Prevalence and significance of anaemia in patients receiving long-course neoadjuvant chemoradiotherapy for rectal carcinoma

MRI-based parameters and clinical risk factors to predict lymph node metastasis in patients with ypT0 rectal cancer after neoadjuvant chemoradiotherapy

BACKGROUNDS

The aim of this study was to assess the significant risk factors that predict lymph node metastasis in ypT0 patients with locally advanced rectal cancer following chemoradiotherapy (CRT). Additionally, the study aimed to identify high-risk groups who would not be suitable candidates for a rectal-preserving strategy, despite achieving a complete tumour response.

METHODS

Between 2013 and 2021, 226 ypT0 patients with stages II/III rectal cancer underwent CRT and radical surgery were enrolled. Two groups of patients were evaluated: those with lymph nodes metastasis and those without. The selection of variables for multivariable logistic regression was conducted through bivariate logistic regression analysis. Furthermore, the determination of optimal cutoff values for risk factors was achieved using ROC curve analysis.

RESULTS

Nearly 8% (18/226) of patients with ypT0 had positive lymph nodes (LN) on final pathology. Four variables resulted as being independent factors of LN metastasis: pre-CRT tumour movability (OR = 8.618, P = 0.003), pre-CRT maximal LN size (OR = 28.474, P = 0.004), post-CRT tumour vertical length (OR = 1.492, P = 0.050), post-CRT anaemia (OR = 10.288, P = 0.001). The optimal cutoff point of pre-CRT maximal LN size and post-CRT tumour vertical length was 7.50 mm and 3.05 cm, respectively.

CONCLUSION

The prevalence of lymph node metastasis remains at 8% among patients who achieve pathological complete regression of the primary tumour. In instances where patients are considered appropriate candidates for a rectal-preserving strategy after clinical complete remission, careful consideration should be given to the selection of this strategy if specific risk factors are present. These risk factors encompass a maximal LN size surpassing 7.50 mm prior to CRT, a fixed tumour prior to CRT, a tumour vertical length exceeding 3.05 cm after CRT, and the existence of anaemia subsequent to CRT.

Predictive Value of the Interaction between CEA and Hemoglobin in Neoadjuvant CCRT Outcomes in Rectal Cancer Patients

The adoption of neoadjuvant concurrent chemoradiotherapy (CCRT) has reshaped the therapeutic landscape, but response prediction remains challenging. This study investigates the interaction between pre-CCRT carcinoembryonic antigen (CEA) and post-CCRT hemoglobin (Hb) levels in predicting the response of locally advanced rectal cancer (LARC) to CCRT. Retrospective data from 93 rectal cancer patients receiving neoadjuvant CCRT were analyzed. Univariate analyses assessed clinical factors associated with tumor regression grade (TRG) and T-stage outcomes. Machine learning identified predictive biomarkers. Interaction effects between CEA and Hb were explored through subgroup analyses. Post-CCRT Hb varied between pre-CCRT CEA groups. The interaction between pre-CCRT CEA and post-CCRT Hb influenced TRG. Males with normal pre-CCRT CEA and anemia showed better treatment responses. Females with elevated pre-CCRT CEA and post-CCRT anemia exhibited poorer responses. The interaction effect between them was significant, indicating that their relationship with TRG was not additive. Inflammatory biomarkers, WBC, neutrophil count, and post-CCRT platelet level correlated with CCRT response. Contrasting with previous findings, anemia was a predictor of better treatment response in males with normal pre-CCRT CEA. The interaction between pre-CCRT CEA and post-CCRT Hb levels predicts the response of LARC to CCRT. CEA, Hb, and sex should be considered when assessing treatment response. Inflammatory biomarkers contribute to response prediction. Understanding these complex relationships can enhance personalized treatment approaches in rectal cancer patients.

The measurement and modification of hypoxia in colorectal cancer: overlooked but not forgotten

Tumour hypoxia is the inevitable consequence of a tumour's rapid growth and disorganized, inefficient vasculature. The compensatory mechanisms employed by tumours, and indeed the absence of oxygen itself, hinder the ability of all treatment modalities. The clinical consequence is poorer overall survival, disease-free survival, and locoregional control. Recognizing this, clinicians have been attenuating the effect of hypoxia, primarily with hypoxic modification or with hypoxia-activated pro-drugs, and notable success has been demonstrated. However, in the case of colorectal cancer (CRC), there is a general paucity of knowledge and evidence surrounding the measurement and modification of hypoxia, and this is possibly due to the comparative inaccessibility of such tumours. We specifically review the role of hypoxia in CRC and focus on the current evidence for the existence of hypoxia in CRC, the majority of which originates from indirect positron emission topography imaging with hypoxia selective radiotracers; the evidence correlating CRC hypoxia with poorer oncological outcome, which is largely based on the measurement of hypoxia inducible factor in correlation with clinical outcome; the evidence of hypoxic modification in CRC, of which no direct evidence exists, but is reflected in a number of indirect markers; the prognostic and monitoring implications of accurate CRC hypoxia quantification and its potential in the field of precision oncology; and the present and future imaging tools and technologies being developed for the measurement of CRC hypoxia, including the use of blood-oxygen-level-dependent magnetic resonance imaging and diffuse reflectance spectroscopy.

Can we optimize CEA as a response marker in rectal cancer?

BACKGROUND AND AIM

carcinoembryonic antigen (CEA) is a biomarker commonly used in colorectal cancer. However, its prognostic value is still controversial. Recent studies demonstrate that CEA produced locally by tumor cells has a higher prognostic value compared to serum CEA. This study aimed to determine whether there was an association between the CEA/tumor size ratio (CEA/ExT) and the pathological tumor response in patients with rectal adenocarcinoma (ADC), who underwent neoadjuvant chemoradiotherapy (N-CRT), followed by surgical tumor resection.

METHODS

a retrospective study was performed of rectal ADC patients who underwent N-CRT followed by curative surgery between March/2012 and October/2017. CEA and tumor extension for pre-treatment CEA/ExT calculation and the pathological response in the surgical specimen after treatment were analyzed.

RESULTS

eighty-nine patients were included, 60.7 % were male and the mean age was 63.8 ± 10.42. There was a good response to N-CRT in 41.6 % of the patients, tumor downstaging occurred in 83.1 % and a complete pathological response in 23.6 % of cases. The average CEA/ExT was 2.01 ng/ml/cm. In the univariate analysis, higher CEA/ExT values were related to a lower frequency of pathological response (p = 0.04) and to a lower frequency of tumor downstaging (p = 0.02). In the multivariate analysis, CEA/ExT was independently related to tumor downstaging (OR: 0.72; 95 % IC: 0.53-0.98, p-0.036).

CONCLUSIONS

lower pre-treatment CEA/ExT values seem to be associated with tumor downstaging and this parameter may be a promising predictor of a more favorable response in patients with rectal ADC undergoing treatment with N-CRT.

Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer

Introduction Anaemia is associated with cancer. In 2014 a new form was introduced in our department requesting a haemoglobin (Hb) result on every two-week wait referral for suspected colorectal cancer (CRC). The aim of this study was to review the impact of this intervention. In particular, the significance of any evidence of anaemia (without additional indices) was investigated. Methods A review was conducted of 1,500 consecutive suspected CRC referrals recorded prospectively over a 10-month period. Data on demographics, referral Hb, referral criteria and outcomes were analysed. Anaemia was defined according to World Health Organization criteria (Hb <120g/l for women, Hb <130g/l for men). Results Overall, 1,015 patients were eligible for inclusion in the study. Over a third (38.2%) were documented as anaemic on referral. These patients were three times more likely to be diagnosed with CRC than non-anaemic patients (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 1.87-5.57). Using a more stringent threshold (Hb <100g/l for women and <110g/l for men), they were four times more likely to have CRC (OR: 4.27, 95% CI: 2.35-7.75). Almost a quarter (23.7%) were actually anaemic at the time of referral but not referred with anaemia. In this subgroup, there was a 2.8-fold increase in risk of CRC diagnosis compared with non-anaemic patients (adjusted OR: 2.77, 95% CI: 1.55-4.95). Conclusions Nearly a quarter of patients not referred with iron deficiency anaemia had evidence of anaemia and this was still associated with a higher rate of CRC detection. A full blood count alone might help to risk stratify symptoms such as change in bowel habit in patients on urgent pathways and identify those cases most likely to benefit from invasive investigation.

Significance of Anemia in Outcomes After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer

BACKGROUND

Approximately one quarter of patients receiving neoadjuvant chemoradiotherapy (NCRT) for locally advanced rectal cancer will be anemic at presentation. The outcomes of these anemic patients have historically been less favorable. We assessed the potential of anemia to act as an independent biomarker for a poor prognosis in patients with locally advanced rectal cancer.

MATERIALS AND METHODS

We performed a retrospective, observational study of consecutive patients with locally advanced rectal adenocarcinoma who underwent NCRT from 2004 to 2009 at 3 English National Health Service trusts. The main outcomes were Rectal Cancer Regression Grade, mortality rate, and disease-free survival. These were compared between the anemic and nonanemic patients.

RESULTS

A total of 273 patients were included. Of these patients, 63 (23%) had a hemoglobin level of < 120 g/L (anemic) at presentation. The Rectal Cancer Regression Grades were higher (less regression) in the anemic patients than in the nonanemic patients (χ² = 10.14; P = .006). A subgroup analysis stratified by disease stage at presentation demonstrated less tumor regression in anemic patients with Dukes stage C disease (Dukes stage B, χ² = 4.31, P = .12; Dukes stage C, χ² = 5.36, P = .07). After adjusting for age, gender, and initial Dukes stage, the anemic patients demonstrated greater mortality rates than the nonanemic patients (hazard ratio, 1.73; 95% confidence interval, 1.05-2.86). The consistency with which the 2 independent reviewers were able to generate the rectal cancer regression grades from the historic pathology reports varied. Also, the subgroup analyses in the present study were often limited by low power.

CONCLUSION

The present large UK study examined patients receiving NCRT for magnetic resonance imaging-proven, locally advanced rectal adenocarcinoma. Our findings have demonstrated that patients who were anemic at presentation have higher regression grades (less regression) in response to the treatment than nonanemic patients. This trend appeared to persist despite radiologic disease stage at presentation. Anemia at presentation was also associated with increased mortality rates compared with that of nonanemic patients.

A single institution's long-term follow-up of patients with pathological complete response in locally advanced rectal adenocarcinoma following neoadjuvant chemoradiotherapy

PURPOSE

This paper aimed to study the long term follow-up of patients with primary rectal adenocarcinoma receiving neoadjuvant chemoradiotherapy who obtained a pathological complete response (pCR) and identify factors predicting complete response.

METHODS

Retrospective review of notes, histology, pre-operative full blood count and imaging of patients with primary rectal adenocarcinoma diagnosed in our institute from 2000 to 2012 from a prospectively maintained database were used. SPSS version 22.0 was used for statistical analysis.

RESULTS

Three hundred eighty patients diagnosed with primary rectal adenocarcinoma were identified, 277 received neoadjuvant chemoradiotherapy followed by curative resection. Forty-six patients obtained a pCR (ypT0N0) with no local recurrence and two metastatic recurrences on follow-up. Patients with a pCR have a significantly improved overall survival and disease-free survival compared to a non-pCR (150.0 and 136.1 vs 77.5 and 84.7 months, p = 0.001). On univariate analysis, increased tumour height above anal verge, low lymph node yield, high pre-operative haemoglobin and a low neutrophil-lymphocyte ratio are significant factors identifying a pCR. Multivariable analysis of the above factors confirmed tumour height above anal verge as significant in obtaining a pCR.

CONCLUSION

Patients with rectal adenocarcinoma who develop a pCR following neoadjuvant chemoradiotherapy have improved overall and disease-free survival. We have identified distance from anal verge, low lymph node yield, high pre-operative haemoglobin and low neutrophil-lymphocyte ratio as significant predictors of developing a pCR.

The impact of anaemia on treatment outcome in patients with squamous cell carcinoma of anal canal and anal margin

Background

Radiochemotherapy is the main treatment for patients with squamous cell carcinoma of the anal canal. Anaemia is reported to have adverse effect on survival in cancer patients. The aim of the study was to evaluate the influence of anaemia on radiochemotherapy treatment outcome in patients with squamous cell carcinoma of the anal canal.

Patients and methods

One hundred consecutive patients with histologically confirmed squamous cell carcinoma of the anal canal were treated radically with 3-dimensional conformal or intensity-modulated radiation therapy followed by brachytherapy or external beam radiotherapy boost and with concurrent mitomycin C and 5-fluorouracil. The influence on survival of pre-treatment, mean on-treatment and end-of-treatment haemoglobin (Hb) concentrations was studied.

Results

The 5-year locoregional control, disease free survival, disease specific survival and overall survival rates for all patients were 72%, 71%, 77% and 62%, respectively. In univariate analysis, patients with pre-treatment and end-of-treatment Hb > 120 g/L survived statistically significantly better compared to patients with Hb ≤ 120 g/L. Patients with mean on-treatment Hb > 120 g/L only had statistically significant better locoregional control and overall survival than patients with Hb ≤ 120 g/L. In multivariate analysis, independent prognostic factors were pre-treatment Hb (> 120 g/L vs. ≤ 120 g/L) for overall survival (hazard ratio [HR] = 0.419, 95% confidence interval [CI] = 0.190–0.927, p = 0.032) and stage (I & II vs. III) for disease specific (HR = 3.523, 95% CI = 1.375–9.026, p = 0.009) and overall survival (HR = 2.230, 95% CI = 1.167–4.264, p = 0.015).

Conclusions

The pre-treatment, mean on-treatment and end-of-treatment Hb concentration > 120 g/L carried better prognosis for patients for with squamous cell carcinoma of the anal canal treated with radiochemotherapy. The pre-treatment Hb > 120 g/L was an independent prognostic factor for overall survival of patients with anal canal cancer.

Is Hemoglobin Level in Patients with Nasopharyngeal Carcinoma Still a Significant Prognostic Factor in the Era of Intensity-Modulated Radiotherapy Technology?

BACKGROUND

Hemoglobin (Hb) levels are regarded as an important determinant of outcome in a number of cancers treated with radiotherapy. However, for patients treated with intensity modulated radiotherapy (IMRT), information regarding the prognostic value of hemoglobin level is scarce.

PATIENTS AND METHODS

A total of 650 patients with nasopharyngeal carcinoma (NPC), enrolled between May, 2005, and November, 2012, were included in this study. The prognostic significance of hemoglobin level (anemia or no-anemia) at three different time points was investigated, including before treatment, during treatment and at the last week of treatment. Univariate and multivariate analyses were conducted using the log-rank test and the Cox proportional hazards model, respectively.

RESULTS

The 5-year OS (overall survival) rate of patients who were anemia and no-anemia before treatment were 89.1%, and 80.7% (P = 0.01), respectively. The 5-year DMFS (distant metastasis-free survival) rate of patients who were anemia and no-anemia before treatment were 88.9%, and 78.2% (P = 0.01), respectively. The 5-year OS rate of patients who were anemia and no-anemia during treatment were 91.7% and 83.3% (P = 0.004). According to multivariate analysis, the pre-treatment Hb level predicted a decreased DMFS (P = 0.007, HR = 2.555, 95% CI1.294-5.046). Besides, the mid-treatment Hb level predicted a decreased OS (P = 0.013, HR = 2.333, 95% CI1.199-4.541).

CONCLUSIONS

Hemoglobin level is a useful prognostic factor in NPC patients receiving IMRT. It is important to control the level of hemoglobin both before and during chemoradiotherapy.

β-Catenin-Gli1 interaction regulates proliferation and tumor growth in medulloblastoma

Background

The Wnt/beta-catenin and the Hedgehog (Hh) pathway interact in various cell types while eliciting opposing or synergistic cellular effects. Both pathways are known as exclusive drivers of two distinct molecular subtypes of medulloblastoma (MB).

In sonic hedgehog (Shh)-driven MB, activation of Wnt signaling has been shown to suppress tumor growth by either beta-catenin-dependent or -independent inhibition of Shh signaling. However, mechanistic insight in how beta-catenin inhibits the Hh pathway is not known.

Findings

Here we show that beta-catenin stabilization by the glycogen synthase kinase 3 inhibitor lithium chloride (LiCl) reduced growth of primary hedgehog-driven MB tumor spheres from patched heterozygous mice (Ptch^+/-) in vitro. LiCl treatment of MB spheres down-regulated the Hh target Gli1, whereas the repressive Gli3 protein (Gli3R) was increased. Mechanistically, we show by co-immunoprecipitation and proximity ligation assay that stabilized beta-catenin physically interacts with Gli1, leading to Gli1 sequestration and inhibition of its transcriptional activity. Reduction of Hh signaling upon LiCl stimulation resulted in reduced proliferation, sphere self renewal, a G2/M arrest and induction of a senescent-like state, indicated by p21 upregulation and by increased staining of senescence-associated beta-galactosidase (SA-betaGal). Moreover, LiCl treatment of subcutaneously transplanted MB cells significantly reduced tumor initiation defined as “tumor take”. Although tumor progression was similar, LiCl-treated tumors showed decreased mitotic figures and phospho-histone H3 staining.

Conclusion

We propose that beta-catenin stabilization increases its physical interaction with Gli1, leading to Gli1 degradation and inhibition of Hh signaling, thereby promoting tumor cell senescence and suppression of “tumor take” in mice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12943-015-0294-4) contains supplementary material, which is available to authorized users.

A retrospective study: the prevalence and prognostic value of anemia in patients undergoing radiotherapy for esophageal squamous cell carcinoma

Background

The relationship between anemia and outcomes after radiotherapy has not been systematically addressed. The study aimed to assess the prevalence and prognostic value of anemia in patients receiving primary radiotherapy for esophageal squamous cell carcinoma (ESCC).

Methods

A total of 103 patients with ESCC were retrospectively reviewed. Anemia was defined as a hemoglobin level <12 g/dl for men and <11 g/dl for women. The 3-year and 5-year overall survival (OS) and disease-free survival (DFS) were analyzed between the anemic and non-anemic groups using the Kaplan-Meier method and the Cox proportional hazards model.

Results

No significant differences were observed in patient characteristics between the anemic and non-anemic groups. The prevalence of anemia was 29.1%. The 3-year and the 5-year OS were 43% and 37%, respectively, in the non-anemic group, and 20% and 17%, respectively, in the anemic group. The 3-year and the 5-year DFS were 37% and 26%, respectively, in the non-anemic group, and 13% and 10%, respectively, in the anemic group. Survival analysis using the Kaplan-Meier method showed that there was significant difference between anemia and non-anemia (P < 0.02). In a multivariate analysis, anemia was identified as a highly significant prognostic factor for 3-year OS (hazard ratio 1.916; P = 0.012) and 3-year DFS (hazard ratio 1.973; P = 0.007), independent of T stage and the status of lymph nodes, and 5-year OS (hazard ratio 1.705; P = 0.027) and 5-year DFS (hazard ratio 1.980; P = 0.005), independent of TNM stage and the status of lymph nodes.

Conclusions

Anemia before primary radiotherapy was associated with poor prognosis and an increased risk of relapse, which may serve as a new prognostic factor for ESCC.

Anemia in malignancies: pathogenetic and diagnostic considerations

OBJECTIVES

The aim of this paper is to review the pathogenesis and diagnostic approaches to anemia in cancer patients.

METHODS

PubMed was queried for various combinations of anemia and cancer-related terms using appropriate filters for articles and practice guidelines published in the last 5 years. Specific searches were conducted for individual pathogenetic mechanisms and malignancies of specific anatomic sites.

RESULTS

Anemia is the commonest hematological manifestation of cancer, afflicting 40-64% of patients treated for malignancies. Pathophysiologically, cancer-related anemia can be classified into four broad but overlapping categories: hypoproliferative anemia including the common anemia of inflammation/chronic disease, hemolytic anemia, miscellaneous etiologies, and uncertain etiologies. Anemia incidence increases with the administration of chemotherapy/radiotherapy. It reduces the quality of life and shortens survival in cancer patients. A positive correlation is observed between anemia and tumor hypoxia. Experimentally, hypoxemia enhances tumor growth and resistance to therapy by stimulating angiogenesis, acquisition of genomic mutations, and increasing resistance to apoptosis as well as to the killing effects of chemo/radiotherapy-generated free radicals.

DISCUSSION

Diagnostic approaches to the anemic cancer patient begin with a detailed clinical history and physical examination. Peripheral blood morphology and reticulocyte count are also helpful. Patients with unexplained anemia are evaluated by standard approaches also used in patients of similar age without malignancy. Serum iron profile and bone marrow examination are often required in difficult cases. This review focuses on major aspects of the pathogenesis of the individual entities. Diagnostic approaches and uncommon causes including hemophagocytic lymphohistiocytosis, acquired hemoglobinopathies, and myelodysplasia are also discussed.

A retrospective study: the prognostic value of anemia, smoking and drinking in esophageal squamous cell carcinoma with primary radiotherapy

BACKGROUND

Few studies have investigated the relationship between anemia, smoking, drinking and survival in esophageal squamous cell carcinoma (ESCC) with primary radiotherapy. This study had the aim of evaluating the prognostic value of anemia, smoking and drinking in patients receiving primary radiotherapy for ESCC.

METHODS

A total of 79 patients who underwent radiotherapy during initial treatment for ESCC were included in this study. The 2-year overall survival (OS) and disease-free survival (DFS) were analyzed between the anemic and non-anemic groups, non-smokers and smokers, and non-drinkers and drinkers using the Kaplan-Meier method and the Cox proportional hazards model.

RESULTS

There were 79 patients (10 male) of median age 63 (range 38 to 84) years. The 2-year OS and DFS were 36% and 25%, respectively, in the non-anemic group, and 17% and 13%, respectively, in the anemic group (P = 0.019 for OS; P = 0.029 for DFS) using the Kaplan-Meier method. Survival analysis using the Kaplan-Meier method showed that the 2-year OS and DFS had no statistical difference between smoking, drinking and survival. In a univariate analysis, anemia was identified as a significant prognostic factor for 2-year OS (hazard ratio (HR) = 1.897; P = 0.024) and 2-year DFS (HR = 1.776; P = 0.036), independent of tumor, lymph node, metastasis (TNM) stage. In a multivariate analysis, anemia was identified as a highly significant prognostic factor for 2-year OS (HR = 2.125; P = 0.011) and 2-year DFS (HR = 1.898; P = 0.025), independent of TNM stage and initial treatment. We found no statistical difference in the 2-year OS and DFS associated with smoking (P > 0.2) and drinking (P > 0.6) using univariate and multivariate analysis.

CONCLUSIONS

Smoking and drinking were not prognostic for 2-year OS or DFS. Anemia before radiotherapy was associated with poor prognosis and an increased risk of relapse, which may serve as a new prognostic characteristic in ESCC treated with primary radiotherapy. Hemoglobin is a routine examination and anemia is therefore simple and quick to determine.