Evaluation of the seventh edition of the tumour, node, metastasis (TNM) classification for colon cancer in two nationwide registries of the United States and Japan

Predictive value of indirect bilirubin before neoadjuvant chemoradiotherapy in evaluating prognosis of local advanced rectal cancer patients

BACKGROUND

Many biomarkers have predictive value for overall survival (OS) and disease-free survival (DFS) in tumor patients. However, the role of indirect bilirubin (IBIL) in local advanced rectal cancer (LARC) patients treated with neoadjuvant chemoradiotherapy (nCRT) has not been studied.

AIM

To explore the predictive value of IBIL before nCRT (pre-IBIL) for the OS and DFS of LARC patients treated with nCRT.

METHODS

A total of 324 LARC patients undergoing nCRT with total mesorectal excision (TME) were enrolled. Preoperative clinical features and postoperative pathological characteristics were collected. Cox regression analysis was performed, and a Cox-based nomogram was developed to predict OS and DFS. We also assessed the predictive performance of the nomogram with calibration plots and receiver operating characteristic (ROC) curves.

RESULTS

Among 324 patients, the median pre-IBIL was 6.2 μmol/L (interquartile range: 4.6 μmol/L-8.4 μmol/L). In the Cox multivariate regression analysis, we found that pre-IBIL, smoking history, tumor regression grade (TRG), vascular invasion, and carbohydrate antigen 19-9 before nCRT (pre-CA19-9) were predictors of OS. Additionally, pre-IBIL, body mass index (BMI), nCRT with surgery interval, TRG, and vascular invasion were predictors of DFS. Predictive nomograms were developed to predict 5-year OS and 5-year DFS with area under the ROC curve values of 0.7518 and 0.7355, respectively. Good statistical performance on internal validation was shown by calibration plots and ROC curves.

CONCLUSION

This study demonstrated that pre-IBIL was an independent prognostic factor for OS and DFS in LARC patients treated with nCRT followed by TME. Nomograms incorporating pre-IBIL, BMI, smoking history, nCRT with surgery interval, TRG, vascular invasion, and pre-CA19-9 could be helpful to predict OS and DFS.

Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection

Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.

A Novel TNM Classification for Colorectal Cancers based on the Metro-ticket Paradigm

Background: Several revisions of the TNM classifications for colorectal cancer (CRC) have acknowledged that the oncological outcomes of stage IIB/IIC CRC are worse than those of stage IIIA. We aimed to develop a novel TNM (nTNM) classification based on the metro-ticket paradigm. Methods: We identified eligible CRC patients from the Surveillance, Epidemiology, and End Results database. The nTNM was developed using distance from the origin on a Cartesian plane incorporating the pN (x-axis) and pT (y-axis) stages, and was compared with the AJCC TNM classification. The areas under the curves (AUCs), calibration curves, and Akaike's information criterion (AIC) were used to evaluate the predictive performances of the two classifications. Clinical benefits were further estimated by decision curve analyses. The validation cohort was applied to validate these findings. Results: A total of 58,192 CRC patients (40,736 training cohort, 17,456 validation cohort) were finally included. In the training cohort, 18,476 patients (45.4%) experienced upstaging and 15,907 patients (39.0%) experienced downstaging in the nTNM classification compared with the TNM classification. Taking the prognosis of stage I as the reference, survival decreased with increasing nTNM stage. The nTNM classification showed better discrimination (AUC, 0.678 vs. 0.667, P<0.001), model-fitting (AIC, 236,525 vs. 237,741), and clinical benefits than the TNM classification. Similar results were found in the validation cohort. Conclusions: The nTNM classification for CRC has better predictive performances and superior accuracy for predicting prognosis compared with the TNM classification. The nTNM classification should therefore be considered in future revisions of the TNM classification.

Staging Paradox and Discrepancy in Adjuvant Chemotherapy in Patients with T4N0, T1-2N1, and T3N1 Colon Cancer

BACKGROUND

A survival paradox between T4N0 (stage IIB/C) and T3N1 (stage IIIB) colon cancer has been rarely reported. The indication and regimen of adjuvant chemotherapy are separately described in the guidelines. This study aimed to elucidate the prognostic factors and investigate proper adjuvant treatment in colon cancer patients at these stages.

METHODS

Patients who underwent R0 resection for pathological T4N0 (n = 49), T1-2N1 (n = 31), or T3N1 (n = 82) colon cancer between 2008 and 2016 at a single institute were retrospectively reviewed. The clinicopathological characteristics, status of adjuvant chemotherapy, and oncologic outcomes of patients with T4N0 tumors were compared with those of patients with T1-2N1 and T3N1 tumors.

RESULTS

The biological characteristics of T4N0 tumors were more aggressive compared with the characteristics of T1-2N1 tumors and were similar to those of T3N1 tumors. The usage rate of oxaliplatin as an adjuvant chemotherapy was significantly lower in T4N0 patients than in T1-2N1 and T3N1 patients. The rate of local recurrence was the highest in patients with T4N0 tumors, and the survival outcomes for patients with T4N0 tumors were significantly worse compared with those of T1-2N1 patients and were similar to those of T3N1 patients. A multivariate analysis revealed that lack of adequate use of oxaliplatin for adjuvant chemotherapy was the only prognostic factor.

CONCLUSIONS

T4N0 colon cancer had similar oncological characteristics and survival outcomes to T3N1 colon cancer. Systematic adjuvant chemotherapy, including oxaliplatin, should be incorporated into the therapy for T4N0 patients as well as T3N1 patients.

LINC00565 promotes the progression of colorectal cancer by upregulating EZH2

The present study aimed to illustrate the role of LINC00565 in aggravating colorectal cancer (CRC) by targeting enhancer of zeste homolog 2 (EZH2). The relative levels of LINC00565 and EZH2 in CRC tissues, based on their Tumor-Node-Metastasis stage and tumor size, were detected by reverse transcription-quantitative polymerase chain reaction. The diagnostic value of LINC00565 in CRC was assessed by depicting receiver operating characteristic curves. Pearson's correlation test was applied to analyze the expression correlation between LINC00565 and EZH2 in CRC tissues. The transfection efficacy of three LINC00565 small interfering RNAs was examined in CRC HCT116 and SW480 cell lines. After knockdown of LINC00565, the proliferative and migratory abilities of CRC cells were detected by Cell Counting Kit-8 and Transwell assays, respectively. The subcellular distribution of LINC00565 was analyzed, and the interaction between LINC00565 and EZH2 was determined by RNA immunoprecipitation. Finally, co-regulation of LINC00565 and EZH2 on CRC cell functions was explored by performing rescue experiments. Results showed that LINC00565 was upregulated in CRC tissues, especially in patients with stage III+IV and in those with large tumor sizes, suggesting its diagnostic value in CRC. EZH2 was also upregulated in CRC tissues, showing a positive correlation with LINC00565. LINC00565 was mainly expressed in the cytoplasm and was found to bind with EZH2. Validation was performed by overexpressing EZH2, which abolished the role of silenced LINC00565 in regulating proliferative and migratory abilities in CRC. Therefore, the upregulation of LINC00565 in CRC tissues was found to stimulate the aggravation of CRC by upregulating EZH2.

Is Radical Surgery Alone Enough in T1-3N1a Colon Cancer?

Background: Low lymphatic tumor burden is associated with a better prognosis. However, it is uncertain whether those patients diagnosed as cN0 found to be pN+ could be a favorable subgroup in stage III disease. Radical surgery alone might avoid overtreatment in those patients.

Methods: Eligible patients diagnosed with colon cancer without metastasis were recruited from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2016 using SEER^*Stat 8.3.5 software (Surveillance Research Program, National Cancer Institute) and divided into two groups: surgery group (n = 3,081) and surgery followed by adjuvant chemotherapy group (n = 4,591). Overall survival (OS) and cause-specific survival (CSS) differences were assessed by Kaplan–Meier analysis, and survival differences were estimated with log-rank tests. Univariate and multivariate Cox proportional hazard regressions were used to assess hazard ratios (HRs) and 95% confidence intervals (CIs) for colon cancer patients.

Results: A total of 7,672 pT1-3N1a colon cancer patients were recruited from 208,751 colon cancer patients. The 5-year CSS rates of patients without and with adjuvant chemotherapy were 80.0 and 90.7%, respectively. The receipt of adjuvant chemotherapy after the radical resection of the primary tumor was independently associated with 57.3% decreased risk of colon cancer-specific mortality compared with surgery alone (HR = 0.427, 95% CI = 0.370–0.492, P < 0.001, using surgery alone as the reference).

Conclusions: Adjuvant chemotherapy was significantly associated with improved prognosis and radical surgery alone did not provide enough treatment for colon cancer with very low lymphatic tumor burden.

Proposal of a modified subclassification system for stage III colorectal cancer: A multi-institutional retrospective analysis

AIM

The prognostic value of the stage III subclassification system based on the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma has not yet been clarified. This study aimed to develop a modified system with optimal risk stratification and compare its performance with the current staging systems.

METHODS

Clinicopathological data from 6855 patients with stage III colorectal cancers who underwent D3 dissection were collected from a nationwide multicenter database. After determining patient survival rates across 13 divisions based on pathological N stage (N1, N2a, and N2b/N3) and tumor depth (T1, T2, T3, T4a, and T4b), except for T1N2a and T1N2b/N3 due to the small number, we categorized patients into three groups and developed a trisection staging system according to the Akaike information criterion. We then compared the Akaike information criterion of the developed system with those of the current staging systems.

RESULTS

The T1N1[rank, 1] division (98.5%) had the most favorable prognosis in terms of 5-year cancer-specific survival, followed by T2N1[2] (93.9%), T2N2a[3] (92.0%), T3N1[4] (87.0%), T3N2a[5] (78.8%), T4aN1[6] (78.7%), T2N2b/N3[7] (77.8%), T4aN2a[8] (75.2%), T4bN1[9] (73.5%), T3N2b/N3[10] (64.7%), T4aN2b/N3[11] (61.5%), T4bN2b/N3[12] (43.0%), and T4bN2a[13] (42.5%). Compared to the categorizations of the Japanese and tumor-node-metastasis systems (Akaike information criterion, 22 684.6 and 22 727.1, respectively), the following stage categorizations were proven to be the most clinically efficacious: T1N1[1 ]-T3N1[4], T3N2a[5 ]-T4bN1[9], and T3N2b/N3[10 ]-T4bN2a[13] (Akaike information criterion, 22 649.2).

CONCLUSION

The proposed modified system may be useful in the risk stratification of patients with stage III colorectal cancer who had undergone D3 dissection.

BMI May Be a Prognostic Factor for Local Advanced Rectal Cancer Patients Treated with Long-Term Neoadjuvant Chemoradiotherapy

OBJECTIVE

This study aims to develop feasible nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of the local advanced rectal cancer (LARC) patients who were treated with neoadjuvant chemoradiotherapy (nCRT) and operation.

METHODS

A total of 243 LARC patients undergoing nCRT followed by total mesorectal excision (TME) were enrolled. Preoperative clinical features and postoperative pathological characteristics were collected. A Cox regression analysis was performed, and Cox-based nomograms were developed to predict the OS and CSS. We assessed the predictive performance of the nomogram with concordance index and calibration plots.

RESULTS

A total of 243 patients were included with a median follow-up period of 46 months (range from 9 to 86 months). Cox regression analysis showed that low BMI (BMI < 18.5, HR= 21.739, P < 0.05), high level of preoperative CA19-9 (HR = 3.369, P = 0.036), high ypStage (HR = 19.768, P < 0.001), positive neural invasion (HR = 4.218, P = 0.026) and no adjuvant chemotherapy (HR = 5.495, P < 0.001) were independent predictors of poor OS. Age ≥70 (HR = 2.284, P <0.001), low BMI (BMI < 18.5, HR = 3.906, P < 0.05), positive preoperative CA19-9 (HR = 1.920, P = 0.012), high ypStage (HR = 5.147, P <0.001) and positive neural invasion (HR = 2.873, P = 0.022) were independent predictors of poor CSS. The predictive nomograms were developed to predict the OS and CSS with a C-index of 0.837 and 0.760. Good statistical performance on internal validation was shown by calibration plots.

CONCLUSION

In conclusion, this study demonstrated that BMI was an independent prognostic factor for OS and CSS in LARC patients treated with nCRT followed TME. A nomogram incorporating BMI, neural invasion, pre-CA19-9, ypStage, age, and adjuvant chemotherapy could be helpful to predict the OS and CSS.

Impact of an organised population screening programme for colorectal cancer: Measurement after first and second rounds

OBJECTIVE

The first and second rounds of the Basque programme for organised colorectal cancer screening were implemented between 2009 and 2014. Our objective was to measure the changes in incidence, tumour, node, metastasis staging distribution and tumour, node, metastasis-adjusted survival of patients with colorectal cancer from 2003 to 2014.

METHOD

Colorectal cancer cases with screening (patients <70 years old) and without screening (patients ≥70 years old) were compared during three four-year periods: 2003-2006, 2007-2010 and 2011-2014 (fully implemented phase). Cox regression, five-year relative survival and cancer probability of death were calculated for each four-year period, age group and tumour, node, metastasis stage. Adjusted incidence rates were analysed by joinpoint regression.

RESULTS

In an analysis of 23,301 cases of colorectal cancer, the incidence in patients younger than 70 years in 2013 showed a 17% annual decrease. The survival hazard ratios for stages I, II and III for 2003-2006 and 2007-2010 were compared to those for 2011-2014. From the first to the third period, diagnosis in the early stages (I and II) rose from 45.1% to 50.9% in the younger patient group and remained stable in the older group (49.6% and 49.4%). Additionally, the five-year relative survival rate increased significantly from 0.67 to 0.82 in those patients younger than 70 years, whereas in patients 70 years or older the rate did not change significantly (0.61 and 0.65).

CONCLUSION

The screening reduced incidence and improved survival by anticipating the diagnosis and by reducing mortality for each tumour, node, metastasis stage in the target population. The effect on survival could also be due to lead-time bias.

Marked impact of tumor location on the appropriate cutoff values and the prognostic significance of the lymph node ratio in stage III colon cancer: a multi-institutional retrospective analysis

BACKGROUND

The prognostic significance of lymph node ratio (LNR) is not constant among studies. Exploration of appropriate location-specific cutoffs might be necessary because the number of lymph nodes harvested is generally higher in right than in left colon cancer. We aimed to determine appropriate cutoff values of LNR in right and left colon cancer and to clarify its clinical significance.

METHODS

The clinicopathologic data of 5463 patients with stage III colon cancer were collected. The best cutoff for LNR as a prognostic indicator for patients with right and left colon cancer was studied separately. We compared the prognostic impact between LNR and the number of lymph node metastasis using the Akaike information criterion (AIC), and evaluated the prognostic significance of LNR in each stage III subcategory.

RESULTS

The best performance was noted when LNR was categorized by cutoffs of 0.16 and 0.22 for right and left colon cancer, respectively. AIC scores were better with these categorizations than with subgrouping by number of positive nodes. LNR-low right colon cancer patients showed better cancer-specific survival than LNR-high in stage IIIA (95.7% vs. 89.3%), IIIB (86.7% vs. 77.2%), and IIIC (71.2% vs. 58.7%). The same results were obtained in left colon cancer patients with stage IIIB (88.3% vs. 80.7%) and IIIC (79.8% vs. 68.4%).

CONCLUSIONS

We demonstrated the difference in the appropriate cutoffs of LNR between right and left colon cancer. Categorization by location-specific cutoff of LNR may be useful for risk stratification of patients with stage III cancer.

Clinicopathological and biomolecular characteristics of stage IIB/IIC and stage IIIA colon cancer: Insight into the survival paradox

BACKGROUND

A survival paradox of stage IIB/IIC and IIIA colon cancer has been consistently observed throughout revisions of the TNM system. This study aimed to understand this paradox with clinicopathological and molecular differences.

METHODS

Clinicopathological characteristics of patients with pathologically confirmed stage IIB/IIC or IIIA colon cancer were retrospectively reviewed from a database. Publicly available molecular data were retrieved, and intrinsic subtypes were identified and subjected to gene sets enrichment analysis (GSEA).

RESULTS

Among the 159 patients included in the clinicopathological analysis, those at stage IIB/IIC had worse 3-year disease-free and overall survival than those at stage IIIA (59.3% vs 91.7%, P < 0.001 and 82.7% vs 98.5%, P < 0.001, respectively), even after adjusting for confounding factors. Data of 95 patients were retrieved from public databases, demonstrating a higher frequency of the microsatellite instable subtype in stage IIB/IIC. The consensus molecular subtype distribution pattern differed between the groups. The GSEA further suggested the protumor inflammatory reaction might be more prominent in stage IIB/IIC.

CONCLUSIONS

The survival paradox in colon cancer was confirmed and appears to be a multifactorial phenomenon not attributed to a single clinicopathologic factor. However, the greater molecular heterogeneity in stage IIB/IIC could contribute to the poor prognosis.

Nutritional status predicts adjuvant chemotherapy outcomes for stage III colorectal cancer

OBJECTIVES

Previously, adjuvant chemotherapy using oxaliplatin was a standard treatment for patients with node-positive colorectal cancer (CRC) who underwent curative surgery. The factor predicting adverse events and therapeutic effect have not yet been established.

METHODS

A retrospective cohort of 42 patients diagnosed with stage III CRC between April 2009 and March 2013 in our institution were included in this study. The indicators of host nutritional status were body weight (BW), body mass index (BMI), serum albumin, Onodera's prognostic nutritional index (OPNI), and Glasgow Prognostic Score (GPS). The indicators of host immunocompetence was total lymphocyte counts, total neutrophil counts, granulocytes/lymphocytes ratio (G/L ratio).

RESULTS

The overall recurrence rate was 26.1%. Patients who had a recurrence were more likely to be older. The recurrence was not associated with type of regimen or adverse events. The cases with a few cumulative doses and relative dose intensity of oxaliplatin experienced significantly more recurrence. Nutritional status indicators, such as the serum albumin level, OPNI, and the modified Glasgow prognostic score (mGPS) were associated with the adjuvant chemotherapy outcome. Our study results indicated worse nutritional status induced worse disease-free survival (DFS) and more recurrence.

CONCLUSION

The host's nutritional status associated with outcomes in stage III CRC patients.

Is cancer history really an exclusion criterion for clinical trial of lung cancer? Influence of gastrointestinal tract cancer history on the outcomes of lung cancer surgery

Objective

Exclusion of patients with a history of other cancer treatment except in situ situation has been considered to be inevitable for clinical trials investigating survival outcome. However, there have been few reports confirming these influences on surgical outcome of lung cancer patients ever.

Methods

Multi-institutional, individual data from patients with non–small cell lung cancer resected between 2000 and 2013 were collected. The patients were divided into two groups: those with a history of gastrointestinal tract cancer (GI group) and those without any history (non-GI group). We compared the outcomes with well-matched groups using propensity scoring to minimize bias related to the nonrandomness. The influence of gastrointestinal tract cancer stage, disease-free interval, and treatment method for gastrointestinal tract cancer on the surgical outcome of non–small cell lung cancer was examined.

Results

We analyzed 196 patients in the GI group and 3732 in the non-GI group. In unmatched cohort, multivariate analyses showed that a history of gastrointestinal tract cancer did not affect overall survival or recurrence-free survival. Independent predictors of poor prognosis included older age, male sex, high carcinoembryonic antigen levels and advanced clinical stage of non–small cell lung cancer. The two groups in the matched cohort demonstrated equivalent overall survival and recurrence-free survival, even in patients with clinical stage I. Gastrointestinal tract cancer stage, disease-free interval and treatment method for gastrointestinal tract cancer were not associated with outcomes.

Conclusions

History of early gastrointestinal tract cancer completely resected is not always necessary for exclusion criteria in clinical trial of lung cancer.

Supervised discretization can discover risk groups in cancer survival analysis

Discretization of continuous variables is a common practice in medical research to identify risk patient groups. This work compares the performance of gold-standard categorization procedures (TNM+A protocol) with that of three supervised discretization methods from Machine Learning (CAIM, ChiM and DTree) in the stratification of patients with breast cancer. The performance for the discretization algorithms was evaluated based on the results obtained after applying standard survival analysis procedures such as Kaplan-Meier curves, Cox regression and predictive modelling. The results show that the application of alternative discretization algorithms could lead the clinicians to get valuable information for the diagnosis and outcome of the disease. Patient data were collected from the Medical Oncology Service of the Hospital Clínico Universitario (Málaga, Spain) considering a follow up period from 1982 to 2008.

Prognostic impact of lymph node skip metastasis in Stage III colorectal cancer

AIM

The aim of this study was to evaluate the prognostic impact of lymph node skip metastasis (LNSM) in patients with Stage III colorectal cancer.

METHOD

Between April 2003 and December 2014, a total of 41 patients with lymph node skip metastasis (skip+) were compared with 86 patients with pericolic lymph node metastases [lymph node distribution (LND)1] and 57 patients with intermediate and/or main lymph node metastasis (LND2+3). All patients had radical D3 lymphadenectomy, performed either laparoscopically or as open surgery.

RESULTS

The frequency of pT1-2 stage cancer was significantly higher in the skip+ group than in the LND1 group (26.8% vs 5.8%, P = 0.001). The number of metastatic lymph nodes in the skip+ group was lower than in the LND2+3 group (1.9 ± 1.5 vs 6.5 ± 6.0, P < 0.001). The 3-year disease-free survival (DFS) of the skip+, LND1 and LND2+3 groups was 64.8%, 69.7% and 40.1%, respectively (P = 0.008). The 3-year systemic recurrence rates of the skip+, LND1 and LND2+3 groups were 30.2%, 20.3% and 48.1%, respectively; (P = 0.002). Cox regression analysis revealed that preoperative carcinoembryonic antigen (CEA) of ≥ 5 ng/ml [hazard ratio (HR) = 2.2, P = 0.029], poor differentiation (HR = 3.8, P = 0.001) and skip+ (HR = 0.2, P = 0.021) were independently prognostic factors for DFS.

CONCLUSION

The prognosis for the LND1-negative lymph node skip metastasis group was better than for the LND2+3 group and was comparable with that of the LND1 group after radical D3 lymphadenectomy.

Adjuvant chemotherapy for colon cancer: the difference between Japanese and western strategies

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer in the western world and also in Japan. The key factors in curing CRC are early detection, surgery and adequate adjuvant chemotherapy if needed.

AREAS COVERED

Based on the results of following pivotal adjuvant trials, FOLFOX or XELOX are considered standard adjuvant chemotherapy for patients with stage III colon cancer in the western countries. On the other hand, 5-FU based monotherapies showed favorable results as adjuvant chemotherapy in Japan providing comparable results to doublet strategies in the western countries. There are two key factors that could provide better outcome: D3 lymph node dissection (LND) and thorough pathological examinations.

EXPERT OPINION

I believe that oxaliplatin based adjuvant chemotherapy may not be suitable for at least substage IIIA patients who underwent D3 surgery and were diagnosed by thorough pathological examinations for the following two reasons: toxicities and strongly stage-dependent added benefit of oxaliplatin in overall survival. We are awaiting the final results of three Japanese ongoing trials focusing on oxaliplatin based adjuvant chemotherapy. These results will hopefully help us create and implement global guidelines for truly standardizing the management of colon cancer prevalent all over the world, and help physicians recommend the treatment strategy available to each patient.

Factors affecting serum albumin in the perioperative period of colorectal surgery: a retrospective study

Background

Albumin is considered a negative acute-phase protein because its concentration decreases during injury and sepsis. Hypoalbuminemia is a risk factor for mortality, postoperative complications, and prolonged hospital stay. The magnitude of the systemic inflammatory response during the perioperative period, as indicated by the acute-phase proteins—C-reactive protein (CRP) in particular—, may help identify the risk of postoperative infectious complication. The correlation between serum albumin and CRP with gastrointestinal cancer has been reported. However, it is unclear whether antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period in colorectal surgery. The primary endpoint of this study was to reveal that antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period of colorectal surgery.

Methods

Thirty-seven patients who underwent elective open colorectal surgery were included in this study. Correlations between preoperative CRP and serum albumin on postoperative day (POD) 3, between preoperative CRP and serum albumin on POD 7 and between CRP on POD 3 and serum albumin on POD 7 were examined. Relationships between preoperative CRP and hypoalbuminemia on POD 3, between preoperative CRP and hypoalbuminemia on POD 7 and between CRP on POD 3 and hypoalbuminemia on POD 7 were examined by receiver operating characteristic analysis.

Results

Three-quarters of patients were older than 65 years of age. Significant correlations were observed between preoperative CRP and serum albumin on POD 3 (p = 0.023), between preoperative CRP and serum albumin on POD 7 (p = 0.023) and between CRP on POD 3 and serum albumin on POD 7 (p < 0.001). The area under the receiver operating characteristic curve of CRP on POD 3 to development of hypoalbuminemia on POD 7 was 0.833 (95 % CI 0.679–0.987) with an optimal threshold of 12.43 mg/dL, sensitivity 75 % and specificity 80 %.

Conclusions

The present study revealed that antecedent CRP was associated with future serum albumin. Additionally, CRP on POD 3 could be useful in predicting the development of hypoalbuminemia on POD 7. This result suggests that CRP on POD 3 may be a valuable indicator for early nutritional intervention.

Management of nodal disease from colon cancer in the laparoscopic era

PURPOSE

In colon cancer (CC), nodal involvement is the main prognostic factor following potentially curative (R0) resection. The purpose of this study was to examine data from the literature to provide an up-to-date analysis of the management of nodal disease with special reference to laparoscopic treatment.

METHODS

MEDLINE and EMBASE databases were searched for potentially eligible studies published in English up to July 15, 2014.

RESULTS

In CC, nodal involvement is a frequent event and represents the main risk of cancer recurrence. Node negative patients recur in 10-30 % of cases most likely due to underdiagnosed or undertreated nodal disease. Extended colonic resections (complete mesocolic excision with central vascular ligation; D3 lymphadenectomy) provides a survival benefit and better local control. Sentinel lymph node mapping in addition to standard surgical resection represents an option for improving staging of clinical node negative patients. Both extended resection and sentinel lymph node mapping are feasible in a laparoscopic setting.

CONCLUSIONS

Both extended colonic resection and sentinel lymph node mapping should play a role in the laparoscopic treatment of CC with the purpose of improving control and staging of nodal disease.

Accuracy of TNM staging in colorectal cancer: a review of current culprits, the modern role of morphology and stepping-stones for improvements in the molecular era

Colorectal cancer (CRC) is the third most common cancer worldwide. Survival is largely stage-dependant, guided by the tumor-node-metastases (TNM) system for TNM assessment. Histopathological evaluation, including assessment of lymph node status, is important for correct TNM staging. However, recent updates in the TNM system have resulted in controversy. A continued debate on definitions resulting in potential up- and downstaging of patients, which may obscure survival data, has led the investigators to investigate other or alternative staging tools. Consequently, additional prognostic factors have been searched for using the regular light microscopy. Among the factors evaluated by histopathology include the evaluation of tumor budding and stromal environment, angiogenesis, as well as involvement of the immune system (including the 'Immunoscore'). We review the current role of histopathology, controversies in TNM-staging and suggested alternatives to better predict outcome for CRC patients in the era of genomic medicine.

Prognosis of lung cancer patients with a past history of colorectal cancer

OBJECTIVES

The prognosis in lung cancer patients with a prior history of extrapulmonary cancer is controversial. In the current multicenter joint research in Japan, we focused on the relationship between a history of colorectal cancer and its prognostic impact in patients with subsequent lung cancer.

METHODS

Between 2000 and 2013, we designed a retrospective multicenter study at three institutes in Japan to evaluate the prognostic factors in lung cancer patients with a previous surgery for colorectal cancer.

RESULTS

The cohorts consisted of 123/4431 lung cancer patients with/without a previous history of surgery for colorectal cancer. The median follow-up period was 6.1 years after lung cancer surgery. The 5-year overall survival in lung cancer patients with/without colorectal cancer was not significantly different, regardless of the stage of lung cancer (overall: 71.3 versus 74.7%, P = 0.1426; Stage I lung cancer: 83.3 versus 84.8%, P = 0.3779; Stage II or more lung cancer: 47.7 versus 54.4%, P = 0.1445). Based on multivariate Cox regression analysis in 4554 lung cancer patients, a past history of colorectal cancer was not a significant prognostic factor (P = 0.5335). Among the 123 lung cancer patients with colorectal cancer, age and absence of adjuvant chemotherapy for colorectal cancer were significant prognostic factors based on multivariate analysis (P = 0.0001 and 0.0236). Furthermore, there was no difference in the overall survival of lung cancer patients according to the stage of colorectal cancer (Stage I: 74.7%; Stage II/III: 66.5%, P = 0.7239).

CONCLUSIONS

A history of antecedent colorectal cancer did not contribute to the prognosis in patients with subsequent lung cancers.

Survival paradox between stage IIB/C (T4N0) and stage IIIA (T1-2N1) colon cancer

BACKGROUND

The survival paradox between stage IIB/C (T4N0) and stage IIIA (T1-2N1) colon cancer remains in the 7th edition of the American Joint Committee on Cancer staging system. This multicenter study aimed to compare the oncologic outcomes of T4N0 and T1-2N1 colon cancers and to investigate the presumptive prognostic factors that might influence the survival paradox.

METHODS

Patients who underwent curative surgery for pT4N0 (n = 224) and pT1-2N1 (n = 135) primary colon cancer between January 1999 and December 2010 at five tertiary referral cancer centers were included for analysis. The clinicopathologic, treatment-related factors, and oncologic outcomes in terms of the 5-year overall survival (5-OS) and 5-year disease-free survival (5-DFS) were compared.

RESULTS

The T4N0 group had significantly worse 5-OS and 5-DFS rates than the T1-2N1 group (5-OS: 84.0 vs. 92.3 %, p = 0.012; 5-DFS: 73.6 vs. 88.0 %, p = 0.001). T4N0 cancers more frequently showed elevated preoperative carcinoembryonic antigen, lower grade of differentiation, larger tumor size, and higher proportions of perineural invasion, microsatellite instability, obstruction, and perforation than T1-2N1 cancers. Peritoneal seeding and liver metastasis were the predominant recurrence pattern in the T4N0 and T1-2N1 groups, respectively (p = 0.042). The T4N0 group showed inferior survival to the T1-2N1 group in postoperative adjuvant chemotherapy (5-OS: 87.1 vs. 93.2 %, p = 0.045; 5-DFS: 76.1 vs. 89.0 %, p = 0.001).

CONCLUSIONS

T4N0 colon cancer had significantly worse oncologic outcomes than T1-2N1 cancer regardless of adjuvant chemotherapy. The survival paradox may result from the biologic aggressiveness of T4N0 colon carcinomas.

Long-term prognostic value of mesorectal grading after neoadjuvant chemoradiotherapy for rectal cancer

BACKGROUND

Mesorectal grading was reported to be a valuable prognostic factor in rectal cancer surgery. Previous studies were retrospective, and had short follow-up.

OBJECTIVE

To assess the long-term influence of total mesorectal excision quality on disease recurrence in mid and low rectal cancer patients who received preoperative neoadjuvant chemoradiotherapy (CRT) and postoperative chemotherapy.

METHODS

One hundred twenty-one patients with rectal cancer had either low anterior resection or abdominoperineal resection. All patients received neoadjuvant CRT and postoperative chemotherapy. Main outcome measures included TNM staging, involvement of the circumferential resection margin (ICRM), mesorectal grading, local and systemic recurrences were recorded.

RESULTS

Follow-up was done for at least 5 years or up to disease recurrence whatever comes first. Mean follow-up time was 59.4 months. Twenty-nine patients had abdominoperineal resection and 92 had low anterior resection. About 7.5% had positive CRM which was significantly correlated with mesorectal grading. Grade 3 mesorectal specimens were obtained in approximately 60% of patients, 27% had grade 2, and only 13% had grade 1 (poor) mesorectal specimens. Poorer mesorectal grading increased with APR and lower rectal tumors. Recurrences occurred in 20% of patients (40% in the first 2 years, 32% in the 3rd year, and 28% in the 4th and 5th years); factors affecting recurrence included lymphovascular invasion, ICRM, and N stage. Mesorectal grading was not a valuable prognostic factor for recurrence unless it resulted in ICRM. Recurrences occurred earlier with poorer mesorectal grade, yet this was not statistically significant.

CONCLUSIONS

Mesorectal grading is a pathologic description that reflects the quality of surgery. However, in patients who received neoadjuvant CRT and postoperative chemotherapy, grading had no long-term prognostic value regarding recurrences unless it resulted in ICRM.

Positive peritoneal washing cytology is a potential risk factor for the recurrence of curatively resected colorectal cancer

PURPOSES

Whether free peritoneal cancer cells should be considered peritoneal dissemination in colorectal cancer patients remains controversial. The aim of this study was to investigate the clinical significance of positive peritoneal washing cytology (PWC) in patients with colorectal cancer.

METHODS

We retrospectively analyzed the records of 771 sequential patients diagnosed with stage 0-III colorectal cancer who underwent R0 resection and had no distant metastases or peritoneal dissemination.

RESULTS

PWC was performed on all 771 patients. Sixty-eight patients experienced metastasis recurrence, 10 of whom experienced peritoneal recurrence. Of the 10 patients with peritoneal recurrence, 6 had positive PWC. Out of the 771 patients, 21 had positive PWC. Of these 21 patients, 6 had peritoneal recurrence, while 4 had distant metastasis and no peritoneal recurrence during the observation period. The 5-year disease-free survival was 89.0 % in the patients with negative PWC vs. 46.8 % in the patients with positive PWC (p < 0.0001, log-rank test). A Cox proportional hazards model revealed that positive PWC was the strongest independent risk factor for cancer-specific recurrence.

CONCLUSIONS

Our study highlights PWC as a useful prognostic tool in patients undergoing curative surgery for colorectal cancer, since positive PWC was shown to be a potential risk factor for recurrence.

Prognostic value of the Glasgow Prognostic Score in metastatic colorectal cancer in the era of anti-EGFR therapies

The Glasgow Prognostic Score (GPS), combination of C-reactive protein and albumin, has proven its prognostic value in metastatic colorectal cancer (mCRC) patients receiving conventional cytotoxic therapy. More recently, anti-EGFR therapies have been validated in mCRC and roll forward the patients' overall survival (OS). We aimed to evaluate the prognostic accuracy of the GPS in patients receiving anti-EGFR therapy in addition to conventional chemotherapy. From January 2007 to February 2012, consecutive mCRC patients who received 5-fluorouracil-based chemotherapy plus cetuximab were included in the present analysis. Patients were eligible for the study if they met the following criteria: advanced pathologically proven MCRC, age >18 years, adequate renal function (creatinine clearance >40 ml/min), C-reactive protein and albumin and performance status evaluation before treatment initiation. A total of 49 patients received cetuximab plus 5-fluorouracil-based chemotherapy (colon, n = 34; rectum, n = 15) and were treated with a median follow-up of 35 months (16.5-74.7). Median age was 48 years old. In addition to cetuximab, patients received oxaliplatin- (n = 34, 60%) or irinotecan (n = 15, 30%)-based chemotherapy. At time of diagnosis, 55, 29 and 16% of patients had a GPS of 0 (n = 27), 1 (n = 14) and 2 (n = 8), respectively. Fifty-five, 29 and 14 % of patients add one, two or ≥3 metastatic sites, respectively. Considering two groups (GPS = 0 and GPS ≥1), median progression-free survivals were significantly different (p = 0.0084). Median OS in the GPS 0, 1 and 2 groups were 38.2, 14 and 12.1 months, respectively (p = 0.0093). The results of the present study confirm that the GPS is still a simple and effective prognostic factor in the era of cetuximab therapy in mCRC patients.