were subcutaneously inoculated with SW480 cells with different treatments. The Wnt signaling was detected.

RESULTS

SLIT2 was poorly expressed and GPC1, HIF-1α, and HIF-2α were highly expressed in human CRC tissues. SLIT2 in CRC cells inhibited GPC1⁺ exosome enrichment and exosomal GPC1 expression. PLC and heparin increased GPC1⁺ exosome enrichment in CRC cells in a concentration-dependent manner. Hypoxia increased the enrichment of GPC1⁺ exosomes in CRC cells depending on HIF-2α expression. GPC1⁺ exosomes stimulated CRC cell proliferation and xenograft tumor growth through activation of Wnt signaling.

CONCLUSIONS

GPC1⁺ exosome enrichment is related to PLC and heparin. Hypoxia increases the enrichment of GPC1⁺ exosomes in CRC cells by activating HIF-2α and downregulating SLIT2. GPC1⁺ exosomes further drive CRC progression by activating Wnt signaling.

Structured and shared MRI staging lexicon and report of rectal cancer: A consensus proposal by the French Radiology Group (GRERCAR) and Surgical Group (GRECCAR) for rectal cancer

PURPOSE

To develop French guidelines by experts to standardize data acquisition, image interpretation, and reporting in rectal cancer staging with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and opinions of experts of GRERCAR (Groupe de REcherche en Radiologie sur le CAncer du Rectum [i.e., Rectal Cancer Imaging Research Group]) and GRECCAR (Groupe de REcherche en Chirurgie sur le CAncer du Rectum [i.e., Rectal Cancer Surgery Research Group]) were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of reporting template and protocol for data acquisition were collected; responses were analyzed and classified as "Recommended" versus "Not recommended" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding patient preparation, MRI sequences, staging and reporting was attained using the RAND-UCLA Appropriateness Method. A consensus was reached for each reporting template item among the experts. Tailored MRI protocol and standardized report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for rectal cancer staging with MRI.

Therapeutic Potential of Naturally Occurring Small Molecules to Target the Wnt/β-Catenin Signaling Pathway in Colorectal Cancer

Simple Summary

Colorectal cancer (CRC) is an emerging public health problem and the second leading cause of death worldwide, with a significant socioeconomic impact in several countries. The 5-year survival rate is only 12% due to the lack of early diagnosis and resistance to available treatments, and the canonical Wnt signaling pathway is involved in this process. This review underlines the importance of understanding the fundamental roles of this pathway in physiological and pathological contexts and analyzes the use of naturally occurring small molecules that inhibits the Wnt/β-catenin pathway in experimental models of CRC. We also discuss the progress and challenges of moving these small molecules off the laboratory bench into the clinical platform.

Abstract

Colorectal cancer (CRC) ranks second in the number of cancer deaths worldwide, mainly due to late diagnoses, which restrict treatment in the potentially curable stages and decrease patient survival. The treatment of CRC involves surgery to remove the tumor tissue, in addition to radiotherapy and systemic chemotherapy sessions. However, almost half of patients are resistant to these treatments, especially in metastatic cases, where the 5-year survival rate is only 12%. This factor may be related to the intratumoral heterogeneity, tumor microenvironment (TME), and the presence of cancer stem cells (CSCs), which is impossible to resolve with the standard approaches currently available in clinical practice. CSCs are APC-deficient, and the search for alternative therapeutic agents such as small molecules from natural sources is a promising strategy, as these substances have several antitumor properties. Many of those interfere with the regulation of signaling pathways at the central core of CRC development, such as the Wnt/β-catenin, which plays a crucial role in the cell proliferation and stemness in the tumor. This review will discuss the use of naturally occurring small molecules inhibiting the Wnt/β-catenin pathway in experimental CRC models over the past decade, highlighting the molecular targets in the Wnt/β-catenin pathway and the mechanisms through which these molecules perform their antitumor activities.

Factors influencing anterior/low anterior resection syndrome after rectal or sigmoid resections

Background/aim

Sphincter-preserving surgery is one of the main goals in the treatment of rectal cancer because it improves the quality of life (QoL). However, some patients may experience disrupted symptoms called anterior or low anterior resection syndrome (LARS). This study was designed to evaluate the frequency and influencing factors of LARS in patients who underwent sigmoid or rectal resection.

Materials and methods

In this retrospective, clinical study, patients who underwent rectal or sigmoid resection and anastomosis due to any benign and malignant reasons were evaluated in terms of LARS between January 2010 and November 2019 at Medical Faculty Hospital of Mersin University. The frequency and severity of LARS were determined by using a standard scale. Furthermore, influencing factors including lesion localization, operation, the proximity of anastomosis to the anal verge, creation of stoma, chemotherapy, and radiotherapy application were investigated.

Results

Out of a total of 550 patients, 276 were included in this study. The major LARS incidence was found as 27.2%. Very low anterior resection (VLAR) (OR = 42.40 (95% CI [11.14–161.36], P < 0.0001), protective ileostomy (OR = 12.83 (95% CI [6.58–25.0], P < 0.0001), end colostomy (OR = 8.55 (95% CI [1.36–53.61], P = 0.022), receiving chemotherapy (OR = 3.08 (95% CI [1.71–5.53], P < 0.0001), and radiotherapy (OR = 2.51 (95% CI [1.38–4.57], P = 0.003) and the ROC analysis showed that creating an anastomosis placed at most 8.5 cm from the anal verge was found to be a major influencing factor on LARS (P < 0.05).

Conclusions

LARS may frequently occur in patients who have undergone rectal resection. In this study, the most important factors influencing LARS were found to be the proximity of anastomosis to the anal canal and creating a protective stoma. Receiving chemoradiotherapy also plays an important role in LARS.

Triumph against cancer: invading colorectal cancer with nanotechnology

INTRODUCTION

Recent statistics have reported colorectal cancer (CRC) as the second leading cause of cancer-associated deaths in the world. Early diagnosis of CRC may help to reduce the mortality and associated complications. However, the conventional diagnostic techniques often lead to misdiagnosis, fail to differentiate benign from malignant tissue or diagnose only at an advanced stage. For the treatment of CRC, surgery, chemotherapy, immunotherapy, and radiotherapy have been employed. However, the quality of living of the CRC patients is highly compromised after employing current therapeutic approaches owing to the toxicity issues and relapse.

AREA COVERED

This review accentuates the molecular mechanisms involved in the pathogenesis, stages of CRC, conventional approaches for diagnosis and therapy of CRC and the issues confronted thereby. It provides an outlook on the advantages of employing nanotechnology-based approaches for prevention, early diagnosis, and treatment of CRC.

EXPERT OPINION

Employing nanotechnology-based approaches has demonstrated promising outcomes in the prevention, diagnosis, and treatment of CRC. Nanotechnology-based approaches can surmount the major drawbacks of traditional diagnostic and therapeutic approaches. Nanotechnology bestows the advantage of early detection of CRC which helps to undertake instant steps for offering efficient therapy and reducing the mortality rates. For the treatment of CRC, nanocarriers offer the benefit of achieving controlled drug release, improved drug bioavailability, enhanced tumor targetability and reduced adverse effects.

Impact of the COVID-19 pandemic during Spain's state of emergency on the diagnosis of colorectal cancer

INTRODUCTION

We evaluate the impact of COVID-epidemic in colorectal cancer (CRC) diagnosis during Spain's state of emergency.

METHODS

We compared newly diagnosed patients with patients diagnosed in the same period of 2019.

RESULTS

A new diagnosis of CRC decreased 48% with a higher rate of patients diagnosed in the emergency setting (12.1% vs. 3.6%; p = .048) and a lower rate diagnosed in the screening program (5.2% vs. 33.3%; p = .000).

CONCLUSIONS

Fewer patients have been diagnosed with CRC, with a higher rate of patients diagnosed in an emergency setting.

Chinese herbal medicines for prevention and treatment of colorectal cancer: From molecular mechanisms to potential clinical applications

Worldwide, colorectal cancer (CRC) is one of the most common malignant tumors, leading to immense social and economic burdens. Currently, the main treatments for CRC include surgery, chemotherapy, radiotherapy and immunotherapy. Despite advances in the diagnosis and treatment of CRC, the prognosis for CRC patients remains poor. Furthermore, the occurrence of side effects and toxicities severely limits the clinical use of these therapies. Therefore, alternative medications with high efficacy but few side effects are needed. An increasing number of modern pharmacological studies and clinical trials have supported the effectiveness of Chinese herbal medicines (CHMs) for the prevention and treatment of CRC. CHMs may be able to effectively reduce the risk of CRC, alleviate the adverse reactions caused by chemotherapy, and prolong the survival time of patients with advanced CRC. Studies of molecular mechanisms have provided deeper insight into the roles of molecules from CHMs in treating CRC. This paper summarizes the current understanding of the use of CHMs for the prevention and treatment of CRC, the main molecular mechanisms involved in these processes, the role of CHMs in modulating chemotherapy-induced adverse reactions, and CHM's potential role in epigenetic regulation of CRC. The current study provides beneficial information on the use of CHMs for the prevention and treatment of CRC in the clinic, and suggests novel directions for new drug discovery against CRC.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND

Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases.

METHODS

Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety.

RESULTS

One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH.

CONCLUSIONS

The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Results of a national survey on the use of stents for the treatment of colonic obstruction

INTRODUCTION

We distributed a survey in order to determine the current indications for the use of colonic stents to treat colonic obstruction in Spain and its compliance with international guidelines.

METHODS

Descriptive study of a survey distributed by the Spanish Association of Surgeons (Asociación Española de Cirujanos), the Catalan Society of Surgery (Societat Catalana de Cirurgia) and the Spanish Society of Digestive Endoscopy (Sociedad Española de Endoscopia Digestiva).

RESULTS

340 valid responses were received: 25% from gastrointestinal specialists, and 75% from general surgeons. During the last year, 44.4% of respondents assessed between 10 and 20 COC. Of these, 52.2% indicated less than 5 stents/year, 75% of which were indicated as a prior step to preferential surgery and only 25% were performed with palliative intent. 55.3% of the participants reported knowing the official guidelines, and 64% of respondents would use the stent as a step prior to surgery in elderly patients with localized disease. 75.9% would place stents as palliative therapy in young patients with carcinomatosis, and 61.8% would use them in stage IV malignancies under treatment with chemotherapy. Only 18.1% knew of the risk of colon perforation after stent placement in patients undergoing treatment with antiangiogenics.

CONCLUSIONS

In Spain, the indication for colonic stents is reserved for selected cases and varies according to the specialty and the years of experience of the respondent. The compliance with international guidelines of most respondents is moderate. It is important to insist on the high risk of perforation after angiogenics, which is unknown to most surgeons.

Improvements in esophageal and gastric cancer care in Sweden-population-based results 2007-2016 from a national quality register

The Swedish National Register for Esophageal and Gastric cancer was launched in 2006 and contains data with adequate national coverage and of high internal validity on patients diagnosed with these tumors. The aim of this study was to describe the evolution of esophageal and gastric cancer care as reflected in a population-based clinical registry. The study population was 12,242 patients (6,926 with esophageal and gastroesophageal junction (GEJ) cancers and 5,316 with gastric cancers) diagnosed between 2007 and 2016. Treatment strategies, short- and long-term mortality, gender aspects, and centralization were investigated. Neoadjuvant oncological treatment became increasingly prevalent during the study period. Resection rates for both esophageal/GEJ and gastric cancers decreased from 29.4% to 26.0% (P = 0.022) and from 38.8% to 33.3% (P = 0.002), respectively. A marked reduction in the number of hospitals performing esophageal and gastric cancer surgery was noted. In gastric cancer patients, an improvement in 30-day mortality from 4.2% to 1.6% (P = 0.005) was evident. Overall 5-year survival after esophageal resection was 38.9%, being higher among women compared to men (47.5 vs. 36.6%; P < 0.001), whereas no gender difference was seen in gastric cancer. During the recent decade, the analyses based on the Swedish National Register for Esophageal and Gastric cancer database demonstrated significant improvements in several important quality indicators of care for patients with esophagogastric cancers. The Swedish National Register for Esophageal and Gastric cancer offers an instrument not only for the control and endorsement of quality of care but also a unique tool for population-based clinical research.

Effect of length of time from diagnosis to treatment on colorectal cancer survival: A population-based study

Evidence is limited regarding the effect of diagnosis-to-treatment interval (DTI) on the survival of colorectal cancer (CRC) patients. In addition, previous studies on treatment delay and CRC survival have largely grouped patients from all stages (I-IV) into one cohort. Our study provides analysis on each stage individually. We conducted a retrospective cohort study with 39,000 newly diagnosed CRC patients obtained from the Taiwan Cancer Registry Database from 2004–2010 to examine the effect of DTIs on overall survival. DTIs were divided into 3 groups: ≤ 30 days (36,115 patients, 90.5% of study patients), 31–150 days (2,533, 6.4%), and ≥ 151 days (1,252, 3.15%). Risk of death was increased for DTI 31–150 days (hazard ratio 1.51; 95% confidence interval 1.43–1.59) and DTI ≥ 151 days (1.64; 1.54–1.76) compared to DTI ≤ 30. This risk was consistent across all cancer stages. Additional factors that increased risk of death include male gender, age >75, Charlson Comorbidity Index ≥7, other catastrophic illnesses, lack of multidisciplinary team involvement, and treatment in a low volume center. From these results, we advise that the DTI for all CRC patients, regardless of cancer staging, should be 30 days or less.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Does obesity impact postoperative outcomes following robotic-assisted surgery for rectal cancer?

INTRODUCTION

Obesity has been identified as a risk factor for both conversion and severe postoperative morbidity in patients undergoing laparoscopic rectal resection. Robotic-assisted surgery (RAS) is proposed to overcome some of the technical limitations associated with laparoscopic surgery for rectal cancer. The aim of our study was to determine if obesity remains a risk factor for severe morbidity in patients undergoing robotic-assisted rectal resection.

PATIENTS

This study was a retrospective review of a prospective database. A total of 183 patients undergoing restorative RAS for rectal cancer between 2007 and 2016 were divided into 2 groups: control (BMI < 30 kg/m²; n = 125) and obese (BMI ≥ 30 kg/m²; n = 58). Clinicopathologic data, 30-day postoperative morbidity, and perioperative outcomes were compared between groups. The main outcome was severe postoperative morbidity defined as any complication graded Clavien-Dindo ≥ 3.

RESULTS

Control and obese groups had similar clinicopathologic characteristics. Severe complications were observed in 9 (7%) and 4 (7%) patients, respectively (p > 0.99). Obesity did not impact conversion, anastomotic leak rate, length of stay, or readmission but was significantly associated with increased postoperative morbidity (29 vs. 45%; p = 0.04) and especially more postoperative ileus (11 vs. 26%; p = 0.01). Obesity and male gender were the two independent risk factors for postoperative overall morbidity (OR 1.97; 95% CI 1.02-3.94; p = 0.04 and OR 2.23; 95% CI 1.10-4.76; p = 0.03, respectively).

CONCLUSION

‎Obesity did not impact severe morbidity or conversion rate following RAS for rectal cancer but remained a risk factor for overall morbidity and especially postoperative ileus.

How to save both transverse colon and continence after extensive left colon surgery: A case report of a new procedure

INTRODUCTION

Nowadays, after wide left colectomy, it is necessary to choose one of the following procedures: a definitive transverse colostomy, an ileo-rectal anastomosis or a right colo-rectal anastomosis (Deloyers procedure).

PRESENTATION OF CASE

We performed our new procedure on a 63 years-old man. After an extensive left proctocolectomy, the intestinal continuity between the transverse colon and rectum was obtained by transposition and rotation of the right colon into the pelvis. After recanalization the patient never lost the functions of the large intestine and progressively restored continence.

DISCUSSION

Saving the transverse colon and the right colon mean achieving not only continence but also a better degree of reabsorption of liquids and vitamin K and group B production in order to keep intestinal functions as similar as possible to the normal physiology.

CONCLUSION

The one-year follow-up surgical and clinical outcomes are encouraging to support the feasibility of this procedure in terms of improving the quality of life: avoiding diarrhea, incontinence and post-operative urgency.

The clinical significance of circulating GPC1 positive exosomes and its regulative miRNAs in colon cancer patients

Colorectal cancer (CRC) is a leading cause of cancer-related deaths worldwide. Recent study found an increased level of glypican-1 positive (GPC1+) plasma exosomes in patients with stage II CRC, but decreased levels of plasma miR-96-5p and miR-149. This study further investigated the clinical significance of plasma GPC1+ exosomes and plasma miR-96-5p and miR-149 levels in stage III CRC patients. To study the effect of these microRNAs on GPC1+ plasma exosomes, we isolated and purified exosomes and overexpressed human GPC1 and the microRNAs miR-96-5p and miR-149 by adenovirus vectors. Overexpression of GPC1 activated epithelial-mesenchymal transition (EMT) which then increased invasion and migration in HT29 and HCT-116 colon cancer cells. In contrast, silencing GPC1 expression and overexpressing miR-96-5p and miR-149 significantly inactivated EMT and decreased invasion and migration of HT29 and HCT-116 cells. miR-96-5p and miR-149 inhibitors significantly increased invasion and migration of HT29 and HCT-116 cells. Our results indicate that high levels of circulating GPC1 positive exosomes before and after surgery as well as low circulating miR-96-5p and miR-149 before surgery indicated a severe clinical status and poor prognosis in stage III colon cancer patients. We conclude that GPC1 can be a biomarker for relapse of stage III CRC and may be involved in EMT activation, invasion, and migration of colorectal cancer cells.

GPC1 exosome and its regulatory miRNAs are specific markers for the detection and target therapy of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. However, a biomarker for a sensitive and simple diagnostic test and highly effective target therapy of CRC is still clinically unavailable. This study is to investigate the evidence and significance of plasma GPC1 positive exosomes as a biomarker of CRC. Results showed that GPC1⁺ exosomes were successfully isolated from tissues and plasma. The percentage of GPC1⁺ exosomes and the GPC1 protein expression in exosomes from tumour tissues and plasma of CRC patients before surgical treatment was significantly elevated compared to that in the peritumoural tissues and the plasma of healthy controls. miR-96-5p and miR-149 expression in tumour tissues and plasma of CRC patients as well as in the GPC1⁺ exosomes from CRC patients were significantly decreased compared to that in the peritumoural tissues and the plasma of healthy controls. Two months after surgical treatment, levels of all tested markers significantly normalized. Overexpression of miR-96-5p and miR-149 significantly decreased GPC1 expression in HT-29 and HCT-116 cells, xenograft tumours, plasma in mice bearing HT-29 and HCT-116 tumours, and the secretion of GPC1⁺ exosomes from the HT-29 and HCT-116 cells and xenograft tumours. Overexpression of miR-96-5p and miR-149 significantly decreased cell viability and increased cell apoptosis in HT-29 and HCT-116 cells, and inhibited the growth of xenograft HT-29 and HCT-116 tumours. In conclusion, the increased plasma GPC1⁺ exosomes and reduced plasma miR-96-5p and miR-149 expression are specific markers for the diagnosis of CRC and targets for the therapy of CRC.

Effects of a Multikinase Inhibitor Motesanib (AMG 706) Alone and Combined with the Selective DuP-697 COX-2 Inhibitor on Colorectal Cancer Cells

In the present study, we investigated the effects of motesanib (AMG 706), a multikinase inhibitor alone and in combination with DuP-697, an irreversible selective inhibitor of COX-2, on cell proliferation, angiogenesis, and apoptosis induction in a human colorectal cancer cell line (HT29). Real time cell analysis (RTCA, Xcelligence system) was used to determine the effects on colorectal cancer cell proliferation. Apoptosis was assessed with annexin V staining and angiogenesis was determined with chorioallantoic membrane model. We found that motesanib alone exerted antiproliferative, antiangiogenic and apoptotic effects on HT29 colorectal cancer cells. Combination with DUP-697 increased the antiproliferative, antiangiogenic and apoptotic effects. Results of this study indicate that motesanib may be a good choice in treatment of colorectal tumors. In addition, the increased effects of combination of motesanib with DuP-697 raise the possibility of using lower doses of these drugs and therefore avoid/minimize the dose-dependent side effects generally observed.

Treatment sequence of synchronously (liver) metastasized colon cancer

No standards for staging, systemic therapy or the timing of an operation are defined for patients newly diagnosed with synchronous metastases and a primary in the colon. An expert group of radiologists, medical, radiation and surgical oncologists therefore came together to discuss staging and treatment sequence for these patients and came up with a recommendation based on current evidence of potential therapeutic options. The discussion was organized to debate recommendations centred on 5 topics and therefore the position paper is built upon these titles and their subtitles.

Addressing unwarranted variations in colorectal cancer outcomes: a conceptual approach

In the clinical setting, the term 'unwarranted variation' refers to variations in patient outcomes that cannot be explained by the patient's underlying illness or medical needs, or the dictates of evidence-based medicine. These types of variations persist even after adjusting for patient-specific factors. Unwarranted variation depends on a complex mix of disparities, including inequalities in access to appropriate care in a wide variety of geographical and cultural settings, in the uptake and application of clinical knowledge, in the prioritization and allocation of resources, and differences in organizational and professional culture. Nevertheless, unwarranted variation has been inexorably linked with clinical practice. Thus, awareness of the antecedents of unwarranted variations in clinical practice is strategically important. In this Perspective, we discuss these antecedents in colorectal cancer clinical care pathways with an emphasis upon the multidisciplinary team (MDT), and suggest pragmatic steps that could be taken to address latent unwarranted variation.

Evidence-based Clinical Management of Acute Malignant Colorectal Obstruction

Acute malignant colorectal obstruction (AMCO) is an emergency associated with colorectal cancer (CRC). Emergency surgery is standard therapy for AMCO, and 1-stage surgery without colostomy is preferable, but it is occasionally difficult in the emergency setting. A self-expandable metallic stent (SEMS) enables noninvasive colonic decompression and subsequent 1-stage surgery, which has been widely applied for CRC with AMCO. However, recent accumulation of high-quality evidence has highlighted some problems and the limited efficacy of SEMS for AMCO. In palliative settings, SEMS placement reduces hospital stay and short-term complication rates, whereas it increases the frequency of long-term complications, such as delayed perforation. SEMS placement does not seem compatible with recent standard chemotherapy including bevacizumab. As a bridge to surgery, while SEMS placement provides a lower clinical success rate than emergency surgery, it can facilitate primary anastomosis without stoma. However, evidence regarding long-term survival outcomes with SEMS in both palliative and bridge to surgery settings is lacking. The efficacy of transanal colorectal tube placement, another endoscopic treatment, has been reported, but its clinical evidence level is low due to the limited number of studies. This review article comprehensively summarizes the current knowledge about surgical and endoscopic management of CRC with AMCO.

Surgery has a key role for quality assurance of colorectal cancer screening programs: impact of the third level multidisciplinary team on lymph nodal staging

PURPOSE

From 2011 to 2013 in the area of the Naples 3 public health district (ASL-NA3), a colorectal cancer screening program (CCSP) was developed. In order to stress the need of quality assurance procedures for surgery and pathology, a third level oncologic pathway was added and set up at a referral colorectal cancer center (RC). Lymph nodal (LN) harvesting, as a process indicator, and nodal positivity were adopted for an interim analysis.

METHODS

The program was implemented by a series of audit meetings and a double type of multidisciplinary team (MDT): "horizontal" and "vertical." Three hundred and forty colorectal cancer (CRC) patients underwent surgery: 119 chose to be operated at the RC (Gr In), 65 were operated at 22 district hospitals (DH) (Gr Out), and 156 symptomatic not screened patients were operated at the RC (Gr Sym).

RESULTS

Statistical analysis revealed differences between Gr In and Gr Out colon groups both for LN harvesting (median of 26 and 11, respectively, P = 0.0001), and for nodal positivity after the first screening round (34.78 and 19.45%, respectively, P = 0.0169). Results were all the more significant in a subset analysis on early T stage colon subgroups (In vs Out) both for LN harvesting (P < 0.0001) and nodal positivity (P < 0.0001).

CONCLUSION

xSignificant differences between RC and DHs were found, particularly for early-stage CRC patients. LN harvesting should be considered as a surrogate marker of quality assurance for at least screening hospitals for "minimum best" standard of care. This should lead to set up a third level in any CCSP.

Colorectal cancer

Colorectal cancer had a low incidence several decades ago. However, it has become a predominant cancer and now accounts for approximately 10% of cancer-related mortality in western countries. The 'rise' of colorectal cancer in developed countries can be attributed to the increasingly ageing population, unfavourable modern dietary habits and an increase in risk factors, such as smoking, low physical exercise and obesity. New treatments for primary and metastatic colorectal cancer have emerged, providing additional options for patients; these treatments include laparoscopic surgery for primary disease, more-aggressive resection of metastatic disease (such as liver and pulmonary metastases), radiotherapy for rectal cancer, and neoadjuvant and palliative chemotherapies. However, these new treatment options have had limited impact on cure rates and long-term survival. For these reasons, and the recognition that colorectal cancer is long preceded by a polypoid precursor, screening programmes have gained momentum. This Primer provides an overview of the current state of the art of knowledge on the epidemiology and mechanisms of colorectal cancer, as well as on diagnosis and treatment.

Anti-tumoral activity of human salivary peptides

Chemotherapy continues to be the standard treatment for advanced or metastasized cancer. However, commonly used chemotherapeutic agents may induce damage in healthy cells and tissues. Thus, in recent years, there has been an increased focus on the development of new, efficient anticancer drugs exhibiting low toxicity and that are not affected by mechanisms of chemoresistance. In the present work, we tested synthetic and naturally obtained human salivary peptides against breast, prostate, colon, osteosarcoma and bladder cancer cell lines (T47-D, PC-3, HT-29, MG63, T-24, respectively). Results have showed that there is a reduced cell population increase that is peptide-, cell- and possibly pathway-specific, with the most potent effect observed in observed in T-47D breast cancer cells. Protein expression and microscopy results further indicate that, in this cell line, the peptide with the sequence GPPPQGGRPQG (GG peptide) interferes with the ability of cell adhesion proteins to stabilize adherens junctions, such as E-cadherin, leading to apoptosis. These promising results encourage future works aimed at disclosing the vast potential of salivary peptides as new therapeutic agents.

Accuracy of preoperative urinary symptoms, urinalysis, computed tomography and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer

BACKGROUND

To determine the accuracy of preoperative urinary symptoms, urinalysis, computed tomography (CT) and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer.

MATERIALS AND METHODS

Records of patients with colorectal cancer and a suspicion of bladder invasion, who underwent tumor resection with partial or total cystectomy between 2002 and 2013 at the Faculty of Medicine Siriraj Hospital, were reviewed. Correlations between preoperative urinary symptoms, urinalysis, cystoscopic finding, CT imaging and final pathological reports were analyzed.

RESULTS

This study included 90 eligible cases (71% male). The most common site of primary colorectal cancer was the sigmoid colon (44%), followed by the rectum (33%). Final pathological reports showed definite bladder invasion in 53 cases (59%). Significant features for predicting definite tumor invasion were gross hematuria (OR 13.6, sensitivity 39%, specificity 73%), and visible tumor during cystoscopy (OR 5.33, sensitivity 50%, specificity 84%). Predictive signs in CT imaging were gross tumor invasion (OR 7.07, sensitivity 89%, specificity 46%), abnormal enhancing mass at bladder wall (OR 4.09, sensitivity 68%, specificity 66%), irregular bladder mucosa (OR 3.53, sensitivity 70%, specificity 60% ), and loss of perivesical fat plane (OR 3.17, sensitivity 81%, specificity 43%). However, urinary analysis and other urinary tract symptoms were poor predictors of bladder involvement.

CONCLUSIONS

The present study demonstrated that the most relevant preoperative predictors of definite bladder invasion in patients with colorectal cancer are gross hematuria, a visible tumor during cystoscopy, and abnormal CT findings.

Stereotactic body radiotherapy (SBRT) reirradiation for pelvic recurrence from colorectal cancer

BACKGROUND AND OBJECTIVES

When surgery is not adequate or feasible, stereotactic body radiotherapy (SBRT) reirradiation has been used for recurrent cancers. We report the outcomes of a series of patients with pelvic recurrences from colorectal cancer reirradiated with SBRT.

METHODS

The Cyberknife(TM) Robotic Stereotactic Radiosurgery system with fiducial based real time tracking was used. Patients were followed with imaging of the pelvis.

RESULTS

Four women and 14 men with 22 lesions were included. The mean dose was 25 Gy in median of five fractions. The mean prescription isodose was 77%, with a median maximum dose of 32.87 Gy. There were two local failures, with a crude local control rate of 89%. The median overall survival was 43 months. One patient had small bowel perforation and required surgery (Grade IV), two patients had symptomatic neuropathy (1 Grade III) and one patient developed hydronephrosis from ureteric fibrosis requiring a stent (Grade III).

CONCLUSIONS

Local recurrence in the pelvis after modern combined modality treatment for colorectal cancer is rare. However it presents a therapeutic dilemma when it occurs; often symptomatic and eventually life threatening. SBRT can be a useful non-surgical modality to control pelvic recurrences after prior radiation for colorectal cancer.

Colorectal carcinogenesis-update and perspectives

Colorectal cancer (CRC) is a very common malignancy in the Western World and despite advances in surgery, chemotherapy and screening, it is still the second leading cause of cancer deaths in this part of the world. Numerous factors are found important in the development of CRC including colonocyte metbolism, high risk luminal environment, inflammation, as well as lifestyle factors such as diet, tobacco, and alchohol consumption. In recent years focus has turned towards the genetics and molecular biology of CRC and several interesting and promising correlations and pathways have been discovered. The major genetic pathways of CRC are the Chromosome Instability Pathway representing the pathway of sporadic CRC through the K-ras, APC, and P53 mutations, and the Microsatellite Instability Pathway representing the pathway of hereditary non-polyposis colon cancer through mutations in mismatch repair genes. To identify early cancers, screening programs have been initiated, and the leading strategy has been the use of faecal occult blood testing followed by colonoscopy in positive cases. Regarding the treatment of colorectal cancer, significant advances have been made in the recent decade. The molecular targets of CRC include at least two important cell surface receptors: the epidermal growth factor receptor and the vascular endothelial growth factor receptor. The genetic and molecular knowledge of CRC has widen the scientific and clinical perspectives of diagnosing and treatment. However, despite significant advances in the understanding and treatment of CRC, results from targeted therapy are still not convincing. Future studies will determine the role for this new treatment modality.

Involving patients in a multidisciplinary European consensus process and in the development of a 'patient summary of the consensus document for colon and rectal cancer care'

CONTEXT

High-quality cancer care should be accessible for patients and healthcare professionals. Involvement of patients as partners in guideline formation and consensus processes is still rarely found. EURECCA, short for European Registration of Cancer Care, is the platform to improve outcomes of cancer care by reducing variation in the diagnostic and treatment process. EURECCA acknowledges the important role of patients in implementation of consensus information in clinical practice.

OBJECTIVE

The aim of this article is to describe the process of involving patients in the consensus process and in developing the patient summary of the consensus for colon and rectal cancer care.

METHODS

The Delphi method for achieving consensus was used. Three online voting rounds and one tele-voting round were offered to an expert panel of oncology professionals and patient representatives. At four different stages, patients and/or patient representatives were involved in the process: (1) during the consensus process, (2) lecturing about the role of the patient, (3) development of the patient summary, and (4) testing the patient summary.

RESULTS

Representatives were invited to the voting and commenting rounds of this process and given an equal vote. Although patients were not consulted during the planning stages of this process, patient involvement increased following the panel's discussion of the implementation of the consensus among the patient population. After the consensus meeting, the patient summary was written by patient representatives, oncologists and nurses. A selection of proactive patients reviewed the draft patient summary; responses were positive and several patient-reported outcomes were added. Questionnaires to evaluate the use and implementation of the patient summary in daily practice are currently being developed and tested. Patient consultation will be needed in future planning for selection of topics.

DISCUSSION

The present study may function as a model for future consensus processes to involve patients at different stages and to implement both patient and healthcare professional versions in daily practice.

[Analysis of factors conditioning admission at the critical care unit of surgical patients. Prospective study of 764 patients operated for 1 year at a university and reference hospital]

OBJECTIVE

Assess what factors determine the income of surgical patients in critical care unit after surgery.

MATERIAL AND METHODS

It included a survey of the 10% of all patients operated by the services of General Surgery, Thoracic Surgery, Maxillofacial Surgery, Vascular Surgery, Urology and Otolaryngology during 2012. We performed a prospective, observational study. Pre-, intra-, and post-operative variables were analyzed. Comparisons were made between patients operated under elective and emergency surgery, and between patients admitted in critical care and admitted directly in the ward, using χ(2) of Pearson correlation with a confidence interval of 95%.

RESULTS

Seven hundred and sixty-four patients were included into the study, 304 were admitted in critical care after surgery and 460 were admitted in the ward. The medical history showed a statistically significant association with intensive care unit admission, well as the fact of being labeled with a high risk for the risk scales. Complexity and duration of the surgery showed a statistically significant association with intensive care unit admission, as well as the fact of present intra-operative complications. Emergency surgery was not significantly associated with intensive care unit admission of surgical patients, although these patients had significantly higher numbers of intra- and post-operative complications, and more exitus than those undergoing elective surgery.

CONCLUSIONS

A greater incidence of intensive care unit admission of patients undergoing emergency surgery should significantly reduce morbimortality rate. The existence of specific protocols for intensive care unit admission for urgent surgery, and greater availability of beds could be useful in this regard.

[Metastasized colonic cancer. When are there no indications for primary resection?]

The determination of an optimal treatment protocol for colonic cancer with synchronous incurable metastases remains a challenge, especially if the primary tumor is asymptomatic. Available data on whether resection of the primary tumor means a benefit or a danger to the patient are limited and inhomogeneous. A survival benefit could be shown only in retrospective studies with a bias against primary chemotherapy. The important question of the quality of life (QOL) remains completely unanswered in this respect. There are numerous groups and guidelines in favor of a primary palliative chemotherapy for these patients, possibly intensified by antibodies. The results of the currently ongoing randomized multicenter SYNCHRONUS study will deliver objective data facilitating the decision-making process with respect to the indications for resection of the primary tumor or primary chemotherapy.