Viewing metastatic colorectal cancer as a curable chronic disease. Am J Clin Oncol. 2012;35:77-80. [PMID: 22257778 DOI: 10.1097/COC.0b013e3181fe4444]

Spouses of patients treated for colon cancer: identification of key caregiver skills using the Delphi method

PURPOSE

Spouses are often the front-line caregivers for colon cancer patients. Providing this support requires a particular set of coping skills. Our objective was to identify key skills that healthcare and medico-social sector professionals could assess in routine practice that would allow them to propose appropriate support to spouses who are accompanying colon cancer patients in their care pathway.

METHODS

An online two-round Delphi study was conducted among French colon cancer patients, spouses and professionals. The content of the Delphi study was developed from a previously published qualitative study.

RESULTS

In the first round of the study, 63% of the participants were professionals (n = 40), 19% spouses (n = 12) and 17% patients (n = 11). In the second round, they were respectively 55% (n = 22), 22% (n = 9) and 22% (n = 9). Twenty-seven of the 75 proposed skills were consensually identified as key skills. Nine were related to emotional and psychological well-being, six to social relations, four to organisation, five to health and three to domestic domains. The three most consensual skills (≥ 90% agreement) for spouses were (1) helping the tired patient in everyday life, (2) stimulating the patient to prevent him/her from giving up and (3) limiting one's amount of personal time to care for the patient.

CONCLUSION

The study identified the key skills needed by spouses of patients being treated for colon cancer. Better awareness of these skills among professionals would enable them to offer tailored support to help patients and spouses maintain their physical and emotional well-being.

Contemporary Outcomes for the Curative Treatment of Colorectal Cancer Pulmonary Metastases

PURPOSE

Treatment of pulmonary metastases (PM) from colorectal cancer (CRC) is the standard of care by several guidelines from Europe and the USA, but the validity of this strategy has been recently questioned, and the available evidence supporting this strategy is weak. We report the outcomes of a curative intent strategy in a very recent and homogenous series of patients.

METHODS

We did a retrospective review of all curative intent surgical or ablative treatment of PM from CRC performed consecutively in 3 French institutions from January 2015 to December 2019. Demographics, clinicopathological, and molecular characteristics were evaluated. Cox regression models were used to identify prognostic factors related to local recurrence and disease-free survival.

RESULTS

Records from 152 patients were reviewed. One-hundred thirty-five patients (88%) had surgical metastasectomy. Median age was 67 years. Most of the patients had a single lesion (66%), and 16% had synchronous PM. Eighty-one patients (53%) experienced recurrence, and the thorax was the most common site of recurrence. Median disease-free survival and overall survival were 35 months and 78 months after PM treatment. At the end of the study, only 17% of the patients died. Pulmonary tumor burden was correlated with disease-free survival in univariate analysis, but multivariate analysis did not find any prognostic factor independently associated with local recurrence or survival.

CONCLUSION

Our finds corroborate existing recommendation for the invasive treatment of PM from CRC in selected patients.

Recurrent colorectal liver metastasis patients could benefit from repeat hepatic resection

Background

Local treatment remains the best option for recurrent colorectal liver metastasis (CRLM). The current study aimed to investigate predictive factors of survival outcomes and select candidates for local treatment for CRLM at first recurrence.

Methods

Data were collected retrospectively from CRLM patients who underwent hepatic resection and developed first recurrence between 2000 and 2019 at our institution.
A nomogram predicting overall survival was established based on a multivariable Cox model of clinicopathologic factors. The predictive accuracy and discriminative ability of the nomogram were determined by the concordance index and calibration curve.

Results

Among 867 patients who underwent curative hepatic resection, 549 patients developed recurrence. Three hundred patients were evaluated and had resectable and liver-limited disease. Among them, repeat liver resection and percutaneous radiofrequency ablation were performed in 88 and 85 patients, respectively. The other 127 patients received only systemic chemotherapy. Multivariable analysis identified primary lymph node positivity, tumor size > 3 cm, early recurrence, RAS gene mutation and no local treatment as independent risk factors for survival outcomes. Integrating these five variables, the nomogram presented a good concordance index of 0.707. Compared with patients who received only systemic chemotherapy, radical local treatment did not significantly improve survival outcomes (median OS: 21 vs. 15 months, p = 0.126) in the high-risk group (total score ≥ 13).

Conclusion

Radical local treatment improved the survival of recurrent CRLM patients. The proposed model facilitates personalized assessments of prognosis for patients who develop first recurrence in the liver.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01323-y.

Superior outcomes of nodal metastases compared to visceral sites in oligometastatic colorectal cancer treated with stereotactic ablative radiotherapy

BACKGROUND

Stereotactic ablative radiotherapy (SBRT) is a radical option for oligometastatic colorectal cancer (CRC) patients, but most data relate to visceral metastases.

METHODS

A prospective, multi-centre database of CRC patients treated with SBRT was interrogated. Inclusion criteria were ECOG PS 0-2, ≤3 sites of disease, a disease free interval of >6 months unless synchronous liver metastases. Primary endpoints were local control (LC), progression free survival (PFS) and overall survival (OS).

RESULTS

163 patients (172 metastases) were analysed. The median FU was 16 months (IQR 12.2-22.85). The LC at 1 year was 83.8% (CI 76.4%-91.9%) with a PFS of 55% (CI 47%-64.7%) respectively. LC at 1 year was 90% (CI 83%-99%) for nodal metastases (NM), 75% (63%-90%) for visceral metastases (VM). NM had improved median PFS (9 vs 19 months) [HR 0.6, CI 0.38-0.94, p = 0.032] and median OS (32 months vs not reached) [HR 0.28, CI 0.18-0.7, p = 0.0062] than VM, regardless of whether the NM were located inside or outside the pelvis. On multivariate analysis, NM and ECOG PS 0 were significant good prognostic factors. An exploratory analysis suggests KRAS WT is also a good prognostic factor.

CONCLUSION

Nodal site is an important prognostic determinant of SBRT that should incorporated into patient selection. We hypothesise this may have an immunoediting basis.

Hepatic metastasis from colorectal cancer

Colorectal cancer (CRC) is one of the most common cancers in the world. About two third of patients with CRC will develop distant recurrence at some point in time. Liver is the most common site where distant metastasis takes place. While the overall survival (OS) of patients with metastatic CRC was poor about 3 decades ago, there has been tremendous improvement in this area in the recent years. With the advent of effective systemic chemotherapy and biologic agents and better understanding of the biological behaviour of the tumour, aggressive treatment strategies such as metastatectomy of the liver metastases (or lung metastases) are now acceptable. More importantly, it has transformed the way how stage IV CRCs are being managed. From predominantly palliative as the primary aim, a comprehensive multidisciplinary approach is now the mainstay of treatment with very successful outcomes. Combination of systemic therapies with liver resection has been shown to be effective in providing promising survival benefits. In addition, other adjunctive modalities in targeting the liver metastases such as ablation, combining resection and ablation, transarterial chemoembolization, stereotactic body radiotherapy (SBRT), hepatic artery perfusion, etc. have also been demonstrated variable outcome in treating colorectal liver metastasis (CRLM). Very recently, transplant oncologists have also explored using liver transplantation as a treatment modality for unresectable CRLM, which has demonstrated very good long-term survival in well selected cases. The new paradigm in the treatment of metastatic CRC has dawned.

Repeated Resections of Hepatic and Pulmonary Metastases from Colorectal Cancer Provide Long-Term Survival

BACKGROUND

Liver and lungs are the two most frequent sites of metastatic spread of colorectal cancer (CRC). Complete resection of liver and/or lung metastases is the only chance of cure, and several studies have reported an improved survival after an aggressive treatment. Nevertheless, CRC liver metastases (CLM) have been recognized as a pejorative factor for patients undergoing pulmonary metastasectomy. We report our experience with patients successively operated on for CRC hepatic and pulmonary metastasis (CPM) and seek to identify prognostic factors.

METHODS

All consecutive patients who had resection of CPM and CLM between 2001 and 2014 were enrolled in the study. Clinicopathological and survival data were retrospectively analysed.

RESULTS

Forty-six patients underwent resections of both CLM and CPM. Hepatic resection preceded pulmonary resection in most cases (91.3%). The median intervals between the resection of the primary tumour and the hepatic recurrence and between hepatic and pulmonary recurrences were 12 months [0-72] and 21.5 months [1-84], respectively. The mortality rate following CPM resection was 4.3%. After a median follow-up of 41.5 months [0-126], 35 patients recurred of whom 14 (40%) and 11(31.4%) could benefit from repeated resection of recurrent CLM and CPM, respectively. The median and 5-year overall survivals (OS) were 53 months and 49%, respectively. No prognostic factor was identified.

CONCLUSION

An aggressive management of CLM and CPM, including repeated resections, may provide a long-term survival comparable to survival of patients with unique metastasectomy. The absence of prognostic factor may reflect the highly selected pattern of the eligible patients.

Ablative stereotactic radiotherapy for oligometastatic colorectal cancer: Systematic review

BACKGROUND

SBRT is a novel modality in treatment for oligometastatic colorectal cancer. We aimed to perform a systematic review of results of SBRT in maintaining LC (local control) for CRC liver and lung oligometastases.

MATERIALS AND METHODS

The review was performed according to PRISMA and PICO guidelines. Database search using keywords: stereotactic, colon, colorectal, cancer, sbrt, sabr returned 457 results. 15 were included in the study. Only cohorts with CRC histology and reported LC were included.

RESULTS

For liver LC rates ranged from 50% to 100% after 1 year and 32% to 91% after 2 years. BED range 40.5-262.5 Gy (Gray). For lung LC rates ranged from 62% to 92% after 1 one year and from 53% to 92% after 2 years. BED range 51.3-262.5 Gy.

CONCLUSIONS

SBRT of oligometastatic CRC offers high LC with low morbidity and toxicity. It requires more observational studies and randomized trials but available data on clinical efficacy is promising, however not yet matured.

Identification of resources and skills developed by partners of patients with advanced colon cancer: a qualitative study

PURPOSE

Family caregivers play an important role in caring for patients with advanced cancer. To become competent, individuals must draw on and mobilise an adequate combination of resources. Our goal was to identify the skills developed by caregivers of patients with advanced cancer and the associated resources mobilised. We chose to do it with partners of patients with colon cancer.

METHODS

The study used a cross-sectional qualitative design based on 20 individual interviews and a focus group. Partners were recruited from patients treated in three hospitals of France. Semi-structured interviews were conducted until data saturation was achieved. Each interview was transcribed verbatim, and thematic analyses were performed to extract significant themes and subthemes.

RESULTS

Results from the individual and focus group interviews showed that the skills implemented by the partners (in domains of social relationships and health, domestic, organisational, emotional and well-being dimensions) were singular constructs, dependant on if resources (personal, external and schemes) may have been missing and insufficient. In addition, partners may have had these resources but not mobilised them.

CONCLUSION

The identification of the skills and associated resources could allow healthcare professionals better identifying and understanding of the difficulties met by partners in taking care of patients. This could enable them to offer appropriate support to help the caregivers in their accompaniment.

The New Era of Transplant Oncology: Liver Transplantation for Nonresectable Colorectal Cancer Liver Metastases

Colorectal cancer (CRC) is the third most incident cancer worldwide. Most of CRC patients will develop distant metastases, mainly to the liver, and liver resection is the only potential chance for cure. On the other hand, only a small proportion of patients with hepatic CRC metastasis are candidates for upfront liver resection. Liver transplantation (LT) is an attractive option for patients with nonresectable CRC liver metastases (NRCLM) without extrahepatic involvement. Initial experiences with LT for NRCLM achieved very poor outcomes, with a 5-year overall survival (OS) lower than 20%. However, these initial studies did not have a standardized patient selection or neoadjuvant or adjuvant therapies. With recent advances in the surgical and medical oncology fields, the landscape has changed. Recent studies from Norway have shown an encouraging 5-year OS of 50% when transplanting patients with NRCLM. Nevertheless, the main concern when expanding the indications for LT is organ shortage. To manage this organ shortage, strategies utilizing live donor liver transplantation are gaining favor. A few ongoing trials are assessing the impact of LT in NRCLM patient survival. Therefore, the aim of this paper is to review the current status of LT for NRCLM.

Preoperative platelet-lymphocyte ratio is an independent prognostic marker and superior to carcinoembryonic antigen in colorectal peritoneal carcinomatosis patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

OBJECTIVE

The aim of this study was to examine the prognostic significance of preoperative inflammatory-based indices, platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio (NLR), and carcinoembryonic antigen (CEA) in predicting overall survival (OS) in patients with colorectal peritoneal carcinomatosis (CPC) treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

Sixty patients with pathologically confirmed CPC treated with CRS and HIPEC between 2003 and 2015 were included. Levels of preoperative PLR, NLR, and CEA were recorded. Univariate and multivariate analyses were conducted to identify prognostic factors associated with OS.

RESULTS

Median OS was 36 months (95% CI, 26.6-45.4) and 5-year OS was 40.5% (95% CI, 27.3-51.6%). Preoperative PLR (p = 0.034) and CEA (p = 0.036) were found to be significant prognostic markers of OS, whereas NLR did not affect OS. PLR remained significant on multivariate analysis (hazard ratio, 1.035; 95% CI, 1.027-1.043; p < 0.001).

CONCLUSION

Our study indicates that preoperative PLR may be used as a prognostic marker in CPC patients undergoing CRS and HIPEC and could be useful in the preoperative setting when selecting patients for surgery. The subset of patients with PLR > 300 have a median OS of 5 months (95% CI, 0-24.6 months), indicating that CRS and HIPEC may not be superior to systemic chemotherapy in this subset of patients.

[Not Available]

OLIGOMETASTASIS AND OLIGOPROGRESSION

Oligometastic progression (or solitary metastases) can justify ablative treatment for metastatic treatment. When such a strategy is discussed, it is important to notice that definition of oligometastases is not consensual both in terms of clinical presentation than on the biological basis. Does a specific biological background truly exist and are there markers that could predict for additional occult disease and its oligo or polymetastatic profile in individuals with demonstrated oligometastasis. This article provides a summary of the state of the art in this field and highlights some current areas of controversies.

Abdominal metastases from colorectal cancer: intraperitoneal therapy

Patients with peritoneal metastasis from colorectal cancer represent a distinct subset with regional disease rather than systemic disease. They often have poorer survival outcomes with systemic chemotherapy. Optimal cytoreductive surgery and intraperitoneal chemotherapy (IPC) offers such patients a more directed therapy with improved survival. In this review, we discuss the diagnosis, evaluation and classification, as well as rational for treatment of peritoneal carcinomatosis (PC) secondary to colorectal cancer.

Intensive surveillance following curative treatment of colorectal cancer allows effective treatment of recurrence even if limited to 4 years

BACKGROUND

Current evidence suggests a survival benefit to post-operative surveillance following curative colorectal cancer resection; however, there is still no consensus on the optimal duration and form.

OBJECTIVES

The objective is to prospectively audit outcomes of an intensive colorectal cancer follow-up scheme for time to recurrence and survival.

METHODS

We used a surveillance protocol designed to incorporate regular clinical, biochemical, radiological and endoscopic measures at pre-defined intervals.

SETTING

The setting was a Department of Colorectal Surgery in a Tertiary Academic Centre. Follow-up was led by specially trained colorectal nurses in conjunction with surgeons.

PATIENTS

Consecutive patients who had undergone curative treatment for colorectal cancer were included in this study.

MAIN OUTCOMES

Outcomes were measured in terms of overall survival and disease recurrence.

RESULTS

There were 436 patients entered into follow-up, all treated with curative intent. Mean age 65.9 years (SD 12.9 years) and 240 male (55.0 %). Ninety-four patients (21.5 %) with stage I disease, 119 (27.3 %) stage IIa, 30 (6.9 %) stage IIb, 18 (4.1 %) stage IIIa, 78 (17.9 %) stage IIIb, 45 (10.4 %) stage IIIc and 52 (11.9 %) stage IV. Overall median survival was 37.5 months for all patients, (range 0.0-207.8 months). Ninety-two (21.1 %) cancer-related deaths were recorded during the course of the study. The overall 5-year actuarial cancer-related survival was 81.7 %. There was a 40.3 % 5-year actuarial survival was recorded in patients with 39 a recurrence, 57.7 % in patients treated with further curative 40 intent and 27.7 % in patients who received palliative treatment 41 (P < 0.001). Ninety-seven percent of recurrences were detected within 4 years of curative treatment.

CONCLUSIONS

This follow-up protocol confers an 81 % overall 5-year actuarial survival. Our study suggests that surveillance after curative resection can be limited to 4 years, which would lead to detection of over 97 % of all recurrences.

Improving treatment and survival: a population-based study of current outcomes after a hepatic resection in patients with metastatic colorectal cancer

BACKGROUND

Population-based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases.

METHODS

Medicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)-Medicare dataset. Patients were stratified into historical (1991-2001) and current (2002-2009) cohorts. Analyses compared treatment, peri-operative outcomes and survival.

RESULTS

Of 31.574 patients with metastatic colorectal cancer to the liver, 14,859 were in the current cohort treated after 2002 and 16,715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period (P < 0.001) with pre/post change from 6.5% pre-2002 to 7.5% currently (P < 0.001). Over time, haemorrhagic and infectious complications declined (both P ≤ 0.047), but 30-day mortality was similar (3.5% versus 3.9%, P = 0.660). After adjusting for predictors of survival, the use of a hepatic resection [hazard ratio (HR) = 0.40, 95% confidence interval (CI): 0.38-0.42, P < 0.001] and treatment after 2002 (HR = 0.88, 95% CI: 0.86-0.90, P < 0.001) were associated with a reduced risk of death.

CONCLUSIONS

Case identification using International Classification of Diseases, 9th Revision (ICD-9) codes is imperfect; however, comparison of trends over time suggests an improvement in multimodality therapy and survival in patients with colorectal metastases to the liver.

γδ T cells as a potential tool in colon cancer immunotherapy

γδ T cells are capable of recognizing tumor cells and exert potent cellular cytotoxicity against a large range of tumors, including colon cancer. However, tumors utilize numerous strategies to escape recognition or killing by patrolling γδ T cells, such a downregulation of NKG2D ligands, MICA/B and ULBPs. Therefore, the combined upregulation of T-cell receptorand NKG2D ligands on tumor cells and induction of NKG2D expression on γδ T cells may greatly enhance tumor killing and unlock the functions of γδ T cells. Here, we briefly review current data on the mechanisms of γδ T-cell recognition and killing of colon cancer cells and propose that γδ T cells may represent a promising target for the design of novel and highly innovative immunotherapy in patients with colon cancer.

Is Stereotactic Body Radiotherapy (SBRT) in lymph node oligometastatic patients feasible and effective?

OBJECTIVES

To review the available data about stereotactic body-radiotherapy (SBRT) for oligometastatic lymph node cancer recurrence.

METHODS

The inclusion criteria for this study were as follows: Medline search for the (1) English language (2) full paper (abstracts were excluded) on (3) adult oligometastatic solid cancer recurrence limited to lymph node that underwent SBRT (4) outcome data available and (5) published up to the 30th April 2014.

RESULTS

38 papers fulfilling the inclusion criteria have been found: 7 review articles and 31 patient series (20 and 11 retrospective and prospective studies, respectively) including between 1 and 69 patients (636 lymph nodes). Twelve articles reported only lymph node SBRT while in 19 - all types of SBRT including lymph node SBRT were presented. Two-year local control, 4-year progression free survival and overall survival was of up to 100%, 30% and 50%, respectively. The progression was mainly out-field (10-30% of patients had a recurrence in another lymph node/nodes). The toxicity was low with mainly mild acute events and single grade 3-4 late events. When compared to SBRT for any oligometastatic cancer, SBRT for lymph node recurrence carried better prognosis and showed lower toxicity.

CONCLUSIONS

SBRT is a feasible approach for oligometastatic lymph node recurrence, offering excellent in-field tumor control with low toxicity profile. The potential abscopal effect has been hypothesized as a basis of these findings. Future studies are warranted to identify the patients that benefit most from this treatment. The optimal combination with systemic treatment should also be defined.

Patterns of recurrence following complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer

BACKGROUND AND OBJECTIVES

CytoReductive Surgery (CRS) combined with Hyperthermic IntraPEritoneal Chemotherapy (HIPEC) has an established role in the treatment of peritoneally metastasized colorectal cancer. The aim of the study was to describe the recurrence patterns and to evaluate treatment options and related survival.

METHODS

Patients treated with CRS + HIPEC in two tertiary referral centers between April 2005 and March 2013 were analyzed retrospectively. The prognostic value of several parameters was calculated using Cox Regression.

RESULTS

One hundred thirty two of 287 patients (46%) with peritoneal carcinomatosis treated with complete CRS and HIPEC were diagnosed with recurrent disease, after a median disease-free interval of 11.4 months. Recurrence were locoregional (43%), distant metastases (26%) or both (31%). Thirty-two of the 132 patients with recurrences (24%) were treated surgically with curative intent, which extended the median survival from 12 months to 43 months, compared to palliative treatment (best supportive care or chemotherapy; P < 0.001). Initial nodal status (P = 0.01) and the number of affected regions at initial CRS (P = 0.02) were significantly correlated to survival after disease recurrence.

CONCLUSION

Disease recurrence after CRS and HIPEC is common; in selected patients, an aggressive surgical approach may be beneficial and extend survival.

MiR-200a regulates epithelial to mesenchymal transition-related gene expression and determines prognosis in colorectal cancer patients

Background:

MicroRNAs (miRNAs) regulate the biological properties of colorectal cancer (CRC) cells and might serve as potential prognostic factors and therapeutic targets. In this study, we therefore globally profiled miRNAs associated with E-cadherin expression in CRC cells in an attempt to identify miRNAs that are associated with aggressive clinical course in CRC patients.

Methods:

Two CRC cell lines (Caco-2 and HRT-18) with different E-cadherin expression pattern were profiled for differences in abundance for more than 1000 human miRNAs using microarray technology. One of the most differentially expressed miRNAs, miR-200a was evaluated for its prognostic role in a cohort of 111 patients and independently validated in 217 patients of the Cancer Genome Atlas data set. To further characterise the biological role of miR-200a expression in CRC, in vitro miR-200a inhibition and overexpression were performed and the effects on cellular growth, apoptosis and epithelial–mesenchymal transition (EMT)-related gene expression were explored.

Results:

In situ hybridisation specifically localised miR-200a in CRC cells. In both cohorts, a low miR-200a expression was associated with poor survival (P<0.05). Multivariate Cox regression analysis identified low levels of miR-200a expression as an independent prognostic factor with respect to cancer-specific survival (HR=2.04, CI=1.28–3.25, P<0.002). Gain and loss of function assays for miR-200a in vitro led to a significantly differential and converse expression of EMT-related genes (P<0.001.) A low expression of miR-200a was also observed in cancer stem cell-enriched spheroid growth conditions (P<0.05).

Conclusions:

In conclusion, our data suggest that low miR-200a expression is associated with poor prognosis in CRC patients. MiR-200a has a regulatory effect on EMT and is associated with cancer stem cell properties in CRC.

F-18 FDG PET/CT in the assessment of patients with unexplained CEA rise after surgical curative resection for colorectal cancer

PURPOSE

We evaluated the role of quantitative assessment by maximum standardized uptake value (SUVmax) on F-18 fluorodeoxyglucose [F-18]FDG positron emission tomography/computed tomography (PET/CT) in stratifying colorectal cancer (CRC) patients with unexplained carcinoembryonic antigen (CEA) rise after surgical curative resection.

MATERIAL AND METHODS

Forty asymptomatic patients (mean age, 64 ± 12 years) with previous CRC and current serum CEA levels >5 ng/ml underwent [F-18] FDG PET/CT 13 ± 3 months after complete surgical resection. The SUVmax was registered on anastomosis and peri-anastomotic tissue lesions, if present. The patients were followed for 24 ± 9 months thereafter. Re-intervention, evidence of newly discovered distant metastases, and death were recognized as main events and constituted surrogate end points. The receiver-operator-curve (ROC) analysis was performed to estimate the optimal SUVmax cut-off to predict patients at high risk of main events. PET/CT results were then related to disease outcome (overall survival; OS).

RESULTS

The mean SUVmax at the anastomotic site was 6.2 ± 3 (range 2.6-15). At multivariate logistic regression analysis, the anastomotic SUVmax remained as the only significant contributor to the prediction of the events (p = 0.004; OR 1.97). The ROC analysis recognized that the optimal threshold of SUVmax to differentiate patients was 5.7. A worse OS was observed in patients presenting with a SUVmax greater than 5.7 as compared to those having lesser (median survival: 16 vs. 31 months; p = 0.002).

CONCLUSIONS

The quantitative assessment by SUVmax on [F-18]FDG PET/CT may be helpful in patients presenting with unexplained CEA rise after curative resection of CRC, by identifying those at risk of main events.

Salvage therapy of small volume prostate cancer nodal failures: a review of the literature

New imaging modalities may be useful to identify prostate cancer patients with small volume, limited nodal relapse ("oligo-recurrent") potentially amenable to local treatments (radiotherapy, surgery) with the aim of long-term control of the disease, even in a condition traditionally considered prognostically unfavorable. This report reviews the new diagnostic tools and the main published data about the role of surgery and radiation therapy in this particular subgroup of patients.

Impact of metastatic colorectal cancer stage and number of treatment courses on patient health care costs and utilization

BACKGROUND

Advances in colorectal cancer (CRC) treatment and improved survival rates have led to higher costs associated with treating CRC.

OBJECTIVE

To examine health care costs and utilization by initial CRC stage at diagnosis and the number of lines of treatment received by patients with metastatic CRC.

METHODS

Adult patients with a diagnosis of CRC made from January 1, 2005 to May 31, 2010 were identified from the Oncology Management registry. Patients with stage IV CRC at initial diagnosis or who had advanced to stage IV CRC at the time of the study were included. Registry data included initial CRC stage and the date of diagnosis. Linked health care claims from a large US health insurance database affiliated with Optum were used to identify health care costs and patient characteristics. Multivariate regression analysis was used to estimate total 4-year health care costs stratified by stage and adjusted for patient characteristics. Follow-up ended at patient death, disenrollment from the health care plan, or study end (November 30, 2010).

RESULTS

A total of 598 patients, followed for an average of 653 days after first evidence of metastasis, were included. At initial diagnosis, 91 patients had stages 0 to III CRC, 310 patients had stage IV CRC, and 197 patients had an unknown stage of CRC. The mean unadjusted total cost per patient (medical + pharmaceutical costs) was $252 200; outpatient hospital visits (excluding radiation and surgery) contributed most to the total cost, at a mean cost of $71 334. Hospitalization costs, with or without surgery (mean, $56 862), accounted for 33% of the $176 135 unadjusted mean cost for medical services (ambulatory visits [office and outpatient], emergency department visits, laboratory/radiology services, and inpatient admission). Chemotherapy and biologics were also costly (mean, $31 112 and $38 276, respectively). A general linear model analysis of estimated 4-year total costs showed that both CRC stage at diagnosis and the number of lines of treatment after metastasis had a statistically significant association with cost (P < 0.001).

CONCLUSION

Variables that had a statistically significant association with cost (P < 0.05) were sex, age group, and follow-up Charlson Comorbidity Index score after metastases. After adjusting for the number of lines of treatment received, total 4-year costs were highest among patients who presented with stage IV CRC and lowest among patients who presented with stage III CRC and developed metastatic disease.

Designing liver resections and pushing the envelope with resections for hepatic colorectal metastases

Current concepts in the management of hepatic metastases have changed dramatically over the past two decades. Multidisciplinary therapies including chemotherapy, surgery, and regional therapy have alone and in combination significantly improved the survival of patients with metastatic colorectal cancer. Conditions that were previously considered hopeless and treated merely for palliation can now be approached with curative intent. In this paper, we review the surgical treatment for colorectal cancer liver metastasis (CRLM) and describe a paradigm-shift in the management of complex heretofore-considered unresectable CRLM. Utilizing advanced multidisciplinary treatment strategies has improved the prognosis of patients with stage IV colorectal cancer to the point where we may question whether CRLM are now a chronic disease.

A systematic review of repeat hepatectomy for recurrent colorectal liver metastases

BACKGROUND

Selected patients with recurrent colorectal liver metastases (CLM) may be resectable by repeat hepatectomy approach. In this review, we aim to collate and evaluate the published evidence for repeat hepatectomy in patients with recurrent CLM.

METHODS

Searches of the Medline and Embase databases were undertaken to identify studies of repeat hepatectomy in patients with recurrent CLM focusing on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

RESULTS

Twenty-two observational studies were reviewed. A total of 1,610 patients underwent second hepatectomy for recurrent CLM. The median percentage of extra-hepatic disease was 15 % (range, 0-39 %). Preoperative chemotherapy was reported in 5/22 studies. Major liver resection was undertaken in 25 % (range, 9-59 %) of patients and the R0 resection rate was 90 % (range, 77-96 %). Postoperative morbidity and mortality after the second hepatectomy were 23 % and 1.2 %, respectively. Recurrence rate after second hepatectomy was 63.9 % (range, 42-91 %) with a median follow-up period of 32 months (range, 19-59 months). Median overall survival was 35 months (range, 19-56 months). The 3-year and 5-year overall survival rates were 55 % (range, 11-82 %) and 42 % (range, 31-73 %), respectively.

CONCLUSION

Second hepatectomy is safe and feasible in selected patients with recurrent CLM and is associated with acceptable perioperative and survival outcomes. Future prospective studies are required to further define the patient selection criteria for repeat hepatectomy and the exact role of perioperative chemotherapy.

CyberKnife robotic image-guided stereotactic radiotherapy for oligometastic cancer : A prospective evaluation of 95 patients/118 lesions

PURPOSE

To evaluate the outcome of robotic CyberKnife (Accuray Inc. Sunnyvale, USA)-based stereotactic radiotherapy (CBK-SRT) for oligometastic cancer patients.

PATIENTS AND METHODS

Between May 2007 and December 2009, 95 patients with a total of 118 lesions underwent CBK-SRT (median dose 24 Gy in 3 fractions).

INCLUSION CRITERIA

adult patients with limited volume cancer; suitability for SRT but not for other local therapies. Primary diagnoses included breast, lung, head and neck, gastrointestinal and other malignancies. Prostate cancer patients were excluded. Concomitant systemic therapy was given in 40 % of cases and median follow-up was 12 months. Toxicity and tumor response were evaluated using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) Scale and Response Evaluation Criteria in Solid Tumors RECIST.

RESULTS

Toxicity was rare and observed mainly in patients with comorbidities or uncontrolled cancer. Out of 87 evaluable lesions, complete radiological response, partial response, stabilization and progressive disease were observed in 15 (17 %), 25 (29 %), 34 (39 %) and 13 (15 %) lesions, respectively. Upon restricting the analysis to lesions treated with CBK-SRT alone (no concomitant therapy), response- and local control (LC) rates remained similar. Actuarial 3-year in-field progression-free survival- (i.e. LC), progression-free survival- (PFS) and overall-survival (OS) rates were 67.6, 18.4, and 31.2 %, respectively. LC was reduced in cases of early recurrence. OS- and cause-specific survival (CSS) rates were significantly lower in patients treated for visceral lesions. Failures were predominantly out-field.

CONCLUSION

CBK-SRT is a feasible therapeutic approach for oligometastastic cancer patients that provides long-term in-field tumor control with a low toxicity profile. Further investigations should focus on dose escalation and optimization of the combination with systemic therapies.

Pre-transplant malignancy: an analysis of outcomes after thoracic organ transplantation

BACKGROUND

Pre-transplant malignancy (PTM) is a relative contraindication to organ transplantation. Studies examining the effect of PTM on outcomes after lung transplantation (LTx) or orthotopic heart transplantation (OHT) are limited. We evaluated the effect of PTM on outcomes after LTx and OHT.

METHODS

We retrospectively reviewed primary adult LTx and OHT recipients in the United Network for Organ Sharing database. Primary stratification was by PTM and secondary stratification by tumor type. Matched cohorts (2:1) and multivariable Cox proportional hazards regression models were used to evaluate mortality.

RESULTS

From 2000 to 2011, 13,613 adults underwent LTx and 19,817 underwent OHT. PTM was present in 740 LTx patients (5.4%) and in 1,117 OHT patients (5.6%). On unadjusted analysis, LTx patients and OHT patients with PTM had similar 30-day, 1-year, and 5-year survivals (p<0.05) compared with patients with no PTM. These findings persisted after risk-adjustment . No tumor types were associated with increased mortality in LTx patients. OHT patients with leukemia, lymphoma, or myeloma (LLM) had a significant increase in univariate mortality at 30 days (hazard ratio [HR], 1.82; p = 0.04), 1 year (HR, 1.93; p<0.001), and 5 years (HR, 1.54; p = 0.01). Matched cohort analysis revealed comparable outcomes in LTx patients but confirmed increased univariate 1-year mortality (HR, 1.89; p = 0.006) in OHT patients with LLM.

CONCLUSIONS

This large study evaluating the effects of PTM found the incidence of PTM was in LTx 5.4% and in OHT 5.6%. In general, PTM does not increase mortality in either cohort; however, OHT patients with LLM have an increased hazard of mortality. Therefore, carefully selected patients with PTM should not be excluded from LTx or OHT.

Patient and work flow and costs associated with staff time and facility usage at a comprehensive cancer centre in Quebec, Canada--a time and motion study

Background

Mapping patient and work flow and cost analysis studies can help determine the most efficient and cost effective way of providing health services while still maintaining the best standards of care. This study used both time and motion methodology and hospital data to assess the contribution of staff time and facility usage to the overall cost of cancer care during patient visits to a comprehensive cancer centre in Quebec, using metastatic colorectal cancer as a model.

Methods

A workflow diagram was created mapping direct and indirect steps involved during a patient’s physician or treatment (FOLFOX/bevacizumab or XELOX/bevacizumab) visit. Staff were timed as they performed each task and this data together with compensation amounts were used to calculate personnel costs. Mean work times and 95% confidence intervals (CI) were calculated. Operation and maintenance (O&M) costs for the Centre were calculated using information from hospital databases. All costs were presented in constant Canadian dollars for the 2010–2011 fiscal year period.

Results

For physician visits, direct and indirect personnel costs were $9.25 (95%CI:$7.00-$11.51) and O&M costs were $60.21, for a total of $69.46 (95%CI:$67.21-$71.72). For treatment visits, personnel and O&M costs were $71.91 (95%CI:$45.53-$98.29) and $62.00 respectively for a total of $133.91 (95%CI:$107.53-$160.29). When calculated for treatment alone, the total cost was $136.06 (95%CI:$109.16-$162.95) for FOLFOX/bevacizumab and $119.94 (95%CI:$96.89-$142.99) for XELOX/bevacizumab. The highest cumulative personnel costs were for the pharmacists and nurses ($38.87 and $34.82 respectively). Regarding patient flow, total time in between steps was 77.6 and 49.5 minutes for a physician or treatment visit respectively.

Conclusions

This study from a health care provider’s perspective, demonstrated that in the context of increasingly expensive therapies, costs associated with staff time and facility usage do not contribute greatly to the overall cost of treating cancer at this cancer centre. It also illustrated the need for improvements in patient and work flow to reduce wait times in the clinic.

Irinotecan-related cholinergic symptoms in patients with colorectal cancer patients: an analysis of 89 cases

AIM: To observe and analyze irinotecan-related cholinergic symptoms in patients with advanced colorectal cancer.

METHODS: A total of 89 patients with advanced colorectal cancer were assigned to receive two different FOLFIRI regimens. The incidence of cholinergic symptoms was recorded, and the correlation of the development of cholinergic symptoms with clinical characteristics, other adverse effects and chemotherapy regimens was analyzed.

RESULTS: Fifty-three patients developed cholinergic symptoms. From the start of infusion, cholinergic symptoms occurred at a median of 150 min (range: 30 min-25 h) and most of them regressed in 24 h. Prophylactic use of atropine could effectively prevent the development of cholinergic symptoms. Cholinergic symptoms were more common in senile patients (75.9% vs 51.7%, P = 0.029), but were not related with other clinical characteristics such as sex and ECOG score. Patients who developed cholinergic symptoms had a decreasing tendency to develop delayed-onset diarrhea. The regimen containing higher dose of fluorouracil was associated with a higher risk of developing mucocitis (50.0% vs 27.5%, P = 0.029).

CONCLUSION: The incidence rate of irinotecan-related cholinergic symptoms is unexpectedly high. The development of irinotecan-related cholinergic symptoms is not related with other adverse effects such as diarrhea and/or bone marrow depression.