1
|
Smith HG, Schlesinger NH, Chiranth D, Qvortrup C. The Association of Mismatch Repair Status with Microscopically Positive (R1) Margins in Stage III Colorectal Cancer: A Retrospective Cohort Study. Ann Surg Oncol 2024:10.1245/s10434-024-15595-0. [PMID: 38907136 DOI: 10.1245/s10434-024-15595-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/28/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND There is mounting evidence that microscopically positive (R1) margins in patients with colorectal cancer (CRC) may represent a surrogate for aggressive cancer biology rather than technical failure during surgery. However, whether detectable biological differences exist between CRC with R0 and R1 margins is unknown. We sought to investigate whether mismatch repair (MMR) status differs between Stage III CRC with R0 or R1 margins. METHODS Patients treated for Stage III CRC from January 1, 2016 to December 31, 2019 were identified by using the Danish Colorectal Cancer Group database. Patients were stratified according to MMR status (proficient [pMMR] vs. deficient [dMMR]) and margin status. Outcomes of interest included the R1 rate according to MMR and overall survival. RESULTS A total of 3636 patients were included, of whom 473 (13.0%) had dMMR colorectal cancers. Patients with dMMR cancers were more likely to be elderly, female, and have right-sided cancers. R1 margins were significantly more common in patients with dMMR cancers (20.5% vs. 15.2%, p < 0.001), with the greatest difference seen in the rate of R1 margins related to the primary tumour (8.9% vs. 4.7%) rather than to lymph node metastases (11.6% vs. 10.5%). This association was seen in both right- and left-sided cancers. On multivariable analyses, R1 margins, but not MMR status, were associated with poorer survival, alongside age, pN stage, perineural invasion, and extramural venous invasion. CONCLUSIONS In patients with Stage III CRC, dMMR status is associated with increased risks of R1 margins following potentially curative surgery, supporting the use of neoadjuvant immunotherapy in this patient group.
Collapse
Affiliation(s)
- Henry G Smith
- Abdominalcenter K, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.
| | - Nis H Schlesinger
- Abdominalcenter K, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Deepthi Chiranth
- Department of Pathology, Copenhagen University Hospital - Rigshospital, Copenhagen, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Copenhagen University Hospital - Rigshospital, Copenhagen, Denmark
| |
Collapse
|
2
|
Smith HG, Nilsson PJ, Shogan BD, Harji D, Gambacorta MA, Romano A, Brandl A, Qvortrup C. Neoadjuvant treatment of colorectal cancer: comprehensive review. BJS Open 2024; 8:zrae038. [PMID: 38747103 PMCID: PMC11094476 DOI: 10.1093/bjsopen/zrae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Neoadjuvant therapy has an established role in the treatment of patients with colorectal cancer. However, its role continues to evolve due to both advances in the available treatment modalities, and refinements in the indications for neoadjuvant treatment and subsequent surgery. METHODS A narrative review of the most recent relevant literature was conducted. RESULTS Short-course radiotherapy and long-course chemoradiotherapy have an established role in improving local but not systemic disease control in patients with rectal cancer. Total neoadjuvant therapy offers advantages over short-course radiotherapy and long-course chemoradiotherapy, not only in terms of increased local response but also in reducing the risk of systemic relapses. Non-operative management is increasingly preferred to surgery in patients with rectal cancer and clinical complete responses but is still associated with some negative impacts on functional outcomes. Neoadjuvant chemotherapy may be of some benefit in patients with locally advanced colon cancer with proficient mismatch repair, although patient selection is a major challenge. Neoadjuvant immunotherapy in patients with deficient mismatch repair cancers in the colon or rectum is altering the treatment paradigm for these patients. CONCLUSION Neoadjuvant treatments for patients with colon or rectal cancers continue to evolve, increasing the complexity of decision-making for patients and clinicians alike. This review describes the current guidance and most recent developments.
Collapse
Affiliation(s)
- Henry G Smith
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Dept. of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin D Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Deena Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Camilla Qvortrup
- Department of Oncology, Rigshospital, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
3
|
Aliseda D, Arredondo J, Sánchez-Justicia C, Alvarellos A, Rodríguez J, Matos I, Rotellar F, Baixauli J, Pastor C. Survival and safety after neoadjuvant chemotherapy or upfront surgery for locally advanced colon cancer: meta-analysis. Br J Surg 2024; 111:znae021. [PMID: 38381934 PMCID: PMC10881053 DOI: 10.1093/bjs/znae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/28/2023] [Accepted: 01/06/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Neoadjuvant chemotherapy is increasingly used to treat locally advanced (T3-4 Nx-2 M0) colon cancer due to its potential advantages over the standard approach of upfront surgery. The primary objective of this systematic review and meta-analysis was to analyse data from comparative studies to assess the impact of neoadjuvant chemotherapy on oncological outcomes. METHODS A systematic review was conducted by searching the MEDLINE and Scopus databases. The search encompassed RCTs, propensity score-matched studies, and controlled prospective studies published up to 1 April 2023. As a primary objective, overall survival and disease-free survival were compared. As a secondary objective, perioperative morbidity, mortality, and complete resection were compared using the DerSimonian and Laird models. RESULTS A total of seven studies comprising a total of 2120 patients were included. Neoadjuvant chemotherapy was associated with a reduction in the hazard of recurrence (HR 0.73, 95% c.i. 0.59 to 0.90; P = 0.003) and death (HR 0.67, 95% c.i. 0.54 to 0.83; P < 0.001) compared with upfront surgery. Additionally, neoadjuvant chemotherapy was significantly associated with higher 5-year overall survival (79.9% versus 72.6%; P < 0.001) and disease-free survival (73.1% versus 64.5%; P = 0.028) rates. No significant differences were observed in perioperative mortality (OR 0.97, 95% c.i. 0.28 to 3.33), overall complications (OR 0.95, 95% c.i. 0.77 to 1.16), or anastomotic leakage/intra-abdominal abscess (OR 0.88, 95% c.i. 0.60 to 1.29). However, neoadjuvant chemotherapy was associated with a lower risk of incomplete resection (OR 0.70, 95% c.i. 0.49 to 0.99). CONCLUSION Neoadjuvant chemotherapy is associated with a reduced hazard of recurrence and death, as well as improved overall survival and disease-free survival rates, compared with upfront surgery in patients with locally advanced colon cancer.
Collapse
Affiliation(s)
- Daniel Aliseda
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
| | - Jorge Arredondo
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Carlos Sánchez-Justicia
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Alicia Alvarellos
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
| | - Javier Rodríguez
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Department of Oncology, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
| | - Ignacio Matos
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Department of Oncology, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
| | - Fernando Rotellar
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Jorge Baixauli
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Carlos Pastor
- Department of General Surgery, Division of Colorectal Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona-Madrid, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| |
Collapse
|
4
|
Smith HG, Schlesinger NH, Qvortrup C, Chiranth D, Lundon D, Ben-Yaacov A, Caballero C, Suppan I, Kok JH, Holmberg CJ, Mohan H, Montagna G, Santrac N, Sayyed R, Schrage Y, Sgarbura O, Ceelen W, Lorenzon L, Brandl A. Variations in the definition and perceived importance of positive resection margins in patients with colorectal cancer - an EYSAC international survey. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107072. [PMID: 37722286 DOI: 10.1016/j.ejso.2023.107072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/03/2023] [Accepted: 09/09/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION Microscopically positive resection margins (R1) are associated with poorer outcomes in patients with colorectal cancer. However, different definitions of R1 margins exist. It is unclear to what extent the definitions used in everyday clinical practice differ within and between nations. This study sought to investigate variations in the definition of R1 margins in colorectal cancer and the importance of margin status in clinical decision-making. MATERIALS AND METHODS A 14-point survey was developed by members of The European Society of Surgical Oncology (ESSO) Youngs Surgeons and Alumni Club (EYSAC) Research Academy targeting all members of the multidisciplinary team (MDT) treating patients with colorectal cancer. The survey was distributed on social media, in ESSO's monthly newsletter and via national societies. RESULTS In total, 137 responses were received. Most respondents were from Europe (89.7%), with the majority from Denmark (56.9%). Less than 2/3 of respondents defined R1 margins as the presence of viable cancer cells ≤1 mm of the margin. Only 60% reported that subdivisions of R1 margins (primary tumour vs tumour deposit vs metastatic lymph node) are routinely available. More than 20% of respondents reported that pathology reports are not routinely reviewed at MDT meetings. Less than half of respondents considered margin status in decision-making for type and duration of adjuvant chemotherapy in Stage III colon cancer. CONCLUSION The definitions and perceived clinical importance of microscopically positive margins in patients with colorectal cancer appear to vary. Adoption of an international dataset for pathology reporting may help to standardise current practices.
Collapse
Affiliation(s)
- H G Smith
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Abdominal Center K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark.
| | - N H Schlesinger
- Abdominal Center K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | - C Qvortrup
- Department of Oncology, Rigshospital, University of Copenhagen, Denmark
| | - D Chiranth
- Department of Pathology, Rigshospital, University of Copenhagen, Denmark
| | - D Lundon
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Mount Sinai Department of Urology, New York, United States
| | - A Ben-Yaacov
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Tel-Hashomer, Israel
| | - C Caballero
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Breast International Group, Brussels, Belgium
| | - I Suppan
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Breast Center, Department of Gynaecology, Rottal-Inn-Kliniken Eggenfelden, Germany
| | - J Herrera Kok
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Upper GI Unit, University Hospital of Leon, Spain
| | - C J Holmberg
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sweden
| | - H Mohan
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Peter MacCallum Cancer Centre in Melbourne, Australia
| | - G Montagna
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - N Santrac
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Surgical Oncology Clinic, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - R Sayyed
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of Surgical Oncology, Patel Hospital, Karachi, Pakistan
| | - Y Schrage
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - O Sgarbura
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of Surgical Oncology, Institut du Cancer Montpellier, University of Montpellier, France
| | - W Ceelen
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of GI Surgery and Cancer Research Institute Ghent (CRIG), Ghent University Hospital, Belgium
| | - L Lorenzon
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - A Brandl
- European Society of Surgical Oncology Young Surgeons and Alumni Club (EYSAC), Italy; Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
| |
Collapse
|
5
|
Smith HG, Chiranth DJ, Schlesinger NH. Do differences in surgical quality account for the higher rate of R1 margins to lymph node metastases in right- versus left-sided Stage III colon cancer: A retrospective cohort study. Colorectal Dis 2022; 25:679-687. [PMID: 36565048 DOI: 10.1111/codi.16459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/06/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
AIM Microscopically positive (R1) margins to lymph node metastases (R1LNM) are associated with poorer oncological outcomes in patients with Stage III colon cancer. R1LNM margins are more common in right-sided cancer, although the cause of this phenomenon is unknown. We sought to investigate whether differences in surgical quality account for the higher rate of R1LNM in right-sided cancers. METHOD Patients treated for Stage III colon cancer from 1 January 2016 to 31 December 2018 were identified using the Danish national cancer registry. Indicators of surgical quality (mesocolic resection grade, median lymph node yield, and length to the distal colonic margin) were compared according to tumour site and margin status. RESULTS In all, 1765 patients were included, 981 (55.6%) with right-sided cancers. R1LNM margins were more common in right-sided cancers (14.4% vs. 6.1%, P < 0.001). All three surgical quality indicators were higher in patients with right-sided cancers (mesocolic resection planes 81.7% vs. 69.5%, P < 0.001; median lymph node yield 28 vs. 25, P < 0.001; ≥5 cm to the distal colon margin 81.2% vs. 53.6%, P < 0.001). When stratified according to margin status, no differences in mesocolic resection planes or resectate length were noted, whilst median lymph node yield was higher in patients with R1LNM margins (29 vs. 27, P = 0.009). CONCLUSION Surgical quality does not appear to be poorer in patients undergoing surgery for right-sided versus left-sided colon cancers in Denmark. Suboptimal surgery does not appear to be responsible for R1LNM margins, implying that these margins may be a surrogate for more aggressive biology.
Collapse
Affiliation(s)
- Henry G Smith
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Deepthi J Chiranth
- Department of Pathology, Rigshospital, University of Copenhagen, Copenhagen, Denmark
| | - Nis H Schlesinger
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|