Elevated preoperative CEA is associated with worse survival in stage I-III rectal cancer patients

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Serum tumor marker and CT body composition scoring system predicts outcomes in colorectal cancer surgical patients

OBJECTIVE

To investigate the prognostic value of preoperative body composition and serum tumor markers (STM) in patients undergoing surgical treatment for colorectal cancer (CRC) and to establish the prognostic score for patients with CRC.

METHODS

This study enrolled 365 patients (training set 245, validation set 120) with CRC who underwent surgical resection. The predictive value of various body composition features and STM for determining CRC prognosis were compared. A novel index score based on the independent risk factors from Cox regression for CRC patients was established and evaluated for its usefulness.

RESULTS

Multivariate Cox regression showed that low skeletal muscle radiodensity (SMD) (p = 0.020), low subcutaneous fat area (SFA) (p = 0.029), high carcinoembryonic antigen (CEA) (p = 0.008), and high alpha-fetoprotein (AFP) (p = 0.039) were all independent prognostic factors for poor overall survival (OS). The multifactorial analysis indicated that high intermuscular fat area (IMFA) (p = 0.033) and high CEA (p = 0.009) were independent prognostic factors for poor disease-free survival (DFS). Based on these findings, two scoring systems for OS and DFS were established in the training datasets. CRC patients who scored higher on the new scoring systems had lower OS and DFS (both p < 0.001) as shown in the Kaplan-Meier survival curves in the training and validation datasets.

CONCLUSION

In predicting the prognosis of CRC patients, SFA and SMD are superior to other body composition measurements. A scoring system based on body composition and STM can have prognostic value and clinical applicability.

CLINICAL RELEVANCE STATEMENT

This scoring system, combining body composition and serum tumor markers, may help predict postoperative survival of CRC patients and help clinicians make well-informed decisions regarding the treatment of patients.

KEY POINTS

Colorectal cancer prognosis can be related to body composition. High intermuscular fat area and CEA were independent prognostic factors for poor disease-free survival. This scoring system, based on body composition and tumor markers, can prognosticate for colorectal cancer patients.

Complications Rate and Related Factors After Laparoscopic Sphincter-Preserving Total Mesorectal Excision for Low Rectal Cancer: A Single-Center Study in Vietnam

BACKGROUND

Colorectal cancer is a significant health concern. Surgery remains a critical component of the multimodal treatment strategy. The laparoscopic sphincter-preserving total mesorectal excision (TME) is increasingly utilized and effective, offering enhanced quality of life for patients compared to previous traditional methods.

OBJECTIVES

This study aims to determine the rate of complications and the related factors associated with complications following laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer.

METHODS

This retrospective study was conducted at the University Medical Center of Ho Chi Minh City from March 2022 to March 2023. It included patients aged 18 years and older diagnosed with low rectal cancer who underwent laparoscopic sphincter-preserving total mesorectal excision. Data on patient demographics, surgical details, and postoperative complications were retrospectively collected and analyzed. Follow-ups were conducted up to six months after surgery.

RESULTS

Of the 83 patients included, the postoperative complications rate was 14.5%. The complications observed included surgical wound infections (five cases), anastomotic leaks (five cases, including three recto-vaginal fistulas and two pelvic abscesses), urinary retention (one case), and pneumonia (one case). A significant finding was the higher rate of distant metastases in patients with complications compared to those without (p=0.033).

CONCLUSION

Laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer is safe and effective, with a high success rate and low complication rate during or after surgery. Anastomotic leakage remains the most significant complication. Despite advancements in surgery, modern suturing tools, and preoperative patient optimization, complications are avoidable. Therefore, understanding the related factors and implementing preventive interventions is crucial.

Extracellular water to total body water ratio, a novel predictor of recurrence in patients with colorectal cancer

Background

Total body water (TBW) fraction, which accounts for 60% of body weight, is an important indicator of body composition, and the extracellular water to TBW ratio (ECW/TBW) is reportedly useful in predicting clinical outcomes of patients with organ disorders. We aimed to clarify the clinical impact of preoperative ECW/TBW status on survival outcomes in cancer patients.

Methods

We used a database of 320 colorectal cancer (CRC) patients who underwent potentially curative resections. Preoperative ECW/TBW was measured using a bioelectrical impedance analysis (BIA), and its correlation with patient survival outcomes, clinicopathological factors, laboratory data, and comorbidities were analyzed.

Results

A high preoperative ECW/TBW was significantly associated with poorer relapse-free survival (RFS; p = 0.001) and overall survival (OS; p = 0.003). A high ECW/TBW ratio was significantly associated with older age (p < 0.001), low BMI (p = 0.009), and right-sided tumors (p = 0.03). In a multivariate analysis, a high ECW/TBW significantly predicted a higher RFS mortality (HR: 2.07, 95% CI: 1.10-3.88, p = 0.024) and OS mortality (HR: 3.23, 95% CI: 1.25-8.36, p = 0.016). Furthermore, a high ECW/TBW was significantly associated with lower hemoglobin (p < 0.001) and albumin levels (p < 0.001), but not comorbidities.

Conclusions

A high preoperative ECW/TBW was a predictive factor for recurrence and poorer overall survival independent of the tumor, node, and metastasis (TNM) stage. Our data suggest that preoperative evaluation of ECW/TBW using BIA might serve as a novel tool for developing CRC treatment strategies.

Prognostic value of the ratio of pretreatment carcinoembryonic antigen to tumor volume in rectal cancer

Background

As a commonly used biomarker in rectal cancer (RC), the prognostic value of carcinoembryonic antigen (CEA) remains underexplored. This study aims to evaluate the prognostic value of pretreatment CEA/tumor volume in RC.

Methods

This retrospective study included patients who underwent pretreatment magnetic resonance imaging (MRI) with histologically confirmed primary rectal adenocarcinoma from November 2012 to April 2018. Patients were divided into high-risk and low-risk groups according to the median values of CEA/Diapath (CEA to pathological diameter), CEA/DiaMRI (CEA to MRI tumor diameter), and CEA/VolMRI (CEA to MRI tumor volume). Cox regression analysis was utilized to determine the prognostic value of CEA, CEA/Diapath, CEA/DiaMRI, and CEA/VolMRI. Stepwise regression was used to establish nomograms for predicting disease-free survival (DFS) and overall survival (OS). Predictive performance was estimated by using the concordance index (C-index) and area under curve receiver operating characteristic (AUC).

Results

A total of 343 patients [median age 58.99 years, 206 (60.06%) males] were included. After adjusting for patient-related and tumor-related factors, CEA/VolMRI was superior to CEA, CEA/Diapath, and CEA/DiaMRI in distinguishing high-risk from low-risk patients in terms of DFS [hazard ratio (HR) =1.83; P=0.010] and OS (HR =1.67; P=0.048). Subanalysis revealed that CEA/VolMRI stratified high death risk in CEA-negative individuals (HR =2.50; P=0.038), and also stratified low recurrence risk in CEA-positive individuals (HR =2.06; P=0.024). In the subanalysis of stage II or III cases, the highest HRs and the smallest P values were observed in distinguishing high-risk from low-risk patients according to CEA/VolMRI in terms of DFS (HR =2.44; P=0.046 or HR =2.41; P=0.001) and OS (HR =1.96; P=0.130 or HR =2.22; P=0.008). The nomograms incorporating CEA/VolMRI showed good performance, with a C-index of 0.72 [95% confidence interval (CI): 0.68-0.79] for DFS and 0.73 (95% CI: 0.68-0.80) for OS.

Conclusions

Higher CEA/VolMRI was associated with worse DFS and OS. CEA/VolMRI was superior to CEA, CEA/Diapath, and CEA/DiaMRI in predicting DFS and OS. Pretreatment CEA/VolMRI may facilitate risk stratification and treatment decision-making.

Artificial intelligence based system for predicting permanent stoma after sphincter saving operations

Although the goal of rectal cancer treatment is to restore gastrointestinal continuity, some patients with rectal cancer develop a permanent stoma (PS) after sphincter-saving operations. Although many studies have identified the risk factors and causes of PS, few have precisely predicted the probability of PS formation before surgery. To validate whether an artificial intelligence model can accurately predict PS formation in patients with rectal cancer after sphincter-saving operations. Patients with rectal cancer who underwent a sphincter-saving operation at Taipei Medical University Hospital between January 1, 2012, and December 31, 2021, were retrospectively included in this study. A machine learning technique was used to predict whether a PS would form after a sphincter-saving operation. We included 19 routinely available preoperative variables in the artificial intelligence analysis. To evaluate the efficiency of the model, 6 performance metrics were utilized: accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiving operating characteristic curve. In our classification pipeline, the data were randomly divided into a training set (80% of the data) and a validation set (20% of the data). The artificial intelligence models were trained using the training dataset, and their performance was evaluated using the validation dataset. Synthetic minority oversampling was used to solve the data imbalance. A total of 428 patients were included, and the PS rate was 13.6% (58/428) in the training set. The logistic regression (LR), Gaussian Naïve Bayes (GNB), Extreme Gradient Boosting (XGB), Gradient Boosting (GB), random forest, decision tree and light gradient boosting machine (LightGBM) algorithms were employed. The accuracies of the logistic regression (LR), Gaussian Naïve Bayes (GNB), Extreme Gradient Boosting (XGB), Gradient Boosting (GB), random forest (RF), decision tree (DT) and light gradient boosting machine (LightGBM) models were 70%, 76%, 89%, 93%, 95%, 79% and 93%, respectively. The area under the receiving operating characteristic curve values were 0.79 for the LR model, 0.84 for the GNB, 0.95 for the XGB, 0.95 for the GB, 0.99 for the RF model, 0.79 for the DT model and 0.98 for the LightGBM model. The key predictors that were identified were the distance of the lesion from the anal verge, clinical N stage, age, sex, American Society of Anesthesiologists score, and preoperative albumin and carcinoembryonic antigen levels. Integration of artificial intelligence with available preoperative data can potentially predict stoma outcomes after sphincter-saving operations. Our model exhibited excellent predictive ability and can improve the process of obtaining informed consent.

High preoperative CEA and systemic inflammation response index (C-SIRI) predict unfavorable survival of resectable colorectal cancer

BACKGROUND

CEA and systemic inflammation were reported to correlate with proliferation, invasion, and metastasis of colorectal cancer. This study investigated the prognostic significance of the preoperative CEA and systemic inflammation response index (C-SIRI) in patients with resectable colorectal cancer.

METHODS

Two hundred seventeen CRC patients were recruited from Chongqing Medical University, the first affiliated hospital, between January 2015 and December 2017. Baseline characteristics, preoperative CEA level, and peripheral monocyte, neutrophil, and lymphocyte counts were retrospectively reviewed. The optimal cutoff value for SIRI was defined as 1.1, and for CEA, the best cutoff values were 4.1 ng/l and 13.0 ng/l. Patients with low levels of CEA (< 4.1 ng/l) and SIRI (< 1.1) were assigned a value of 0, those with high levels of CEA (≥ 13.0 ng/l) and SIRI (≥ 1.1) were assigned a value of 3, and those with CEA (4.1-13.0 ng/l) and SIRI (≥ 1.1), CEA (≥ 13.0 ng/l), and SIRI (< 1.1) were assigned a value of 2. Those with CEA (< 4.1 ng/l) and SIRI (≥ 1.1) and CEA (4.1-13.0 ng/l) and SIRI (< 1.1) were assigned a value of 1. The prognostic value was assessed based on univariate and multivariate survival analysis.

RESULTS

Preoperative C-SIRI was statistically correlated with gender, site, stage, CEA, OPNI, NLR, PLR, and MLR. However, no difference was observed between C-SIRI and age, BMI, family history of cancer, adjuvant therapy, and AGR groups. Among these indicators, the correlation between PLR and NLR is the strongest. In addition, high preoperative C-SIRI was significantly correlated with poorer overall survival (OS) (HR: 2.782, 95% CI: 1.630-4.746, P < 0.001) based on univariate survival analysis. Moreover, it remained an independent predictor for OS (HR: 2.563, 95% CI: 1.419-4.628, p = 0.002) in multivariate Cox regression analysis.

CONCLUSION

Our study showed that preoperative C-SIRI could serve as a significant prognostic biomarker in patients with resectable colorectal cancer.

Clinical Significance of Preoperative and Postoperative Serum CEA and Carbohydrate Antigen 19-9 Levels in Patients Undergoing Curative Resection of Locally Recurrent Rectal Cancer

BACKGROUND

Local recurrence is common after curative resection for rectal cancer. Although one expects radical resection of locally recurrent rectal cancer to be curative, the postoperative re-recurrence rate is relatively high. Therefore, identifying risk factors for recurrence may improve the prognosis of locally recurrent rectal cancer with early therapeutic intervention.

OBJECTIVE

This study aimed to evaluate the relationship between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis in locally recurrent rectal cancer to validate their usefulness for postoperative surveillance in locally recurrent rectal cancer.

DESIGN

This was a single-center retrospective cohort study.

SETTING

The study is based on data obtained from procedures at the Osaka University Hospital.

PATIENTS

Ninety patients underwent radical resection for locally recurrent rectal cancer between January 2000 and January 2015.

MAIN OUTCOME MEASURES

We evaluated the correlation between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis after complete resection of locally recurrent rectal cancer and the serum CEA and carbohydrate antigen 19-9 levels at the diagnosis of postoperative re-recurrence.

RESULTS

The median preoperative serum CEA level was 4 ng/mL and carbohydrate antigen 19-9 level was 12 U/mL. Of the 90 patients, 43.3% had serum CEA ≥5 ng/mL, and 15.6% had serum carbohydrate antigen 19-9 ≥37 U/mL. Preoperatively, this serum carbohydrate antigen 19-9 level strongly correlated with poorer prognoses regarding cancer-specific survival. Postoperatively, serum CEA ≥5 ng/mL significantly correlated with a worse prognosis. At the time of diagnosis of re-recurrence after resection of locally recurrent rectal cancer, 53.2% of patients had serum CEA ≥5 ng/mL, and 23.4% of patients had serum carbohydrate antigen 19-9 ≥37 U/mL.

LIMITATIONS

The study was limited by its single-center retrospective design, an insufficient sample size, and a relatively long study period.

CONCLUSIONS

High serum levels of carbohydrate antigen 19-9 preoperatively and CEA postoperatively are associated with poor prognosis after locally recurrent rectal cancer. Furthermore, we found a high rate of serum CEA elevation in the diagnosis of postoperative re-recurrence. See Video Abstract at http://links.lww.com/DCR/C106 .

IMPORTANCIA CLNICA DE LOS NIVELES SRICOS PREOPERATORIOS Y POSOPERATORIOS DE CEA Y CA EN PACIENTES SOMETIDOS A RESECCIN CURATIVA DE CNCER DE RECTO LOCALMENTE RECURRENTE

ANTECEDENTES:La recurrencia local es común después de la resección curativa del cáncer de recto. Aunque se espera que la resección radical del cáncer rectal localmente recurrente sea curativa, la tasa de recurrencia posoperatoria es relativamente alta. Por lo tanto, la identificación de los factores de riesgo de recurrencia puede mejorar el pronóstico del cáncer de recto localmente recurrente con una intervención terapéutica temprana.OBJETIVO:Evaluamos la relación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico en el cáncer de recto localmente recurrente para validar su utilidad para la vigilancia posoperatoria en el cáncer de recto localmente recurrente.DISEÑO:Este fue un estudio de cohorte retrospectivo de un solo centro.AJUSTE:El estudio se basa en datos obtenidos de procedimientos en el Hospital Universitario de Osaka.PACIENTES:Noventa pacientes fueron sometidos a resección radical por cáncer de recto localmente recurrente entre Enero de 2000 y Enero de 2015.PRINCIPALES MEDIDAS DE RESULTADOS:Evaluamos la correlación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico después de la resección completa del cáncer de recto localmente recurrente y los niveles séricos de CEA y CA19-9 en el diagnóstico de recurrencia posoperatoria.RESULTADOS:La mediana de los niveles séricos preoperatorios de CEA y CA19-9 fueron de 4 ng/mL y 12 U/mL, respectivamente. De los 90 pacientes, el 43,3 % tenía CEA sérico ≥5 ng/mL y el 15,6 % tenía CA19-9 sérico ≥37 U/mL. Antes de la operación, este nivel sérico de CA19-9 se correlacionó fuertemente con peores pronósticos con respecto a la supervivencia específica del cáncer. Después de la operación, el CEA sérico ≥5 ng/mL se correlacionó significativamente con un peor pronóstico. En el momento del diagnóstico de recurrencia después de la resección del cáncer de recto localmente recurrente, el 53,2 % de los pacientes tenían CEA sérico ≥5 ng/mL y el 23,4 % de los pacientes tenían CA19-9 sérico ≥37 U/mL.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro, un tamaño de muestra insuficiente y un período de estudio relativamente largo.CONCLUSIONES:Los niveles séricos altos de CA19-9 antes de la operación y de CEA después de la operación están asociados con un mal pronóstico después del cáncer de recto localmente recurrente. Además, encontramos una alta tasa de elevación del CEA sérico en el diagnóstico de recurrencia posoperatoria. Consulte el Video Resumen en http://links.lww.com/DCR/C106 . (Traducción-Dr. Yesenia Rojas-Khalil ).

Development and validation of a prognostic nomogram for rectal cancer patients who underwent surgical resection

Objective: The purpose of this study was to develop and validate a nomogram model for the prediction of survival outcome in rectal cancer patients who underwent surgical resection. Methods: A total of 9,919 consecutive patients were retrospectively identified using the Surveillance, Epidemiology, and End Results (SEER) database. Significant prognostic factors were determined by the univariate and multivariate Cox analysis. The nomogram model for the prediction of cancer-specific survival (CSS) in rectal cancer patients were developed based on these prognostic variables, and its predictive power was assessed by the concordance index (C-index). Calibration curves were plotted to evaluate the associations between predicted probabilities and actual observations. The internal and external cohort were used to further validate the predictive performance of the prognostic nomogram. Results: All patients from the SEER database were randomly split into a training cohort (n = 6,944) and an internal validation cohort (n = 2,975). The baseline characteristics of two cohorts was comparable. Independent prognostic factors were identified as age, pT stage, lymph node metastasis, serum CEA level, tumor size, differentiation type, perineural invasion, circumferential resection margin involvement and inadequate lymph node yield. In the training cohort, the C-index of the nomogram was 0.719 (95% CI: 0.696-0.742), which was significantly higher than that of the TNM staging system (C-index: 0.606, 95% CI: 0.583-0.629). The nomogram had a C-index of 0.726 (95% CI: 0.691-0.761) for the internal validation cohort, indicating a good predictive power. In addition, an independent cohort composed of 202 rectal cancer patients from our institution were enrolled as the external validation. Compared with the TNM staging system (C-index: 0.573, 95% CI: 0.492-0.654), the prognostic nomogram still showed a better predictive performance, with the C-index of 0.704 (95% CI: 0.626-0.782). Calibration plots showed a good consistency between predicted probability and the actual observation in the training and two validation cohorts. Conclusion: The nomogram showed an excellent predictive ability for survival outcome of rectal cancer patients, and it might provide an accurate prognostic stratification and help clinicians determine individualized treatment strategies.

Current Surgical Methods in Local Rectal Excision

Background

The treatment of rectal cancer has evolved with the advancement of surgical techniques. Less invasive approaches are becoming more accepted as the primary treatment method.

Summary

Such methods as transanal excision, transanal endoscopic microsurgery, and transanal minimally invasive surgery can reduce morbidity and mortality rates. However, not all patients are suitable candidates for these procedures, and proper diagnostics are necessary to establish indications. Compared to total mesorectal excision, transanal excision techniques have been shown to have fewer complications and comorbidities while still being able to remove cancerous tissue entirely. Transanal excision is the simplest method, where the operator removes visible rectal lesions. The basic principle of transanal endoscopic microsurgery is to dilate the rectum mechanically and by air insufflation and then use special surgical instruments to remove suspicious lesions under the vision of a telescope. Transanal minimally invasive surgery combines transanal endoscopic microsurgery and single-incision laparoscopic surgery, making the hard-to-reach proximal rectum accessible to classic laparoscopic instruments.

Key Message

Local excision techniques, when used as a monotherapy for treating patients with rectal cancer, have established themselves as a curative and less radical treatment for strictly selected patients with early rectal carcinoma, leading to improved quality of life. When combined with other modalities such as neoadjuvant chemoradiotherapy, total neoadjuvant therapy, and immunotherapy, transanal surgery can be offered to patients with locally advanced rectal cancer as part of the organ preservation strategy. This review will discuss the patient selection and technical aspects of transanal surgery, showcasing its current role in treating rectal carcinoma.

A CT-Based Radiomics Nomogram in Predicting the Postoperative Prognosis of Colorectal Cancer: A Two-center Study

RATIONALE AND OBJECTIVES

This retrospective study aimed to develop a practical model to determine overall survival after surgery in patients with colorectal cancer according to radiomics signatures based on computed tomography (CT) images and clinical predictors.

MATERIALS AND METHODS

A total of 121 colorectal cancer (CRC) patients were selected to construct the model, and 51 patients and 114 patients were selected for internal validation and external testing. The radiomics features were extracted from each patient's CT images. Univariable Cox regression and least absolute shrinkage and selection operator regression were used to select radiomics features. The performance of the nomogram was evaluated by calibration curves and the c-index. Kaplan-Meier analysis was used to compare the overall survival between these subgroups.

RESULTS

The radiomics features of the CRC patients were significantly correlated with survival time. The c-indexes of the nomogram in the training cohort, internal validation cohort and external test cohort were 0.782, 0.721, and 0.677. Our nomogram integrated the optimal radiomics signature with clinical predictors showed a significant improvement in the prediction of CRC patients' overall survival. The calibration curves showed that the predicted survival time was close to the actual survival time. According to Kaplan-Meier analysis, the 1-, 2-, and 3-year survival rates of the low-risk group were higher than those of the high-risk group.

CONCLUSION

The nomogram combining the optimal radiomics signature and clinical predictors further improved the predicted accuracy of survival prognosis for CRC patients. These findings might affect treatment strategies and enable a step forward for precise medicine.

Long-term follow-up of HER2 overexpression in patients with rectal cancer after preoperative radiotherapy: A prospective cohort study

BACKGROUND

The role of HER2 overexpression in rectal cancer is controversial.

AIM

To assess the role of HER2 overexpression in the long-term prognosis of rectal cancer.

METHODS

Data from patients with locally advanced rectal cancer who underwent total mesorectal excision after short-course radiotherapy at Beijing Cancer Hospital between May 2002 and October 2005 were collected. A total of 151 tissue samples of rectal cancer were obtained using rigid proctoscopy before neoadjuvant radiotherapy, followed by immunohistochemistry and fluorescence in situ hybridisation to determine the patients’ HER2 expression status. Univariate and multivariate analyses of the associations between the clinicopathological factors and HER2 status were performed. Survival was estimated and compared using the Kaplan-Meier method based on HER2 expression status, and the differences between groups were verified using the log-rank test.

RESULTS

A total of 151 patients were enrolled in this study. A total of 27 (17.9%) patients were ultimately confirmed to be HER2-positive. The follow-up duration ranged from 9 mo to 210 mo, with a median of 134 mo. Distant metastasis and local recurrence occurred in 60 (39.7%) and 24 (15.9%) patients, respectively. HER2 positivity was significantly associated with the pre-treatment lymph node stage (pre-N) (P = 0.040), while there were no differences between HER2 status and age, sex, preoperative CEA levels (pre-CEA), T stage, and lympho-vascular invasion. In terms of prognosis, HER2 overexpression was correlated with distant metastasis (P = 0.002) rather than local recurrence (P > 0.05). The multivariate analysis demonstrated that elevated pre-CEA [P = 0.002, odds ratio (OR) = 3.277, 97.5% confidence interval (CI): 1.543-7.163], post N(+) (P = 0.022, OR = 2.437, 97.5%CI: 1.143-5.308) and HER2(+) (P = 0.003, OR = 4.222, 97.5%CI: 1.667-11.409) were risk factors for distant metastasis. The survival analysis showed that there were significant differences between rectal cancer patients in terms of disease-free survival (DFS) [hazard ratio: 1.69 (95%CI: 0.91-3.14); P = 0.048] and overall survival (OS) [1.95 (1.05-3.63); P = 0.0077].

CONCLUSION

HER2 overexpression is a potential biomarker for predicting lymph node metastasis and distant metastasis, which are associated with worse long-term DFS and OS in rectal cancer patients with locally advanced disease.

Predictors of pathologic complete response in patients with residual flat mucosal lesions after neoadjuvant chemoradiotherapy for locally advanced rectal cancer

OBJECTIVE

The accurate prediction of tumor response to neoadjuvant chemoradiotherapy (nCRT) remains challenging. Few studies have investigated pathologic complete response (ypCR) prediction in patients with residual flat mucosal lesions after treatment. This study aimed to identify variables for predicting ypCR in patients with residual flat mucosal lesions after nCRT for locally advanced rectal cancer (LARC).

METHODS

Data of patients with residual flat mucosal lesions after nCRT who underwent radical resection between 2009 and 2015 were retrospectively collected from the LARC database at Peking University Cancer Hospital. Univariate and multivariate analyses of the association between clinicopathological factors and ypCR were performed, and a nomogram was constructed by incorporating the significant predictors.

RESULTS

Of the 246 patients with residual flat mucosal lesions included in the final analysis, 56 (22.8%) had ypCR. Univariate and multivariate analyses showed that pretreatment cT stage (pre-cT) ≤T2 (P=0.016), magnetic resonance tumor regression grade (MR-TRG) 1-3 (P=0.001) and residual mucosal lesion depth =0 mm (P<0.001) were associated with a higher rate of ypCR. A nomogram was developed with a concordance index (C-index) of 0.759 and the calibration curve showed that the nomogram model had good predictive consistency. The follow-up time ranged from 3.0 to 113.3 months, with a median follow-up time of 63.77 months. The multivariate Cox regression model showed that the four variables in the nomogram model were not risk factors for disease-free survival (DFS) or overall survival (OS).

CONCLUSIONS

Completely flat mucosa, early cT stage and good MR-TRG were predictive factors for ypCR instead of DFS or OS in patients with LARC with residual flat mucosal lesions after nCRT. Endoscopic mucosal re-evaluation before surgery is important, as it may contribute to decision-making and facilitate nonoperative management or organ preservation.

Can CCRT/RT Achieve Favorable Oncologic Outcome in Rectal Cancer Patients With High Risk Feature After Local Excision?

Purpose

The oncologic outcome of concurrent chemoradiotherapy (CCRT) after local excision in patients with high-risk early rectal cancer as compared with radical operation has not been reported. The aim of this study is to compare the oncologic outcome between radical operation and adjuvant CCRT after local excision for high-risk early rectal cancer.

Materials and Methods

From January 2005 to December 2015, 266 patients diagnosed with early rectal cancer and treated with local excision who showed high-risk characteristics were retrospectively analyzed. Propensity score matching was applied in a ratio of 1:4, comparing the CCRT/radiotherapy (RT) (n = 34) and radical operation (n = 91) groups. Univariate and multivariate analyses were performed to identify prognostic factors for survival.

Results

The median follow-up period was 112 months. The 5-year disease-free survival rate and the 5-year overall survival of the radical operation group were significantly higher than those of the CCRT/RT group after propensity score matching (96.7% vs. 70.6%, p &lt;0.001; 100% vs. 91.2%, p = 0.005, respectively). In a multivariate analysis, salvage therapy type and preoperative carcinoembryonic antigen (CEA) were prognostic factors for 5-year disease-free survival (p &lt;0.001 and p = 0.021, respectively). The type of salvage therapy, the preoperative CEA, and the pT were prognostic factors for 5-year overall survival (p = 0.009, p = 0.024, and p = 0.046, respectively).

Conclusions

Patients who undergo radical operations after local excision with a high-risk early rectal cancer had better survival than those treated with adjuvant CCRT/RT. Therefore, radical surgery may be recommended to high-risk early rectal cancer patients who have undergone local excision for more favorable oncologic outcomes.

Early Postoperative Serum Carcinoembryonic Antigen Is a Stronger Independent Prognostic Factor for Stage II Colorectal Cancer Patients Than T4 Stage and Preoperative CEA

BACKGROUND

Serum carcinoembryonic antigen (CEA) is an important biomarker for diagnosis, prognosis, recurrence, metastasis monitoring, and the evaluation of the effect of chemotherapy in colorectal cancer (CRC). However, few studies have focused on the role of early postoperative CEA in the prognosis of stage II CRC.

METHODS

Patients with stage II CRC diagnosed between January 2007 and December 2015 were included. Receiver operating characteristic (ROC) curves were used to obtain the cutoff value of early postoperative CEA, CEA ratio and CEA absolute value. The areas under curves (AUCs) were used to estimate the predictive abilities of the CEA and T stage. The stepwise regression method was used to screen the factors included in the Cox regression analysis. Before and after propensity score (PS) - adjusted Cox regression and sensitivity analysis were used to identify the relationship between early postoperative CEA and prognosis. Meta-analysis was performed to verify the results. Kaplan-Meier survival curves were used to estimate the effects of CEA on prognosis.

RESULTS

We included 1081 eligible patients. ROC curves suggested that the cutoff value of early postoperative CEA was 3.66 ng/ml (P <0.001) and the AUC showed early postoperative CEA was the most significant prognostic marker in stage II CRC (P = 0.0189). The Cox regression and sensitivity analysis before and after adjusting for PS both revealed elevated early postoperative CEA was the strongest independent prognostic factor of OS, DFS, and CSS (P < 0.001). Survival analysis revealed that patients with elevated early postoperative CEA had lower OS (53.62% VS 84.16%), DFS (50.03% VS 86.75%), and CSS (61.77% VS 90.30%) than patients with normal early postoperative CEA (P < 0.001). When the postoperative CEA was positive, the preoperative CEA level showed no significant effect on the patient's prognosis (all P-values were > 0.05). Patients with a CEA ratio ≤0.55 or CEA absolute value ≤-0.98 had a worse prognosis (all P-values were < 0.001). Survival analysis suggested that adjuvant chemotherapy for stage II CRC patients with elevated early postoperative CEA may improve the CSS (P = 0.040).

CONCLUSIONS

Early postoperative CEA was a better biomarker for prognosis of stage II CRC patients than T stage and preoperative CEA, and has the potential to become a high-risk factor to guide the prognosis and treatment of stage II CRC patients.

The advanced lung cancer inflammation index is a novel independent prognosticator in colorectal cancer patients after curative resection

BACKGROUND

The advanced lung cancer inflammation index (ALI), which comprehensively evaluates the patient body composition and inflammation/nutritional status, is reportedly associated with the patient outcome in lung cancer. However, the clinical significance in colorectal cancer (CRC) patients after curative resection remains unclear.

METHODS

A total of 813 CRC patients after curative resection between April 2005 and June 2019 in a single institution were retrospectively enrolled. The association of the preoperative ALI (calculated as follows: body mass index × albumin value/neutrophil-to-lymphocyte ratio) with clinicopathological factors, postoperative complications, and survival was analyzed.

RESULTS

A low ALI was significantly associated with male gender, older age, a higher depth of tumor invasion, progressed TNM stage, and preoperative carcinoembryonic antigen (CEA) positivity. Both postoperative complications and severe complications occurred more frequently in the ALI-low group than in the ALI-high group (P < .001 and P < .001, respectively), especially postoperative complications in stage III patients (P < .001) and severe complications in stages II and III patients (P = .024 and P = .004, respectively). In addition, a low ALI was an independent predictor of a poor overall survival (hazard ratio: 2.30, 95% confidence interval: 1.52-3.50, P < .001) and relapse-free survival (hazard ratio: 1.73, 95% confidence interval: 1.22-2.44, P = .002), especially in older patients, and in patients without lymph node metastasis or severe postoperative complications.

CONCLUSION

This study suggests that preoperative ALI may serve as a novel independent predictive index for severe postoperative complications and recurrence in CRC patients after curative resection.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

The Predictive Values of Pretreatment Controlling Nutritional Status (CONUT) Score in Estimating Short- and Long-term Outcomes for Patients with Gastric Cancer Treated with Neoadjuvant Chemotherapy and Curative Gastrectomy

Purpose

Previous studies have demonstrated the usefulness of the controlling nutritional status (CONUT) score in nutritional assessment and survival prediction of patients with various malignancies. However, its value in advanced gastric cancer (GC) treated with neoadjuvant chemotherapy and curative gastrectomy remains unclear.

Materials and Methods

The CONUT score at different time points (pretreatment, preoperative, and postoperative) of 272 patients with advanced GC were retrospectively calculated from August 2004 to October 2015. The χ² test or Mann-Whitney U test was used to estimate the relationships between the CONUT score and clinical characteristics as well as short-term outcomes, while the Cox proportional hazard model was used to estimate long-term outcomes. Survival curves were estimated by using the Kaplan-Meier method and log-rank test.

Results

The proportion of moderate or severe malnutrition among all patients was not significantly changed from pretreatment (13.5%) to pre-operation (11.7%) but increased dramatically postoperatively (47.5%). The pretreatment CONUT-high score (≥4) was significantly associated with older age (P=0.010), deeper tumor invasion (P=0.025), and lower pathological complete response rate (CONUT-high vs. CONUT-low: 1.2% vs. 6.6%, P=0.107). Pretreatment CONUT-high score patients had worse progression-free survival (P=0.032) and overall survival (OS) (P=0.026). Adjusted for pathologic node status, the pretreatment CONUT-high score was strongly associated with worse OS in pathologic node-positive patients (P=0.039).

Conclusions

The pretreatment CONUT score might be a straightforward index for immune-nutritional status assessment, while being a reliable prognostic indicator in patients with advanced GC receiving neoadjuvant chemotherapy and curative gastrectomy. Moreover, lower pretreatment CONUT scores might indicate better chemotherapy responses.

Elevated serum carcinoembryonic antigen level after curative surgery is a prognostic biomarker of stage II-III colorectal cancer

BACKGROUND

High preoperative carcinoembryonic antigen (CEA) is a well-known risk factor for stage II-III colorectal cancer (CRC); however, in most cases, cancer does not recur. Conversely, postoperative CEA (post-CEA) is occasionally measured, and high post-CEA patients often develop recurrence; however, the clinical significance of post-CEA testing is unknown. The purpose of this study was to determine whether post-CEA elevation might indicate a poor prognosis for stage II-III CRC patients who underwent curative surgery.

PATIENTS AND METHODS

482 patients with pathological stage II-III CRC were included. Univariate and multivariate analyses were performed to evaluate post-CEA levels.

RESULTS

Multivariate analysis showed that elevated post-CEA (hazard ratio (HR): 3.14, P < 0.001), pathological lymph node metastasis (pN+), and pathological T4 (pT4) are associated with poor recurrence-free survival (RFS), and that elevated post-CEA (HR: 3.12; P = 0.002), pN+, pT4, age >70, and smoking are independently associated with poor overall survival. Subgroup analysis among stage III patients, in combination with the risk classification of the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) study, showed that elevated post-CEA is a significant indicator of poor prognosis for RFS in both low-risk (73.8% vs. 21.2%, P < 0.001) and high-risk (49.9% vs. 25.0%, P = 0.04) groups.

CONCLUSIONS

Post-surgical CEA elevation is independently associated with poor prognosis in stage II-III CRC. Adding post-CEA levels to the IDEA risk classification may provide a more reliable indicator of the need for individualized surveillance and adjuvant chemotherapeutic strategies.

Prognostic risk factors and survival models for T3 locally advanced rectal cancer: what can we learn from the baseline MRI?

OBJECTIVES

To evaluate the baseline MRI characteristics for predicting survival outcomes and construct survival models for risk stratification to facilitate personalized treatment and follow-up strategies in patients with MRI-defined T3 (mrT3) locally advanced rectal cancer (LARC).

METHODS

We retrospectively reviewed 256 mrT3 LARC patients evaluated between 2008 and 2012 in our institution, with an average follow-up period of 6.8 ± 1.2 years. The baseline MRI characteristics, clinical data, and follow-up information were evaluated. The patients were randomized into a training cohort (TC, 186 patients) and validation cohort (VC, 70 patients). The TC dataset was used to develop multivariate nomograms for disease-free survival (DFS) and overall survival (OS), while the VC dataset was used for independent validation of the models. Harrell concordance (C) indices and Hosmer-Lemeshow calibration were used to evaluate the performances of the models.

RESULTS

Baseline mrT3 substage, extramural venous invasion (EMVI) grading, mucinous adenocarcinoma, mesorectal fascia involvement, elevated pretreatment carcinoembryonic antigen level, and neoadjuvant chemoradiotherapy (NCRT) were independent predictors of DFS. T3 substage, EMVI grading, and NCRT were also independent predictors of OS. The nomograms constructed permitted the individualized prediction of 3-year and 5-year DFS and 5-year OS with high discrimination (C-index range, 0.833-0.892) and good calibration in the TC and VC.

CONCLUSIONS

We have identified baseline MRI characteristics that help independently predict survival outcomes in patients with mrT3 LARC. The survival models based on these characteristics allow for the individualized pretreatment risk stratification in patients with mrT3 LARC.

KEY POINTS

• Baseline MRI characteristics can independently stratify risk and predict survival outcomes in patients with mrT3 LARC. • The nomograms built using selected baseline MRI characteristics facilitate the individualized pretreatment risk stratification and help with clinical decision-making in patients with mrT3 LARC. • MR-defined risk factors should, therefore, be carefully reported in the baseline MRI evaluation.

Postoperative serum carcinoembryonic antigen levels cannot predict survival in colorectal cancer patients with type II diabetes

BACKGROUND

Most clinical guidelines recommend measuring postoperative carcinoembryonic antigen (CEA) levels to predict the prognosis of colorectal cancer. However, type II diabetes can increase serum CEA levels which may bias the prognosis. Thus, we aimed to evaluate the impact of type II diabetes on CEA prognostic accuracy in colorectal cancer.

METHODS

This retrospective cohort study included 407 patients who underwent curative resection for stage I to III colorectal adenocarcinoma in a single institution between January 2010 and June 2018. The patients were categorized into two groups according to their postoperative serum CEA levels: group A <5.0 ng/mL (n = 341) and group B ≥5.0 ng/mL (n = 66). Patients were also categorized into two subgroups according to their history of type II diabetes: patients with type II diabetes mellitus (n = 112) and patients without type II diabetes (n = 295).

RESULTS

The 3-year disease-free survival (DFS) rates were significantly higher in patients with normal postoperative CEA (group A, 83.8%) than in patients with elevated preoperative and postoperative CEA (group B, 63.6%) (p < 0.001). However, although patients with type II diabetes mellitus had higher postoperative CEA levels than those without type II diabetes mellitus (3.1 vs 2.5 ng/mL, p < 0.001), group B patients with type II diabetes mellitus had a significantly higher 3-year DFS rate than those without type II diabetes mellitus (80.0% vs 55.6%, p = 0.003).

CONCLUSION

Type II diabetes was associated with higher preoperative and postoperative CEA levels in patients with colorectal cancer. Consequently, elevated postoperative CEA level was not associated with shorter 3-year DFS in patients with type II diabetes, as opposed to patients without type II diabetes. Therefore, colorectal cancer patients with type II diabetes may need alternative tumor markers to be used during the surveillance strategy after curative surgery.

Survival outcomes following laparoscopic vs open surgery for non-metastatic rectal cancer: a two-center cohort study with propensity score matching

BACKGROUND?>

Laparoscopic surgery for rectal cancer is commonly performed in China. However, compared with open surgery, the effectiveness of laparoscopic surgery, especially the long-term survival, has not been sufficiently proved.

METHODS?>

Data of eligible patients with non-metastatic rectal cancer at Nanfang Hospital of Southern Medical University and Guangdong Provincial Hospital of Chinese Medicine between 2012 and 2014 were retrospectively reviewed. Long-term survival outcomes and short-term surgical safety were analysed with propensity score matching between groups.

RESULTS

Of 430 cases collated from two institutes, 103 matched pairs were analysed after propensity score matching. The estimated blood loss during laparoscopic surgery was significantly less than that during open surgery (P = 0.019) and the operative time and hospital stay were shorter in the laparoscopic group (both P < 0.001). The post-operative complications rate was 9.7% in the laparoscopic group and 10.7% in the open group (P = 0.818). No significant difference was observed between the laparoscopic group and the open group in the 5-year overall survival rate (75.7% vs 80.6%, P = 0.346), 5-year relapse-free survival rate (74.8% vs 76.7%, P = 0.527), or 5-year cancer-specific survival rate (79.6% vs 87.4%, P = 0.219). An elevated carcinoembryonic antigen, <12 harvested lymph nodes, and perineural invasion were independent prognostic factors affecting overall survival and relapse-free survival.

CONCLUSIONS?>

Our findings suggest that open surgery should still be the priority recommendation, but laparoscopic surgery is also an acceptable treatment for non-metastatic rectal cancer.

Prognostic values of CEA, CA19-9, and CA72-4 in patients with stages I-III colorectal cancer

OBJECTIVE

The purpose of this study was to explore the relationship between the levels of three tumor markers (TMs), carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and CA72-4, and the prognoses of colorectal cancer patients.

METHODS

From January 2012 to December 2015, 101 patients with stages I-III colorectal cancer treated in the general surgery department of Nanfang Hospital, Southern Medical University were included in this retrospective study. The patients' blood was collected at different time points to determine their biochemical index values. The CA19-9 and CEA levels were measured using a chemiluminescence analyzer, and the CA72-4 level was determined using a semi-automatic enzyme-free analyzer. The relationship between the tumor marker expressions and the prognoses of patients with colorectal cancer was analyzed.

RESULTS

The sensitivity of the combined quantification of the three TMs was higher than quantifying just one of them, but the specificity was decreased. Those three TM levels were stable at two years after the operations, and they were significantly lower than they were before the operations (P < 0.05). A Kaplan Meier survival curve analysis showed that, compared with the patients with normal levels, the patients with increased levels of the three TMs had significantly shorter overall survival times and higher recurrence rates (P < 0.05).

CONCLUSION

The combined quantification of CEA, CA19-9, and CA72-4 is of great significance in determining the prognoses of colorectal cancer patients. It is helpful to predict the outcomes of patients with stages I-III colorectal cancer two years after their operations.

Prognostic value of postoperative serum carcinoembryonic antigen levels in colorectal cancer patients who smoke

Serum carcinoembryonic antigen (CEA) levels can help predict the prognosis of colorectal cancer patients. Accordingly, high preoperative CEA levels that is not restored after surgery are indicative of a worse outcome. On the other hand, smoking can increase serum CEA levels independently of the disease status. Thus, we aimed to evaluate the impact of smoking on the prognostic value of serum CEA levels. This retrospective cohort study included 273 patients who underwent curative resection for stage I–III colorectal adenocarcinoma at a single institution, between January 2010 and December 2017. Patients were grouped as follows: group A, normal preoperative and postoperative CEA levels (n = 152); group B, elevated preoperative CEA levels that returned to reference values after surgery (n = 69); and group C, elevated postoperative serum CEA levels (n = 52). Patients were also grouped according to their smoking history: group S (current smokers, n = 79) and group NS (never and former smokers, n = 194). Group A showed a higher 3-year disease-free survival (DFS) rate (84.9%) than groups B (75.4%) and C (62.0%) (p < 0.001). Postoperative serum CEA levels were significantly higher in the S group than in the NS group (2.6 vs. 3.1 ng/mL, p = 0.009), whereas preoperative levels were similar (3.8 vs. 4.1, p = 0.182). Further, smokers showed higher 3 year-DFS rates than nonsmokers in group C (83.3% vs. 43.9%, p = 0.029). This suggests that while elevated postoperative CEA levels are associated with lower DFS rates in never and former smokers, they are not associated with lower DFS rates in current smokers. We conclude that persistent smoking alters the prognostic value of postoperative serum CEA levels in colorectal cancer patients and that, consequently, alternative surveillance strategies need to be developed for colon cancer patients with smoking habits.

Clinical Significances of Positive Postoperative Serum CEA and Post-preoperative CEA Increment in Stage II and III Colorectal Cancer: A Multicenter Retrospective Study

Background: Carcinoembryonic antigen (CEA) is the most common serum tumor marker in colorectal cancer (CRC). Nevertheless, few previous studies demonstrated the impacts of postoperative CEA and post-preoperative CEA increment on prognosis of CRC.

Methods: Patients with stage II and III CRC were included from January 2009 to December 2015. All clinical and follow-up data were collected. Patients were divided into four different groups according to the levels of postoperative serum CEA and post-preoperative CEA trends. Chi-square test was used to analyze the relationship between clinical variables and categorized postoperative CEA and CEA increment. Cox proportional hazard regression was used for univariate and multivariable analyses. The log-rank test was performed to compare PFS and OS among groups.

Results: Patients, 1,008, who underwent radical surgery, were enrolled. Our results showed that positive postoperative CEA and CEA increment were related to clinical stage, T stage, N stage, tumor differentiation, and lymphatic invasion (p < 0.05). Univariate and multivariable analysis results suggested that positive postoperative CEA and CEA increment were independent prognostic factors for PFS (HR = 3.149, 95% CI, 2.426–4.088, p = 0.000 for postoperative CEA; HR = 2.708, 95% CI, 2.106–3.482, p = 0.000 for CEA increment) and OS (HR = 3.414, 95% CI, 2.549–4.574, p = 0.000 for postoperative CEA; HR = 2.373, 95% CI, 1.783–3.157, p = 0.000 for CEA increment). The survival analyses revealed positive postoperative CEA, and CEA increment predicted worse prognosis. Furthermore, our results indicated that the 3- and 5-year PFS rates were 86.6 and 78.4% in group A, but decreased to 25.3 and 7.2% in group D (p < 0.001). Similarly, the 3- and 5-year OS rates for group A were 92.5 and 83.9%, much higher than group D (p < 0.001). In other words, patients with both postoperative CEA elevation and CEA increment had the worst prognosis.

Conclusions: Positive postoperative CEA and CEA increment were independent prognostic factors for stage II and III CRC. Additionally, postoperative CEA and CEA increment had significant impacts on PFS and OS of CRC.

12-Chemokine signature, a predictor of tumor recurrence in colorectal cancer

Tertiary lymphoid structures (TLSs) provide an immunological antineoplastic effect. Recent evidences link a unique 12-chemokine (CCL2, -3, -4, -5, -8, -18, -19, -21, CXCL9, -10, -11, -13) signature status from tumor tissue and the TLS expression. However, the potential significance of 12-chemokine signature status for clinical use is unknown. We aimed to evaluate the association of 12-chemokine signature status with patient outcomes in colorectal cancer (CRC). We used integrated data of resected 975 CRC cases within three independent cohorts from France, Japan and the United States (GSE39582, KUMAMOTO from Kumamoto university hospital and TCGA). The association of 12-chemokine signature status with clinicopathological features, patient outcome, TLS expression status and key tumor molecular features was analyzed. Patients with low 12-chemokine signature status had a significant shorter relapse-free survival in discovery cohort (HR: 1.61, 95% CI: 1.11-2.39, p = 0.0123), which was confirmed in validation cohort (HR: 3.31, 95% CI: 1.33-10.08, p = 0.0087). High 12-chemokine signature status had significant associations with right-sided tumor, high tumor-localized TLS expression, BRAF mutant, CIMP-high status and MSI-high status. Furthermore, RNA-seq based analysis showed that high 12-chemokine signature status was strongly associated with inflammation-related, immune cells-related and apoptosis pathways (using gene set enrichment analysis), and more tumor-infiltrating immune cells, such as cytotoxic T lymphocytes and myeloid dendritic cells (using MCP-counter analysis). We investigated a promising effect of 12-chemokine signature status in CRC patients who underwent resection. Our data may be helpful in developing novel immunological treatment strategies for CRC.

A competing-risk nomogram to predict cause-specific death in elderly patients with colorectal cancer after surgery (especially for colon cancer)

Background

Clinically, when the diagnosis of colorectal cancer is clear, patients are more concerned about their own prognosis survival. Special population with high risk of accidental death, such as elderly patients, is more likely to die due to causes other than tumors. The main purpose of this study is to construct a prediction model of cause-specific death (CSD) in elderly patients using competing-risk approach, so as to help clinicians to predict the probability of CSD in elderly patients with colorectal cancer.

Methods

The data were extracted from Surveillance, Epidemiology, and End Results (SEER) database to include ≥ 65-year-old patients with colorectal cancer who had undergone surgical treatment from 2010 to 2016. Using competing-risk methodology, the cumulative incidence function (CIF) of CSD was calculated to select the predictors among 13 variables, and the selected variables were subsequently refined and used for the construction of the proportional subdistribution hazard model. The model was presented in the form of nomogram, and the performance of nomogram was bootstrap validated internally and externally using the concordance index (C-index).

Results

Dataset of 19,789 patients who met the inclusion criteria were eventually selected for analysis. The five-year cumulative incidence of CSD was 31.405% (95% confidence interval [CI] 31.402–31.408%). The identified clinically relevant variables in nomogram included marital status, pathological grade, AJCC TNM stage, CEA, perineural invasion, and chemotherapy. The nomogram was shown to have good discrimination after internal validation with a C-index of 0.801 (95% CI 0.795–0.807) as well as external validation with a C-index of 0.759 (95% CI 0.716–0.802). Both the internal and external validation calibration curve indicated good concordance between the predicted and actual outcomes.

Conclusion

Using the large sample database and competing-risk analysis, a postoperative prediction model for elderly patients with colorectal cancer was established with satisfactory accuracy. The individualized estimates of CSD outcome for the elderly patients were realized.

Association of T Stage and Serum CEA Levels in Determining Survival of Rectal Cancer

Purpose: To investigate the association of T stage and serum carcinoembryonic antigen (CEA) levels in determining oncologic outcomes of rectal cancer. Methods: Patients diagnosed with stage I-II rectal cancer patients were identified from the Surveillance, Epidemiology, and End Results database. Results: In stage T1N0M0 disease, elevated level of serum CEA (C1) was associated with 227.6% increased risk of mortality compared to normal level of serum CEA (C0; hazard ratio = 3.276, 95% confidence interval = 2.781-3.858, P < 0.001). Conclusions: Stage T1N0M0 rectal cancer, when involved in preoperative serum CEA elevation, may be a surrogate of biologically aggressive disease and correlate with unfavorable oncologic outcomes. Moreover, this subgroup of rectal cancer deserves more clinical attention of oncologists.

Prognostic impact of preoperatively elevated and postoperatively normalized carcinoembryonic antigen levels following curative resection of stage I-III rectal cancer

BACKGROUND

Preoperative and early postoperative serum carcinoembryonic antigen (CEA) levels are known prognostic factors in rectal cancer. Recently, a large-scale study on colon cancer revealed that "preoperatively elevated and postoperatively normalized CEA levels" is not an indicator of poor prognosis. However, whether this hold true in rectal cancer patients is unknown. This study aimed to investigate the prognostic significance of preoperatively elevated and postoperatively normalized CEA levels in rectal cancer patients undergoing curative resection.

METHODS

Subjects were consecutive stage I-III rectal cancer patients who underwent curative resection without preoperative treatment at National Cancer Center Hospital between 2000 and 2015. Overall survival (OS) and the hazard function of recurrence or death were analyzed according to the CEA levels, as follows: normal preoperative CEA (normal group), preoperatively elevated but postoperatively normalized CEA (normalized group), and preoperatively and postoperatively elevated CEA (elevated group).

RESULTS

The normalized group (n =235) had worse OS (HR 1.49, 95% CI 1.08-2.04; P = .0142) compared to the normal group (n = 1208), and better OS compared to the elevated group (n = 47) (HR 0.53, 95% CI 0.31-0.91; P = .0208). The elevated group had the highest and earliest peak in hazard function, followed by the normalized group and the normal group, with median times to recurrence of 8.8, 15.5, and 18.5 months, respectively (P = .0223).

CONCLUSIONS

Prognosis after resection of rectal cancer was worse in patients with preoperatively elevated and postoperatively normalized CEA compared to those with normal preoperative CEA. Patients with elevated preoperative CEA might require intensive follow-up even if levels normalize after resection, especially in earlier periods, for early detection of recurrence.

Long-term outcomes and recurrence pattern of 18F-FDG PET-CT complete metabolic response in the first-line treatment of metastatic colorectal cancer: a lesion-based and patient-based analysis

Background

18F-FDG PET-CT is commonly used to monitor treatment response in patients with metastatic colorectal cancer (mCRC). With improvement in systemic therapy, complete metabolic response (CMR) is increasingly encountered but its clinical significance is undefined. The study examined the long-term outcomes and recurrence patterns in these patients.

Methods

Consecutive patients with mCRC who achieved CMR on PET-CT during first-line systemic therapy were retrospectively analysed. Measurable and non-measurable lesions identified on baseline PET-CT were compared with Response Criteria in Solid Tumors (RECIST) on CT on a per-lesion basis. Progression free (PFS) and Overall Survival (OS) were compared with clinical parameters and treatment characteristics on a per-patient basis.

Results

Between 2008 and 2011, 40 patients with 192 serial PET-CT scans were eligible for analysis involving 44 measurable and 38 non-measurable lesions in 59 metastatic sites. On a per-lesion basis, 46% also achieved Complete Response (CR) on RECIST criteria and sustained CMR was more frequent in these lesions (OR 1.727, p = 0.0031). Progressive metabolic disease (PMD) was seen in 12% of lesions, with liver metastasis the most common. Receiver operating characteristics (ROC) curve analysis revealed the optimal value of SUVmax for predicting PMD of a lesion was 4.4 (AUC 0.734, p = 0.004). On a per-patient basis, 14 patients achieved sustained CMR and their outcomes were better than those with PMD (median OS not reached vs 37.7 months p = 0.0001). No statistical difference was seen in OS between patients who achieved PR or CR (median OS 51.4 vs 44.2 months p = 0.766).

Conclusion

Our results provided additional information of long-term outcomes and recurrence patterns of patients with mCRC after achieving CMR. They had improved survival and sustained CMR using systemic therapy alone is possible. Discordance between morphological and metabolic response was consistent with reported literature but in the presence of CMR the two groups had comparable outcomes.

Analysis of Clinical characteristics to predict pathologic complete response for patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy

To explore clinical characteristics which could be applied to predict pathologic complete response (pCR) for patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy (neo-CRT) and total mesorectal excision (TME). 297 patients with locally advanced rectal cancer (cT3-4 or cN+) who were treated with neo-CRT followed by TME were retrospectively reviewed. Clinical characteristics including age, gender, tumor distance from anus, serum CEA, hemoglobin levels before treatment and clinical TN stage were used to investigate the association with pCR after neo-CRT. Seventy-nine (26.6%) patients achieved pCR after neo-CRT. pCR were achieved in 42 (34.4%) patients in cT1-3 stage and 37 (21.1%) in cT4 stage. pCR rate was 36.4% and 16.4% for patients with pre-treatment serum CEA ≤5.33ng/ml and >5.33ng/ml, respectively. Uni- and multi-variate analyses revealed that pre-treatment serum CEA level ≤5.33ng/ml and clinical T stage, (i.e., cT1-3 versus cT4) were highly correlated with pCR (p < 0.05). Clinical T stage and pre-treatment serum CEA level were strongly associated with pCR for patients with locally advanced rectal cancer treated with neo-CRT followed by TME which could be applied as clinical predictors for pCR.

Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer

BACKGROUND

The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection.

METHODS

A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins.

RESULTS

Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263).

CONCLUSION

Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.

The impacts of surgery of the primary cancer and radiotherapy on the survival of patients with metastatic rectal cancer

The role of surgery of the primary cancer and radiation in metastatic colorectal cancer (mCRC) is still controversial currently, and evidence implied that colon cancer (CC) and rectal cancer (RC) should be treated with difference. Hence we focused on metastatic rectal cancer (mRC) solely to compare the cancer cause-specific survival (CSS) of patients receiving varied treatments of the primary cancer: no treatment, surgery only, radiation only, and surgery plus radiation, based on the records of the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8669 patients were included. Results demonstrated that the 2-year CSS was 28.1% for no treatment group, 30.7% for only radiation group, 50.2% for only surgery group, and 66.5% for surgery plus radiation group, reaching statistical difference (P < 0.001). Furthermore, the CSSs of mRC patients in the surgery group were similar regardless of resection ranges (P = 0.44). Besides, we analyzed the prognostic factors for mRC and found carcinoembryonic antigen (CEA) level, metastasis (M) stage, Tumor (T) stage, tumor size, differentiate grade, age and marital status should be taken into consideration when estimating the prognosis. Particularly, patients with normal CEA level or M1a stage showed a significant survival advantage. Overall, present study suggested that surgery of the primary cancer and radiation might help to improve the survival of mRC patients, especially when both treatments were conducted. Our results may assist clinicians to make better treatment strategy for patients with mRC.

Comparison of systemic inflammatory and nutritional scores in colorectal cancer patients who underwent potentially curative resection

BACKGROUND

Various systemic inflammatory and nutritional scores have been reported to predict postoperative outcomes. This study aimed to investigate the best systemic inflammatory and nutritional scores in colorectal cancer (CRC) patients who underwent potentially curative resection.

METHOD

We evaluated 468 consecutive CRC patients in this study. Comparisons of systemic inflammatory and nutritional scores, including the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic index (PI), prognostic nutritional index (PNI), and modified Glasgow prognostic score (mGPS), were performed using univariate/multivariate analyses for patient survival.

RESULTS

The PNI and mGPS, but not the NLR, PLR, and PI, were significantly associated with overall and relapse-free survival. The mGPS, but not the PNI, was strongly correlated with TNM stage (P < 0.001). Cox multivariate analysis showed that both the PNI and mGPS were exclusive independent prognostic factors for both overall and relapse-free survival (P < 0.001). Furthermore, the PNI status predicted patient survival more clearly than the mGPS in combination with TNM stage.

CONCLUSIONS

This study suggests that the PNI and mGPS are useful predictive scores in CRC patients who undergo potentially curative resection, especially the PNI in combination with TNM stage. Routine evaluation of the host status using the scores may be useful in CRC treatment.

CONUT: a novel independent predictive score for colorectal cancer patients undergoing potentially curative resection

BACKGROUND

Controlling nutritional status (CONUT) score, calculated from serum albumin and total cholesterol concentrations and total lymphocyte count, is reportedly valuable for nutritional assessment. This study investigated whether CONUT score was predictive of outcomes in colorectal cancer (CRC) patients undergoing surgical resection.

METHODS

Preoperative CONUT scores were retrospectively evaluated in 417 CRC patients who underwent potentially curative resection at Kumamoto University Hospital from March 2005 to August 2014. Patients were divided into four groups based on preoperative CONUT scores: normal, light, moderate, and severe. The associations of CONUT score with clinicopathological factors, patient survival, and postoperative complications were examined.

RESULTS

CONUT score correlated significantly with age (P < 0.001), body mass index (P = 0.005), carcinoembryonic antigen (P = 0.002), and carbohydrate antigen 19-9 (P = 0.005) concentrations. Overall survival (OS) rate was significantly lower in patients with moderate/severe than light or normal CONUT scores. CONUT score was independently prognostic of OS [moderate/severe vs. normal, hazard ratio = 5.92, 95 % confidence interval (CI) 2.30-14.92; P < 0.001)]. Patients with moderate/severe CONUT scores were at greater risk for complications, especially for severe complications. Multivariate analysis showed that CONUT score was independently predictive of severe complications (moderate/severe vs. normal, odds ratio = 4.51, 95 % CI 1.89-10.74; P < 0.001).

CONCLUSIONS

CONUT score may predict survival and postoperative severe complications in CRC patients undergoing potentially curative resection. Management of CRC patients may need consideration of host nutritional status.

Surface Profiling of Extracellular Vesicles from Plasma or Ascites Fluid Using DotScan Antibody Microarrays

DotScan antibody microarrays were initially developed for the extensive surface profiling of live leukemia and lymphoma cells. DotScan's diagnostic capability was validated with an extensive clinical trial using mononuclear cells from the blood or bone marrow of leukemia or lymphoma patients. DotScan has also been used for the profiling of surface proteins on peripheral blood mononuclear cells (PBMC) from patients with HIV, liver disease, and stable and progressive B-cell chronic lymphocytic leukemia (CLL). Fluorescence multiplexing allowed the simultaneous profiling of cancer cells and leukocytes from disaggregated colorectal and melanoma tumor biopsies after capture on DotScan. In this chapter, we have used DotScan for the surface profiling of extracellular vesicles (EV) recovered from conditioned growth medium of cancer cell lines and the blood of patients with CLL. The detection of captured EV was performed by enhanced chemiluminescence (ECL) using biotinylated antibodies that recognized antigens expressed on the surface of the EV subset of interest. DotScan was also used to profile EV from the blood of healthy individuals and the ascites fluid of ovarian cancer patients. DotScan binding patterns of EV from human plasma and other body fluids may yield diagnostic or prognostic signatures for monitoring the incidence, treatment, and progression of cancers.

Study of the Annexin A1 and Its Associations with Carcinoembryonic Antigen and Mismatch Repair Proteins in Colorectal Cancer

PURPOSE

Annexin-A1 (ANXA1) has been implicated in various tumor types, but few studies have investigated its involvement in colorectal cancer. The study aimed to analyze ANXA1 expression in the normal margin and colorectal tumor tissues of 104 patients who underwent surgery for colorectal cancer and to associate the ANXA1 expression with predictive clinicopathological variables.

METHODS

Hematoxylin-eosin and immunohistochemical staining were used for the analysis.

RESULTS

ANXA1 expression was higher in colorectal cancer than in normal margin tissue (p = 0.0001). However, no differences were observed when we analyzed the ANXA1 expression in colon and rectal tumors (p = 0.830). Also, this protein positivity was associated with increased carcinoembryonic antigen levels (p = 0.004). Our data in the DNA-mismatch repair proteins expression was in accordance to the literature. And their positivity was not associated with ANXA1 presence in colorectal cancer.

CONCLUSION

The high incidence of ANXA1 positive expression in colorectal cancer and its association with carcinoembryonic antigen levels might indicate the importance of this protein in the colorectal cancer biology.

Predictive Value of CEA for Survival in Stage I Rectal Cancer: a Population-Based Propensity Score-Matched Analysis

BACKGROUND

The aim of the study was to assess whether preoperative carcinoembryonic antigen (CEA) level is an independent predictor of overall- and cancer-specific survival in stage I rectal cancer.

METHODS

Stage I rectal cancer patients were identified in the Surveillance, Epidemiology, and End Results database between 2004 and 2011. The impact of an elevated preoperative CEA level (C1-stage) compared with a normal CEA level (C0-stage) on overall and cancer-specific survival was assessed using risk-adjusted Cox proportional hazard regression models and propensity score methods.

RESULTS

Overall, 1932 stage I rectal cancer patients were included, of which 328 (17 %) patients had C1-stage. The 5-year overall and cancer-specific survival for patients with C0-stage were 85.7 % (95 % CI 83.2-88.2 %) and 94.7 % (95 % CI 93.1-96.3 %), versus 76.8 % (95 % CI 70.9-83.1 %) and 88.1 % (95 % CI 83.3-93.2 %) for patients with C1-stage (P < 0.001 and P = 0.001). The negative impact of C1-stage on overall and cancer-specific survival was confirmed by risk-adjusted Cox proportional hazard regression analysis (hazard ratio [HR] = 1.57, 95 % CI = 1.15-2.16, P = 0.007 and 2.04, 95 % CI = 1.25-3.33, P = 0.006), and after propensity score matching (overall survival [OS]: HR = 1.46, 95 % CI = 1.02-2.08, P = 0.044 and cancer-specific survival [CSS]: HR = 3.28, 95 % CI = 1.78-6.03, P < 0.001).

CONCLUSION

This is the first population-based investigation of a large cohort of exclusively stage I rectal cancer patients providing compelling evidence that elevated preoperative CEA level is a strong predictor of worse overall and cancer-specific survival.

Long-term Outcomes of Laparoscopic versus Open Surgery for Rectal Cancer: A Single-center Retrospective Analysis

BACKGROUND/AIMS

Laparoscopic surgery has been proven to be an effective alternative to open surgery in patients with colon cancer. However, data on laparoscopic surgery in patients with rectal cancer are insufficient. The aim of this study was to compare the long-term outcomes of laparoscopic and open surgery in patients with rectal cancer.

METHODS

A total of 307 patients with rectal cancer who were treated by open and laparoscopic curative resection at Kosin University Gospel Hospital (Busan, Korea) between January 2002 and December 2011 were reviewed retrospectively.

RESULTS

Regarding treatment, 176 patients underwent an open procedure and 131 patients underwent a laparoscopic procedure. The local recurrence rate after laparoscopic resection was 2.3%, compared with 5.7% after open resection (p = 0.088). Distant metastases occurred in 6.9% of the laparoscopic surgery group, compared with 24.4% in the open surgery group (p < 0.001). In univariate analysis, age (≥ 75 years vs. ≤ 60 years), preoperative staging, surgical approach (open vs. laparoscopic), elevated initial CEA level, elevated follow-up CEA level, number of positive lymph nodes, and postoperative chemotherapy affected overall survival and disease free survival. However, in multivariate analysis, the surgical approach apparently did not affect long-term oncologic outcome.

CONCLUSIONS

In this study, long-term outcomes after laparoscopic surgery for rectal cancer were not inferior to those after open surgery. Therefore, laparoscopic surgery would be an alternative operative tool to open resection for rectal cancer, although further investigation is needed.

Predictors for regional lymph node metastasis in T1 rectal cancer: a population-based SEER analysis

BACKGROUND

Local resection of early-stage rectal cancer significantly reduces perioperative morbidity compared with radical resection. Identifying patients at risk of regional lymph node metastasis (LNM) is crucial for long-term survival after local resection.

METHODS

Patients after oncological resection of T1 rectal cancer were identified in the Surveillance, Epidemiology, and End Results register 2004-2012. Potential predictors of LNM and its impact on cancer-specific survival were assessed in logistic and Cox regression with and without multivariable adjustment.

RESULTS

In total, 1593 patients with radical resection of T1 rectal cancer and a minimum of 12 retrieved regional lymph nodes were identified. The overall LNM rate was 16.3 % (N = 260). A low risk of LNM was observed for small tumor size (P = 0.002), low tumor grade (P = 0.002) and higher age (P = 0.012) in multivariable analysis. The odds ratio for a tumor size exceeding 1.5 cm was 1.49 [95 % confidence interval (CI) 1.06-2.13], for G2 and G3/G4 carcinomas 1.69 (95 % CI 1.07-2.82) and 2.72 (95 % CI 1.50-5.03), and for 65- to 79-year-old and over 80-year-old patients 0.65 (95 % CI 0.43-0.96) and 0.39 (95 % CI 0.18-0.77), respectively. Five-year cancer-specific survival for patients with LNM was 90.0 % (95 % CI 85.3-95.0 %) and for patients without LNM 97.1 % (95 % CI 95.9-98.2 %, hazard ratio = 3.21, 95 % CI 1.82-5.69, P < 0.001).

CONCLUSIONS

In this population-based analysis, favorable cancer-specific survival rates were observed in nodal-negative and nodal-positive T1 rectal cancer patients after primary radical resection. The predictive value of tumor size, grading and age for LNM should be considered in medical decision making about local resection.

[Prognostic value of preoperative carcinoembryogenic antigen: Is it useful in all stages of colorectal cancer?]

INTRODUCTION

Recent reports have reopened discussion of the prognostic value of elevated pre-treatment carcinoembryonic antigen (CEA) levels in colorectal cancer. Due to the discrepancies in the published results, we aimed to analyze the possible predictive value of CEA, both overall and in different tumoral stages in our environment.

PATIENTS AND METHODS

We retrospectively studied 303 consecutive patients with colorectal cancer resected with curative intent by analysing tumor-related mortality. The frequency of patients with increased CEA levels (> 5mg/l) was registered. Univariate and multivariate analyses of survival curves were performed, comparing patients with increased CEA levels and those with CEA levels within normal limits, both in the overall series and in the different pTNM tumoral stages.

RESULTS

Frequency of patients with CEA>5mg/l was 31%. The median clinical follow-up was 83 months. A poor survival rate was registered in the multivariate analysis of the whole series in patients with high CEA levels: hazard ratio (HR)=1.81; 95% confidence interval (95% CI)=(1.15-3.10); P=.012. This predictive value was only maintained in stage II in the survival analysis of the distinct tumoral stages (n=104): HR=3.02; 95% CI=(1.22-7.45); P=.017.

CONCLUSIONS

Before treatment, 31% of our patients with colorectal cancer resected with curative intent had pathological CEA values. In the overall series, a high pretreatment CEA level showed an independent prognostic value for poor survival. When pTNM tumoral stages were analyzed separately, CEA level had predictive value only in pTNM II tumors.

Clinicopathologic features and oncologic outcomes of colorectal cancer patients with extremely high carcinoembryonic antigen

PURPOSE

The aim of this study is to investigate the clinicopathologic features and oncologic outcomes of colorectal cancer patients with extremely elevated (≥50 ng/mL) preoperative serum carcinoembryonic antigen (CEA) levels.

METHODS

We enrolled 756 primary colorectal cancer patients with elevated preoperative CEA levels (≥5 ng/mL) who underwent surgery between 2004 and 2010 and compared clinicopathologic features according to preoperative CEA levels of 5-50 ng/mL (n = 676) and ≥50 ng/mL (n = 80). The impact of extremely elevated CEA on overall survival (OS) and disease-free survival (DFS) was analyzed using Kaplan-Meier analysis and the Cox proportional hazards model.

RESULTS

The median follow-up period was 43 months (range, 0-121). Patients with preoperative CEA ≥50 ng/mL demonstrated higher rates of advanced T stage (97.3 vs. 88.6%, p = 0.016) and distant metastasis (33.8 vs. 17.9%, p = 0.002), but not lymph node metastasis (54.1 vs. 52.2%, p = 0.807). The 5-year OS rate was 69.1%, and the 3-year DFS rate of curatively resected patients (n = 641; 84.8%) was 68.9%. In multivariate analysis, preoperative CEA ≥50 ng/mL, as well as age, N stage, vascular invasion, perineural invasion, post/preoperative CEA ratio ≥0.32, and palliative resection, was an independent predictor of OS. However, for patients treated with curative resection, preoperative CEA ≥50 ng/mL was not significantly associated with DFS or OS (p = 0.053 and 0.157, respectively).

CONCLUSIONS

Colorectal cancer patients with extremely elevated (≥50 ng/mL) preoperative CEA had advanced disease more frequently but comparable oncologic outcomes if curative resection was performed.

Apparent Diffusion Coefficient (ADC) value: a potential imaging biomarker that reflects the biological features of rectal cancer

Objective

We elected to analyze the correlation between the pre-treatment apparent diffusion coefficient (ADC) and the clinical, histological, and immunohistochemical status of rectal cancers.

Materials and Methods

Forty-nine rectal cancer patients who received surgical resection without neoadjuvant therapy were selected that underwent primary MRI and diffusion-weighted imaging (DWI). Tumor ADC values were determined and analyzed to identify any correlations between these values and pre-treatment CEA or CA19-9 levels, and/or the histological and immunohistochemical properties of the tumor.

Results

Inter-observer agreement of confidence levels from two separate observers was suitable for ADC measurement (k  =  0.775). The pre-treatment ADC values of different T stage tumors were not equal (p  =  0.003). The overall trend was that higher T stage values correlated with lower ADC values. ADC values were also significantly lower for the following conditions: tumors with the presence of extranodal tumor deposits (p  =  0.006) and tumors with CA19-9 levels ≥ 35 g/ml (p  =  0.006). There was a negative correlation between Ki-67 LI and the ADC value (r  =  −0.318, p  =  0.026) and between the AgNOR count and the ADC value (r  =  −0.310, p  =  0.030).

Conclusion

Significant correlations were found between the pre-treatment ADC values and T stage, extranodal tumor deposits, CA19-9 levels, Ki-67 LI, and AgNOR counts in our study. Lower ADC values were associated with more aggressive tumor behavior. Therefore, the ADC value may represent a useful biomarker for assessing the biological features and possible relationship to the status of identified rectal cancers.

The advantage of circulating tumor cells over serum carcinoembryonic antigen for predicting treatment responses in rectal cancer

AIM

The objective of this study was to investigate the clinical significance of circulating tumor cells (CTCs) on the evaluation and prediction of treatment responses in rectal cancer patients compared with serum carcinoembryonic antigen (CEA).

MATERIALS & METHODS

Both CTCs and CEA levels of 103 rectal cancer patients (66 with stage II-III and 37 with recurrence or metastasis) were analyzed before and after chemoradiotherapy. CTCs were detected using EpCAM magnetic bead-based enrichment combined with cytometric identification.

RESULTS

CTCs were detected in all patients while no tumor cells were found in healthy controls. CTC levels in metastatic patients were significantly higher than those with recurrence or stage II-III rectal cancer. There is a close relationship between CTC levels and treatment outcomes but serum CEA did not have any correlation.

CONCLUSION

CTCs are promising markers for the evaluation and prediction of treatment responses in rectal cancer patients, superior to the conventional tumor marker CEA.

Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis

OBJECTIVE

To assess the putative impact of perioperative blood transfusions on overall and disease-free survival in patients undergoing curative resection of stage I-III rectal cancer by applying propensity-scoring methods.

BACKGROUND

Whether perioperative blood transfusions negatively impact survival remains a matter of great debate.

METHODS

In a single-center study, 401 patients undergoing open curative resection of stage I-III rectal cancer between 1996 and 2008 were assessed. The median follow-up was 34.2 months. Patients who did and did not receive perioperative blood transfusions were compared using Cox regression and propensity score analyses.

RESULTS

Overall, 217 patients (54.1%) received blood transfusions. Patients' characteristics were highly biased concerning transfusions (propensity score 0.77±0.23 vs. 0.28±0.25; P<0.001). In unadjusted analysis, blood transfusions were associated with a 119% increased risk of mortality [hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.34-3.57, P=0.001]. In propensity score-adjusted Cox regression (HR: 1.02, 95% CI: 0.65-1.58, P=0.970), blood transfusions did not increase the risk of overall survival. Similarly, in propensity score-adjusted Cox regression (HR: 0.86, 95% CI: 0.60-1.23, P=0.672), blood transfusions were not associated with an increased risk of recurrence.

CONCLUSIONS

This is the first propensity score-based analysis providing compelling evidence that worse oncological outcomes after curative rectal cancer resection in patients receiving perioperative blood transfusions are caused by the clinical circumstances requiring transfusions, not due to the blood transfusions themselves. Therefore, concerns about overall and disease-free survival should be no issue in the decision-making regarding perioperative blood transfusions in patients undergoing curative rectal cancer resection.

Alternatives for the intensive follow-up after curative resection of colorectal cancer. Potential novel biomarkers for the recommendations

Early diagnosis of recurrence and metastasis of colorectal cancer following surgery of curative intent is of vital importance in terms of survival and quality of life. The consistent implementation of appropriate patient follow-up strategy is therefore essential. Debates over the methodology, evaluation and strategy of follow-up have been known for many years, and continue today. By introducing several follow-up models, the present paper offers different options featuring certain individual, national and international, conceptual and financial aspects. Colorectal cancer is an important public health concern due to its destructive nature and frequency, it is therefore essential to develop new monitoring strategies, involving new biomarkers and extensive clinical validation. Since the recurrence rate is very high in high-risk patients, the improvement of individual patient risk estimates and the utilization of a corresponding follow-up model require broad international co-operation and common practice, along with the determination of optimal levels of evidence.

Combined preoperative CEA and CD44v6 improves prognostic value in patients with stage I and stage II colorectal cancer

AIM

Combination of biomarkers may improve diagnosis and have better prognostic value than single markers. The purpose of this study was to investigate whether combined CEA and CD44v6 improves prognostic value in stage I and stage II (stage I/II) colorectal cancer (CRC).

METHODS

Preoperative serum CEA level and the expression of CD44v6 in CRC tissues were examined by electrochemiluminescence immunoassay and immunohistochemistry, respectively. The association of CEA and CD44v6 with clinicopathological features and their possible prognostic values was analyzed.

RESULTS

The preoperative elevated serum CEA level and positive CD44v6 expression were detected in 30.1 % (52/173) serum samples and 60.5 % (101/167) CRC tissues, respectively. Patients with an elevated-CEA level or a CD44v6-negative tumor had a worse disease-specific survival (DSS) than those with a normal-CEA level or CD44v6-positive tumor (P = 0.024, P = 0.012, respectively). Moreover, CD44v6 expression could be used in discriminating patients from good to poor prognosis in normal-CEA subgroup (P = 0.043), but not in elevated-CEA subgroup (P = 0.563). Multivariate analysis revealed that combined CEA and CD44v6 was an independent prognostic factor for patients with stage I/II CRC (P = 0.023). However, serum CEA level only retained a borderline significance for correlation with a worse DSS (P = 0.059), and CD44v6 expression alone was not an independent prognostic factor for DSS in multivariate analysis (P = 0.123).

CONCLUSION

These results suggested that combined CEA/CD44v6 had better prognostic value than CEA or CD44v6 alone for patients with stage I/II CRC.