The Conventional Technique Versus the No-touch Isolation Technique for Primary Tumor Resection in Patients With Colon Cancer (JCOG1006): A Multicenter, Open-label, Randomized, Phase III Trial

Changes to circulating tumor cells in the central vein during laparoscopic versus transanal endoscopic surgeries for rectal cancer: can surgical approach make a difference?

Background

The oncological safety of transanal total mesorectal excision (taTME) remains uncertain, and its special surgical approach may contribute to tumor cell dissemination. Thus, we conducted a study to investigate the impact of surgical approach on circulating tumor cell (CTC) counts and phenotypes in rectal cancer.

Methods

This is a prospective randomized controlled study (ClinicalTrials: NCT05109130). The patients were randomized to either the taTME (n = 49) or laparoscopic TME (laTME) (n = 48) groups. Blood samples were collected from the central vein to measure CTC counts and phenotypes at three time points: preoperative (t1), immediately post-tumor removal (t2), and one week post-surgery (t3). The effect of surgical procedure on CTCs at each time point was analyzed, with the primary endpoint being the change in CTC counts from t1 to t3 for each surgical approach. This study adheres to Consolidated Standards of Reporting Trials Guidelines.

Results

The baseline clinicopathologic characteristics of the laTME and taTME groups were balanced. The change in CTC count from t1 to t3 was 1.81 ± 5.66 in the laTME group and 2.18 ± 5.53 in the taTME group. The taTME surgery was non-inferior to laTME in terms of changing CTC counts (mean difference [MD]: -0.371; 95% confidence interval [CI]: -2.626 to 1.883, upper-sided 95% CI of 1.883 < 2, non-inferiority boundary value). Compared with that at t1, the CTC count at t2 did not change significantly. However, higher CTC counts were detected at t3 than at t2 in the taTME (P = 0.032) and laTME (P = 0.003) groups. From t1 to t3, CTC counts significantly increased in both the taTME (P = 0.008) and laTME (P = 0.031) groups. There were no significant differences in CTC phenotype changes between the two groups from t1 to t3.

Conclusions

Compared with laTME, taTME did not affect CTC counts and phenotypes. Our findings indicate that taTME is not inferior to laTME in terms of CTC changes from an oncological perspective.

Localized colorectal cancer database integrating 4 randomized controlled trials; (JCOG2310A)

Although phase III randomized controlled trials (RCTs) represent the most robust statistical approach for answering clinical questions, they require massive expenditures in terms of time, labor, and funding. Ancillary and supplementary analyses using RCTs are sometimes conducted as alternative approaches to answering clinical questions, but the available integrated databases of RCTs are limited. In this background, the Colorectal Cancer Study Group (CCSG) of the Japan Clinical Oncology Group (JCOG) established a database of ancillary studies integrating four phase III RCTs (JCOG0212, JCOG0404, JCOG0910 and JCOG1006) conducted by the CCSG to investigate specific clinicopathological factors in pStage II/III colorectal cancer (JCOG2310A). This database will be updated by adding another clinical trial data and accelerating several analyses that are clinically relevant in the management of localized colorectal cancer. This study describes the details of this database and planned and ongoing analyses as an initiative of JCOG cOlorectal Young investigators (JOY).

The safety and short-term effect of mixed approach in laparoscopic right hemicolectomy for right colon cancer compared with middle approach: a retrospective study

PURPOSE

To investigate whether the mixed approach is a safe and advantageous way to operate laparoscopic right hemicolectomy.

METHODS

A retrospective study was performed on 316 patients who underwent laparoscopic right hemicolectomy in our center. They were assigned to the middle approach group (n = 158) and the mixed approach group (n = 158) according to the surgical approaches. The baseline data like gender、age and body mass index as well as the intraoperative and postoperative conditions including operation time, blood loss, postoperative hospital stay and complications were analyzed.

RESULTS

There were no significant differences in age, sex, BMI, ASA grade and tumor characteristics between the two groups. Compared with the middle approach group, the mixed approach group was significantly lower in terms of operation time (217.61 min vs 154.31 min, p < 0.001), intraoperative blood loss (73.8 ml vs 37.97 ml, p < 0.001) and postoperative drainage volume. There was no significant difference in the postoperative complications like postoperative anastomotic leakage, postoperative infection and postoperative intestinal obstruction.

CONCLUSIONS

Compared with the middle approach, the mixed approach is a safe and advantageous way that can significantly shorten the operation time, reduce intraoperative bleeding and postoperative drainage volume, and does not prolong the length of hospital stay or increase the morbidity postoperative complications.

Liquid biopsy after resection of pancreatic adenocarcinoma and its relation to oncological outcomes. Systematic review and meta-analysis

BACKGROUND

It has been hypothesised that manipulation during surgery releases tumoral components into circulation. We investigate the effect of surgery on plasma-borne DNA biomarkers and the oncological outcomes in resectable pancreatic ductal adenocarcinoma (PDAC). We also compare non-touch isolation techniques (NTIT) with standard techniques.

MATERIALS AND METHODS

We performed a systematic review and a meta-analysis of studies analysing liquid biopsy as circulating tumour DNA (ctDNA), circulating tumour cells (CTCs), and messenger RNA (mRNA) in resectable PDAC patients who underwent surgery and its association with overall survival (OS) and disease-free survival (DFS). Research in EMBASE, Web of Science and PubMed was performed. The ctDNA shift negative-to-positive (ctDNA -/+) or ctDNA shift positive-to-negative (ctDNA +/-) before and after surgery was evaluated.

RESULTS

Twelve studies comprising 413 patients were included. Shorter OS and DFS were identified in patients with positive ctDNA status before (HR = 2.28, p = 0.005 and HR = 2.16, p = 0.006) or after surgery (HR = 3.88, p < 0.0001 and HR = 3.81, p = 0.03), respectively. Surgical resection increased the rate of ctDNA +/-. There were no differences in OS or DFS in the ctDNA +/- group compared with ctDNA +/+ or ctDNA -/+. However, there was a trend to shorter OS in the ctDNA -/+ group (HR = 5.00, p = 0.09). No differences between NTIT and standard techniques on liquid biopsy status were found.

CONCLUSION

Positive ctDNA in the perioperative period is associated with a worse prognosis. Surgical resection has a role in the negativisation of liquid biopsy status. More studies are needed to assess the potential of minimally invasive techniques on ctDNA dynamics.

Influence of the no-touch isolation technique on oncologic outcomes for patients with colon cancer undergoing curative surgery: A systematic review and meta-analysis

OBJECTIVE

To explore the influence of the no-touch isolation technique (NTIT) on oncologic outcomes for patients with colon cancer (CC) undergoing curative surgery.

BACKGROUND

Although several studies have investigated this topic, there have been no meta-analyses exploring the influence of NTIT on oncologic outcomes for these patients.

METHODS

We performed a comprehensive electronic literature search of studies published prior to March 2022 to identify those that compared oncologic outcomes for patients with CC who did or did not undergo NTIT. We conducted a meta-analysis using a random-effects model to calculate risk ratio (RRs) and 95% confidence intervals (CIs), analyzing heterogeneity using I2 statistics.

RESULTS

Four studies involving a total of 2885 patients with CC who underwent curative surgery met the inclusion criteria for this meta-analysis. The 5-year overall survival (OS) rate was 76.6% for patients with CC who underwent NTIT and 77.2% for those who did not. A meta-analysis of the 3 studies that reported 5-year OS revealed no significant difference between groups (RR, 0.84; 95% CI, 0.62-1.16; P = 0.30; I2 = 70%). In addition, there were no significant differences in 5-year recurrence-free survival (RR, 1.17; 95% CI, 0.93-1.48; P = 0.19; I2 = 45%), and 5-year liver recurrence-free survival (RR, 0.95; 95% CI 0.62, 1.46; P = 0.82; I2 = 65%).

CONCLUSIONS

The use of NTIT has no significant influence on oncologic outcomes for patients with CC undergoing curative surgery.

A randomized phase II study comparing preoperative mFOLFOX6 versus FOLFOXIRI for locally advanced colon cancer: JCOG2006

The prognosis of locally advanced colon cancer (LACC) with surgical resection followed only by adjuvant chemotherapy is poor. Preoperative chemotherapy for LACC patients with risk factors such as cT4bN+ or cT3-4aN2-3 has attracted attention. Here, the authors describe the rationale and design of JCOG2006, a randomized phase II study comparing preoperative chemotherapy with mFOLFOX6 versus FOLFOXIRI for LACC. Their efficacy and safety are evaluated and a determination of which is the more promising treatment will be conducted in a subsequent phase III trial. A total of 86 patients will be accrued from 44 institutions over 2 years. The primary end point is the proportion of patients with a Tumor Regression Score of 0-2, and secondary end points include overall survival, response rate and adverse events. Clinical Trial Registration: jRCTs031210365 (https://jrct.niph.go.jp/).

Intraoperative Diagnosis of Serosal Invasion in Gastric Cancer by Magnifying Endoscopy with Narrow-Band Imaging for Intraoperative Measurement Decision

Purpose: To establish a precise diagnostic method for serosal invasion in gastric cancer (GC) during surgery using therapeutic measures, and facilitate quick decision-making. Methods: A total of 19 GC patients treated in the department of gastrointestinal surgery of Fujian Provincial Hospital between April 2019 and December 2020 were enrolled. An electronic gastroscopy with a magnifying endoscope with narrow-band imaging was used to photograph the serosal surface of the GC lesion site and the normal gastric wall around the lesion during surgery. The endoscopic diagnosis was confirmed on the basis of the microvascular phenotype of the serosal surface and validated by comparison with the pathological diagnosis. Results: Under the specific endoscopy, serosal invasion, including subserosal tissue invasion and serosal layer invasion, was diagnosed by observing the capillary morphology change, and capillary diameter and density increase. According to the pathological diagnosis, the accuracy of serosal invasion diagnosis was 94.7%, the sensitivity was 100%, the specificity was 75%, the positive predictive value was 93.8%, and the negative predictive value was 100%. To further distinguish the subserosal tissue invasion and serosal layer invasion, the magnifying endoscope with narrow-band imaging possessed a 78.9% accuracy by distinguishing irregular changes in microvessels. Conclusions: Magnifying endoscope with narrow-band imaging is less time-consuming than pathological diagnosis. Intraoperative diagnosis using microvascular observation can accurately detect serosal invasion. It is of value for the intraoperative diagnosis in GC patients.

Long Term Outcomes of No-Touch Isolation Principles Applied in Pancreaticoduodenectomy for Treatment of Pancreatic Adenocarcinoma: A Multicenter Retrospective Study with Propensity Score Matching

Background: The recurrence and liver metastasis rates are still high in pancreatic head cancer with curative surgical resection. A no-touch isolation principle in pancreaticoduodenectomy (PD) may improve this situation, however, the exact advantages and efficacy of these principles have not been confirmed. Materials and methods: Among 370 patients who underwent PD, three centers were selected and classified into two groups: the no-touch PD group (n = 70) and the conventional PD group (n = 300). Propensity score matching was used to control for selection bias at a ratio of 1:1. The confounding variables were age, sex, body mass index, adjuvant chemotherapy, carbohydrate antigen 19-9, tumor size and tumor differentiation. Results: Patients in the no-touch PD group had better overall survival (OS) and disease-free survival (DFS) than those in the conventional PD group (OS: 17 vs. 13 months, p = 0.0035, DFS: 15 vs. 12 months, p = 0.087), with lower 1- and 2-year disease-related mortality rates (1-year: 32.9% vs. 47%, p = 0.032; 2-year: 42.5% vs. 82% p = 0.000) and recurrence and liver metastasis rates (1-year: 30.0% vs. 43.3%, p = 0.041; 2-year: 34.3% vs. 48.7%, p = 0.030). Compared with the matched conventional PD group, the no-touch PD group also had a better OS (17 vs. 12 months, p = 0.032). Conclusions: Our study showed the no-touch isolation principle may be a better choice to improve long-term survival for pancreatic cancer patients.

A new approach: Laparoscopic right hemicolectomy with priority access to small bowel mesentery

Background

For laparoscopic right hemicolectomy, the intermediate approach is commonly employed. However, this approach possesses several disadvantages. In this study, we compare priority access to the small bowel mesentery and the intermediate approach.

Methods

The clinical data of 196 patients admitted to the First Hospital of Chongqing Medical University for laparoscopic right hemicolectomy from January 2019 to January 2022 were retrospectively collected and divided into the small bowel mesenteric priority access and traditional intermediate access groups. The operative time, intraoperative bleeding, number of lymph node dissection, postoperative anal venting time, toleration of solid and liquid intake, and postoperative hospital stay and complications were compared between the two different approaches.

Results

In total, 81 cases of small bowel mesenteric priority access and 115 cases of intermediate approach for right hemi-colonic radical resection were compared. The operative time was 191.98 ± 46.05 and 209.48 ± 46.08 min in the small bowel mesenteric priority access and intermediate access groups, respectively; the difference was statistically significant. There were no significant differences in the intraoperative bleeding and lymph node clearance. However, the scatter plot analysis showed that severe intraoperative bleeding was relatively less frequent in the small mesenteric priority access group, compared with that in the intermediate approach group. Additionally, there were no statistically significant differences in the first exhaust and defecation times, hospital stay after operation, toleration of solid and liquid intake, and postoperative complication between the two groups.

Conclusion

In laparoscopic right hemicolectomy, the small bowel mesenteric priority approach can significantly shorten the operation time compared with the intermediate approach. It can reduce intraoperative bleeding and the operation is simple and safe to perform, making it suitable for less experienced surgeons. Therefore, the small bowel mesenteric priority approach has the potential to be a suitable alternative and deserves further clinical promotion and application.

Development of the Peritoneal Metastasis: A Review of Back-Grounds, Mechanisms, Treatments and Prospects

Peritoneal metastasis is a malignant disease which originated from several gastrointestinal and gynecological carcinomas and has been leading to a suffering condition in patients for decades. Currently, as people have gradually become more aware of the severity of peritoneal carcinomatosis, new molecular mechanisms for targeting and new treatments have been proposed. However, due to the uncertainty of influencing factors involved and a lack of a standardized procedure for this treatment, as well as a need for more clinical data for specific evaluation, more research is needed, both for preventing and treating. We aim to summarize backgrounds, mechanisms and treatments in this area and conclude limitations or new aspects for treatments.

Self-expanding metal stent placement and pathological alterations among obstructive colorectal cancer cases

BACKGROUND

Experimental studies suggest that self-expanding metal stents (SEMSs) enhance the aggressive behavior of obstructive colorectal cancer. The influence of SEMS placement on pathological alterations remains to be elucidated.

AIM

To determine whether SEMS placement is associated with molecular or pathological features of colorectal carcinoma tissues.

METHODS

Using a nonbiased molecular pathological epidemiology database of patients with obstructive colorectal cancers, we examined the association of SEMS placement with molecular or pathological features, including tumor size, histological type, American Joint Committee on Cancer (AJCC)-pTNM stage, and mutation statuses in colorectal cancer tissues compared with the use of transanal tubes. A multivariable logistic regression model was used to adjust for potential confounders.

RESULTS

SEMS placement was significantly associated with venous invasion (P < 0.01), but not with the other features examined, including tumor size, disease stage, mutation status, and lymphatic invasion. In both the univariable and multivariable models with adjustment for potential factors including tumor location, histological type, and AJCC-pT stage, SEMS placement was significantly associated with severe venous invasion (P < 0.01). For the outcome category of severe venous invasion, the multivariable odds ratio for SEMS placement relative to transanal tube placement was 19.4 (95% confidence interval: 5.24–96.2). No significant differences of disease-free survival and overall survival were observed between SEMS and transanal tube groups.

CONCLUSION

SEMS placement might be associated with severe venous invasion in colorectal cancer tissue, providing an impetus for further investigations on the pathological alterations by SEMSs in colorectal cancer development.