When does curatively treated colorectal cancer recur? An Australian perspective

A systematic review of population-based studies on metachronous metastases of colorectal cancer

BACKGROUND

The occurrence of metachronous metastases (MM) of colorectal (CRC), colon (CC), and rectal (RC) cancer of population-based studies has not been compiled in a systematic review previously.

METHODS

MEDLINE, Embase, and Cochrane Library were searched for primary studies of any design from inception until January 2021 and updated in August 2023 (CRD42021261648). The PRISMA guidelines were adopted, and the Newcastle-Ottawa Quality Assessment Scale used for risk of bias assessment. Outcomes on overall and organ-specific MM were extracted. A narrative analysis followed.

RESULTS

Out of 2143 unique hits, 162 publications were read in full-text and 37 population-based cohort studies published in 1981-2022 were included. Ten studies adopted time-dependent analyses; eight were registry-based and seven had a low risk of bias. Three studies reported 5-year recurrence rate of MM overall of stages I-III; for CRC, it was 20.5%, for CC, it was 18% and 25.6%, and for RC, it was 23%. Four studies reported 5-year recurrence rate of organ-specific MM of stages I-III-for CRC, it was 2.2% and 5.5% for peritoneal metastases and 5.8% for lung metastases and for CC 4.5% for peritoneal metastases. Twenty-seven studies reported proportions of patients diagnosed with MM, but data on the length of follow-up was incomplete and varied widely. Proportions of patients with CRC stages I-III that developed MM overall was 14.4%-26.1% in 10 studies. In relation to the enrollment period, a downward trend may be discernible.

CONCLUSION

Studies adopting a more appropriate analysis were highly heterogeneous, whereas uncertain data of partly inadequate studies may indicate that MM are overall declining.

The health-related quality of life of early-onset colorectal cancer patients: an Australian cross-sectional study

AIM

Early-onset colorectal cancer (EOCRC) patients are more likely to have advanced disease and undergo more aggressive treatment modalities. However, current literature investigating the health-related quality of life (HRQoL) of EOCRC patients is scarce. This study aimed to determine the HRQoL of an Australian cohort of EOCRC patients including a subset who underwent pelvic exenteration (PE) or cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHOD

A cross-sectional study of EOCRC patients treated at the Royal Prince Alfred Hospital, Sydney Australia was performed. Patients were divided into groups based on the time interval from their index operation: ≤2 years and >2 years. HRQoL was evaluated using the SF-36v2 questionnaire.

RESULTS

A total of 50 patients were included. For patients ≤2 years from surgery, the median physical component summary (PCS) and mental health component summary (MCS) scores were 53.3 (36.4-58.9) and 47.3 (37.5-55.7). In the >2 years group, the median PCS and MCS scores were 50.6 (43.3-57.7) and 50.2 (39.04-56.2), respectively. Stage I (vs. stage II) disease and emergency (vs. elective) surgery conferred poorer PCS scores in patients ≤2 years from surgery. No other variables impacted PCS or MCS scores in EOCRC patients in either group.

CONCLUSIONS

HRQoL of EOCRC patients was equivocal to the Australian population. Having an earlier stage of diagnosis and emergency index operation was associated with poorer levels of physical functioning in patients ≤2 years from surgery. However, because of the limitations of this study, these findings require validation in future large-scale prospective research.

Identifying Recurrences Among Non-Metastatic Colorectal Cancer Patients Using National Health Data Registries: Validation and Optimization of a Registry-Based Algorithm in a Modern Danish Cohort

Purpose

Colorectal cancer (CRC) recurrence is not routinely recorded in Danish health data registries. Here, we aimed to revalidate a registry-based algorithm to identify recurrences in a contemporary cohort and to investigate the accuracy of estimating the time to recurrence (TTR).

Patients and Methods

We ascertained data on 1129 patients operated for UICC TNM stage I-III CRC during 2012-2017 registered in the CRC biobank at the Department of Molecular Medicine, Aarhus University Hospital, Denmark. Individual-level data were linked with data from the Danish Colorectal Cancer Group database, Danish Cancer Registry, Danish National Registry of Patients, and Danish Pathology Registry. The algorithm identified recurrence based on diagnosis codes of local recurrence or metastases, the receipt of chemotherapy, or a pathological tissue assessment code of recurrence more than 180 days after CRC surgery. A subgroup was selected for validation of the algorithm using medical record reviews as a reference standard.

Results

We found a 3-year cumulative recurrence rate of 20% (95% CI: 17-22%). Manual medical record review identified 80 recurrences in the validation cohort of 522 patients. The algorithm detected recurrence with 94% sensitivity (75/80; 95% CI: 86-98%) and 98% specificity (431/442; 95% CI: 96-99%). The positive and negative predictive values of the algorithm were 87% (95% CI: 78-93%) and 99% (95% CI: 97-100%), respectively. The median difference in TTR (TTR_{Medical_chart}-TTR_algorithm) was -8 days (IQR: -21 to +3 days). Restricting the algorithm to chemotherapy codes from oncology departments increased the positive predictive value from 87% to 94% without changing the negative predictive value (99%).

Conclusion

The algorithm detected recurrence and TTR with high precision in this contemporary cohort. Restriction to chemotherapy codes from oncology departments using department classifications improves the algorithm. The algorithm is suitable for use in future observational studies.

Proteomics and phosphoproteomics analysis of tissues for the reoccurrence prediction of colorectal cancer

BACKGROUND

Many stage II/III colorectal cancer (CRC) patients may relapse after routine treatments. Aberrant phosphorylation can regulate pathophysiological processes of tumors, and finding characteristic protein phosphorylation is an efficient approach for the prediction of CRC relapse.

RESEARCH DESIGN AND METHODS

We compared the tissue proteome and phosphoproteome of stage II/III CRC patients between the relapsed group (n = 5) and the non-relapsed group (n = 5). Phosphopeptides were enriched with Ti⁴⁺-IMAC material. We utilized label-free quantification-based proteomics to screen differentially expressed proteins and phosphopeptides between the two groups. Gene Ontology (GO) analysis and Ingenuity Pathway Analysis (IPA) were used for bioinformatics analysis.

RESULTS

The immune response of the relapsed group (Z-score -2.229) was relatively poorer than that of the non-relapsed group (Z-score 1.982), while viability of tumor was more activated (Z-score 2.895) in the relapsed group, which might cause increased relapse risk. The phosphorylation degrees of three phosphosites (phosphosite 1362 of TP53BP1, phosphosite 809 of VCL and phosphosite 438 of STK10) might be reliable prognostic biomarkers.

CONCLUSIONS

Some promising proteins and phosphopeptides were discovered to predict the relapse risk in postoperative follow-ups.

The utility of surveillance CT scans in a cohort of survivors of colorectal cancer

PURPOSE

Colorectal cancer (CRC) is the third most common cancer worldwide. After curative intent treatment, international guidelines recommend surveillance protocols which include annual CT chest, abdomen and pelvis (CAP) and serum carcinoembryonic antigen (CEA) monitoring which aim to improve overall survival by early detection of recurrence. Despite the widespread recommendations, robust evidence of an overall survival benefit is lacking. Our study aimed to quantify the utility of annual CT CAP as a surveillance modality in comparison to the rate of potentially harmful false-positive and incidental findings.

METHODS

High-risk stage II and stage III CRC patients were retrospectively identified from the Sydney Cancer Survivorship Centre database. Findings on surveillance CT were classified into confirmed recurrence or the potentially harmful findings of (a) false-positive or (b) clinically significant incidental finding.

RESULTS

A total of 376 surveillance CT CAPs were performed in 174 survivors between 12 September 2013 and 30 June 2020. The recurrence rate during the study period was 23/174 (13.2%) with the majority of recurrences detected by abnormal CEA (14/23, 60.9%) versus surveillance CT (4/23, 17.4%), with the remainder identified on non-surveillance CT (5/23, 21.7%). Curative intent surgery was performed in 12/23 people with CRC recurrence. Surveillance CT was shown to result in high levels of false-positive (31/174, 17.8% of patients) or clinically significant incidental findings (30/174, 17.2% of patients). The risk of identifying these potentially harmful findings was ongoing with each year of surveillance CT.

CONCLUSION

Surveillance CT was associated with low detection rates and high rates of potentially harmful findings bringing this surveillance modality under further scrutiny.

IMPLICATIONS FOR CANCER SURVIVORS

An increased emphasis should be placed on educating survivors on the benefits of surveillance CT weighed against the risk of potentially harmful findings.

Proteomics analysis of tissue small extracellular vesicles reveals protein panels for the reoccurrence prediction of colorectal cancer

Many stage II/III colorectal cancer (CRC) patients might relapse after routine treatment and there is a great need of reliable biomarkers for predicting its reoccurrence risk. Small extracellular vesicles (sEVs) could regulate many pathophysiological processes of diseases, which are promising source for biomarker discovery. In this study, we implemented a MS-based workflow that utilizes data-dependent acquisition (DDA) for discovery and parallel reaction monitoring (PRM) for validation of high relapse risk related biomarkers. We compared the protein profiling of sEVs from CRC tissues and paired adjacent tissues in relapsed group (n = 5) and non-relapsed group (n = 5). 417 and 1140 proteins were differentially expressed between the tumor tissues and adjacent tissues in relapsed group and non-relapsed group, respectively. Bioinformatics analysis showed that immunity of the relapsed patients (Z-score - 0.69) was relatively poorer than the non-relapsed patients (Z-score 2.59), while chronic inflammatory response was activated (Z-score 3.0), which might enhance the reoccurrence risk. Four proteins (HLA-DPA1, S100P, NUP205, PCNA) showed significant expressions in the adjacent tissues of the relapsed group by PRM validation. ROC analysis of HLA-DPA1 (AUC = 0.96) achieved the best classification accuracy in separating the relapsed group and the non-relapsed group. Our data demonstrate that tissue-derived sEVs harbor prognostic proteomic signatures of CRC. SIGNIFICANCE: In this research, our proteomics analysis of tissue sEVs revealed that poor immunity as well as chronic inflammatory of the CRC relapsed patient likely lead to poor prognosis and high risk of reoccurrence. The significant expression levels of four proteins (HLA-DPA1, S100P, NUP205, PCNA) in the adjacent tissues of the relapsed group might be used to predict the risk of relapse in postoperative follow-ups.

Results of systematic second-look surgery plus hipec in perforated or pt4 colon cancer. Case series

Background

Perforated or pT4 colonic tumors have a bad prognosis with a high rate of relapse, including peritoneal relapse (20–30%). Our aim is to analyze the effectiveness of Second Look surgery (SLS) + hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients for early treatment of peritoneal relapse (PR) or for preventing it.

Patients and methods

Patients previously operated for colon cancer, either pT4 or perforated (M0), with no evidence of disease at any level after adjuvant chemotherapy, who undergo systematic SLS + HIPEC (Oxaliplatin 30 min) one year after the initial surgery.

Results

Since February 2014 to July 2018, we performed SLS + HIPEC in 42 patients with M0, either pT4 (n = 33) or perforated (n = 9) colon cancer. Although during SLS there were suspicious lesions in 15 cases (37.5%), they were histologically confirmed in only 4 (9.5%). Histologically confirmed peritoneal relapse (PR) rate at SLS was 6% in pT4 (2/33) and 22.2% in perforated tumors (2/9). Prophylactic HIPEC was performed in all the cases. There was no postoperative mortality. Grade III-IV morbidity occurred in 19% (8/42). With a median follow-up of 33.8 months after primary tumor surgery, 6/42 patients (14.3%) presented peritoneal relapse (PR). 3-year peritoneal disease free survival was 86%, with 3-year disease free survival of 78.6% and 5-year overall survival (OS) of 97.4%.

Conclusion

Peritoneal relapse and survival rates are remarkable in these groups of, a priori, very bad prognosis, which could suggest a beneficial effect of HIPEC.

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Prospective study trying to decrease peritoneal relapse in perforated or pT4 CRC.

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20–30% of perforated or pT4 CRC develop peritoneal metastases in the follow-up.

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We find peritoneal disease at Second Look surgery before seen in the image tests.

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Second-Look Surgery + HIPEC decreases peritoneal relapse and gets better survival.