Prognostic Analysis of Lymphovascular Invasion in Stages I-III Colorectal Cancer: A Retrospective Study Based on Propensity Score Match

INTRODUCTION

Lymphovascular invasion (LVI) is a micropathological tumor factor believed to increase the risk of tumor metastasis and spread. Propensity score matching (PSM) is a statistical method that can control confounding factors. Current research rarely considers the confounding relationship between LVI and other factors that may influence prognosis. This study aimed to investigate the relationship between LVI and prognosis in patients with stage I-III colorectal cancer (CRC) by using propensity score matching (PSM).

METHODS

This was a retrospective study involving 610 patients. PSM was used to adjust for baseline differences between the groups. The survival rates were calculated. A nomogram was constructed based on the Cox proportional hazards model before matching. The C-index, receiver operating characteristic curve (ROC), and calibration curve were used to evaluate the nomogram.

RESULTS

A total of 150 patients tested positive for LVI, accounting for 24.6% of the total, and 120 couples of patients were identified after PSM. The survival curve and Cox proportional hazards model after matching confirmed the adverse effects of LVI on tumor prognosis. The Cox proportional hazards model before matching showed that age, carcinoembryonic antigen level, T stage, N stage, histologic grade and LVI were independent prognostic factors. The C-index of the nomogram established based on the Cox proportional hazards model was 0.787 (95% CI=0.728-0.845). The areas under the curve were 0.796 in the 3-year ROC.

CONCLUSIONS

LVI is an adverse prognostic factor in patients with stage I-III colorectal cancer.

Multiple High-Risk Features for Stage II Colon Carcinoma Portends Worse Survival Than Stage III Disease

BACKGROUND

High-risk features in stage II colon cancer worsen survival and serve as an impetus for adjuvant chemotherapy. Limited data exist on the effect of multiple high-risk features on survival.

OBJECTIVE

The study aimed to compare the survival of 0, 1, or multiple high-risk features in stage II to stage III colon cancer.

DESIGN

Patients with stage II and III colon cancer diagnosed between 2010 and 2016 were identified using the Survival, Epidemiology, and End Results database. Patients with stage II colon cancer were then classified according to the presence of 0, 1, or 2 or more of the following high-risk features: pathologic T4, perineural invasion, fewer than 12 lymph nodes assessed, or poor histologic differentiation. Overall survival and cause-specific survival were calculated. Each group was then stratified on the basis of whether chemotherapy was given.

SETTINGS

This study used the Survival, Epidemiology, and End Results database (2010-2016).

PATIENTS

Patients who had stage II or III colon cancer were included.

MAIN OUTCOME MEASURES

The primary outcome measures were 5-year overall survival and cause-specific survival.

RESULTS

A total of 65,831 patients were studied. Of these, 18,056 patients with stage II cancer had 0 high-risk features, 9426 had 1 high-risk feature, and 3503 had 2 or more high-risk features. There were 34,842 patients diagnosed with stage III disease. The 5-year overall survival and cause-specific survival for patients with stage II cancer with 2 or more high-risk features (49.2%, 59.5%) were lower than those without high-risk features (74.9%, 90.7%), with 1 high-risk feature (67.1%, 82.4%), or stage III disease (59.1%, 68.1%; p < 0.05). Although chemotherapy is associated with improved cause-specific survival in stage III disease, it is associated with worse cause-specific survival in patients with stage II disease.

LIMITATIONS

This study being a retrospective database analysis is the main limitation. Also, lymphovascular invasion, margin status, and clinical obstruction or perforation were absent from the dataset.

CONCLUSIONS

Multiple high-risk features in stage II colon cancer predict worse survival than lymph node metastasis. Chemotherapy is associated with adverse cause-specific survival in patients with stage II disease. Further study into this group should focus on the type and duration of adjuvant therapy and biological features of these tumors. See Video Abstract at http://links.lww.com/DCR/B929 .

MLTIPLES CARACTERSTICAS DE ALTO RIESGO PARA EL CARCINOMA DE COLON EN ESTADIO II PRESAGIAN PEOR SUPERVIVENCIA QUE LA ENFERMEDAD EN ESTADIO III

ANTECEDENTES:Las características de alto riesgo en el cáncer de colon en estadio II empeoran la supervivencia y sirven como impulso para la quimioterapia adyuvante. Existen datos limitados sobre el efecto de múltiples características de alto riesgo en la supervivencia.OBJETIVO:Comparar la supervivencia de cero, una o múltiples características de alto riesgo en el cáncer de colon en estadio II con la enfermedad en estadio III.DISEÑO:Los pacientes con cáncer de colon en estadio II y III diagnosticados entre 2010 y 2016 se identificaron mediante la base de datos de supervivencia, epidemiología y resultados finales. Luego, los pacientes en etapa II se clasificaron según la presencia de cero, 1 o 2+ de las siguientes características de alto riesgo: T4 patológico, invasión perineural, menos de 12 ganglios linfáticos evaluados (< 12 ganglios linfáticos) o mala diferenciación histológica. Se calculó la supervivencia observada y específica de la causa. Luego, cada grupo se estratificó en función de si se administró quimioterapia.ESCENARIO:Este estudio utilizó la base de datos de supervivencia, epidemiología y resultados finales, 2010-2016.PACIENTES:Los pacientes tenían cáncer de colon en estadio II o III.PRINCIPALES MEDIDAS DE RESULTADO:La medida principal fue la supervivencia observada a 5 años y la supervivencia por causa específica.RESULTADOS:Se estudiaron un total de 65,831 pacientes. 18,056 pacientes estaban en estadio II sin características de alto riesgo, 9.426 con 1 característica de alto riesgo y 3.503 con 2+ características de alto riesgo. Hubo 34.842 pacientes a los que se les diagnosticó enfermedad en estadio III. La supervivencia observada a los 5 años y la supervivencia específica de la causa para los pacientes con cáncer en estadio II con 2+ características de alto riesgo (49.2 %, 59.5 %) fueron más bajas, en comparación con aquellos sin características de alto riesgo (74.9 %, 90.7 %), con 1 característica de alto riesgo (67.1 %, 82.4 %) o enfermedad en estadio III (59.1 %, 68.1 %) (p < 0.05). Si bien la quimioterapia se asocia con una mejor supervivencia por causa específica en la enfermedad en estadio III, se asocia con una peor supervivencia por causa específica en pacientes con enfermedad en estadio II.LIMITACIONES:Este es un análisis de base de datos retrospectivo. La invasión linfovascular, el estado de los márgenes y la obstrucción o perforación clínicas estaban ausentes en la base de datos.CONCLUSIONES:Múltiples características de alto riesgo en el cáncer de colon en estadio II predicen una peor supervivencia que la metástasis en los ganglios linfáticos. La quimioterapia se asocia con una supervivencia específica de causa adversa en pacientes con enfermedad en estadio II. El estudio adicional de este grupo deberá centrarse en el tipo y la duración de la terapia adyuvante y las características biológicas de estos tumores. Consulte Video Resumen en http://links.lww.com/DCR/B929 . (Traducción-Dr. Jorge Silva Velazco ).

Is High-Grade Tumor Budding an Independent Prognostic Factor in Stage II Colon Cancer?

BACKGROUND

Risk factors, including lymphatic, vascular, and perineural invasion, are considered indications for adjuvant treatment in stage II colon cancer. However, tumor budding is not included in the above risk factors.

OBJECTIVE

This study aimed to assess the value of tumor budding as a prognostic factor in stage II colon cancer.

DESIGN

This is a retrospective cohort study.

SETTINGS

This study was conducted in a tertiary referral center.

PATIENTS

This study examined 1390 patients with stage II colon cancer who received curative resection from 2007 to 2013 at an institution.

INTERVENTIONS

These patients were classified according to tumor budding status: low-grade tumor budding (less than 10 buds) and high-grade tumor budding (10 buds or more). Differences between the 2 groups were corrected by propensity score matching.

MAIN OUTCOME MEASURES

Disease-free survival and overall survival were the primary end points.

RESULTS

Among 1390 patients, 146 (10.5%) had high-grade tumor budding. The high-grade tumor budding group showed adverse histological characteristics such as advanced T stage, histological grade of differentiation, and presence of lymphatic/perineural invasion. After matching, the 5-year disease-free survival rate for the high-grade tumor budding group was significantly lower than for the low-grade group. We also compared survival outcomes according to tumor budding grade for patients who did not have risk factors and did not receive adjuvant treatment. The 5-year overall survival was similar between the 2 groups. However, the 5-year disease-free survival decreased significantly in the high-grade tumor budding group than in the low-grade tumor budding group.

LIMITATIONS

This was a retrospective study with a single-center design.

CONCLUSIONS

High-grade tumor budding is a poor prognostic factor in stage II colon cancer and is considered one of the risk factors for adjuvant treatment. See Video Abstract at http://links.lww.com/DCR/B962 .

ES LA GEMACIN TUMORAL UN FACTOR PRONSTICO INDEPENDIENTE EN EL CNCER DE COLON EN ESTADIO II

ANTECEDENTES:Los factores de riesgo, incluida la invasión linfática/vascular/perineural, se consideran indicaciones para el tratamiento adyuvante en el cáncer de colon en estadio II. Sin embargo, la gemación tumoral (desdiferenciación tumoral aislada), no está incluida en los factores de riesgo anteriores.OBJETIVO:El objeto de este estudio fue evaluar el valor de la gemación tumoral como factor pronóstico en el cáncer de colon en estadio II.DISEÑO:Este es un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se realizó en un centro de referencia terciario.PACIENTES:Este estudio analizó 1390 pacientes con cáncer de colon en estadio II que recibieron una resección curativa entre 2007 y 2013 en una institución.INTERVENCIONES:Estos pacientes se clasificaron según el estado de gemación tumoral: gemación tumoral de bajo grado (<10 yemas) y gemación tumoral de alto grado (≥10 yemas). Las diferencias entre los dos grupos se corrigieron mediante el emparejamiento por puntaje de propensión.PRINCIPALES MEDIDAS DE VALORACIÓN:La supervivencia libre de enfermedad y la supervivencia global fueron los puntos finales primarios.RESULTADOS:Entre 1.390 pacientes, 146 (10,5%) tenían brotes tumorales de alto grado. El grupo de gemación tumoral de alto grado mostró características histológicas adversas como estadio T avanzado, grado histológico de diferenciación y presencia de invasión linfática/perineural. Después del emparejamiento, la tasa de supervivencia libre de enfermedad a cinco años para el grupo de brotes de tumores de alto grado fue significativamente menor que para el grupo de bajo grado. También comparamos los resultados de supervivencia según el grado de gemación del tumor para pacientes que no tenían factores de riesgo y que no recibieron tratamiento adyuvante. La supervivencia global a cinco años fue similar entre los dos grupos. Sin embargo, la supervivencia libre de enfermedad a cinco años disminuyó significativamente en el grupo de brotes de tumores de alto grado que en el grupo de brotes de tumores de bajo grado.LIMITACIONES:Este fue un estudio retrospectivo con un diseño de centro único.CONCLUSIÓNES:La gemación tumoral de alto grado es un factor de mal pronóstico en el cáncer de colon estadio II y se considera uno de los factores de riesgo para el tratamiento adyuvante. Consulte Video Resumen en http://links.lww.com/DCR/B962 . (Traducción-Dr. Ingrid Melo ).

Recurrence-Free Survival Outcomes Based on Novel Classification Combining Lymphovascular Invasion, Perineural Invasion, and T4 Status in Stage II-III Colon Cancer

Background

T4 tumor, lymphovascular invasion (LVI) and perineural invasion (PNI) are regarded as one of risk factors and associated with poor outcomes in colorectal cancer. The relationship between these three combined risk factors and the prognosis for colon cancer is not yet clear. The purpose of this study was to evaluate the prognostic value of combining the risk factors T4 tumor, LVI, and PNI in stage II–III colon cancer.

Methods

Between January 2011 and December 2019, we retrospectively reviewed the medical records of patients who underwent curative resection for stage II–III colon cancer at four Hallym University-affiliated hospitals. These patients are categorized into three groups based on T4, LVI and PNI: no-risk group (no risk factors), low-risk group (one risk factor), and high-risk group (two or more risk factors).

Results

Of 1684 patients, the incidence of no-, low-, and high-risk group were 49.3%, 32.6%, 18.0%, respectively. The median follow-up period was 48.9 months, and the 5-year recurrence-free survival (RFS) rate decreased from 78.5% to 58.7% as the number of risk factors increased (P < 0.001). Cox’s proportional hazard regression models showed that T4 (P < 0.001), LVI (P = 0.043), and PNI (P = 0.018) were independent prognostic factors for poor RFS. In subgroup analysis in stage II colon cancer, patients with one or more risk factors showed the better 5-year RFS rate when they received adjuvant chemotherapy than in those who did not (P < 0.001). Poor/mucinous differentiation, obstruction, and lymph-node positivity were independent predictors in the high risk group.

Conclusion

The present study showed the histological combination of LVI, PNI, and T4 indicates a poor prognosis for RFS in patients with stage II–III colon cancer. Therefore, patients with one of these risk factors should be considered for chemotherapy and have close follow-up.

The Prognostic Reliability of Lymphovascular Invasion for Patients with T3N0 Colorectal Cancer in Adjuvant Chemotherapy Decision Making

Simple Summary

This retrospective analysis evaluated the prognostic implications of lymphovascular invasion (LVI) associated with adjuvant chemotherapy in 1634 patients with pT3N0 colorectal cancer. Extensive pathologic review and dual immunohistochemical (IHC) staining with CD31 and D2-40 were undertaken in a subset of 242 patients to determine the reliability of LVI as a prognostic factor. The diagnosis of LVI and PNI changed in 82 (33.9%) and 61 (25.2%) patients, respectively, after central pathologic review (mean follow up duration, 50 (1–114) months). Five-year recurrence-free survival (RFS) and overall survival (OS) rates were 92% and 94.8%, respectively. Before and after pathologic review, LVI was not associated with OS but was associated with RFS after reviewing patients with pT3N0 colorectal cancer. In this patient cohort, the prognostic implications of LVI may have been underrecognized when using hematoxylin and eosin staining slides only for pathologic diagnoses, possibly leading to low recurrence prediction rates.

Abstract

Lymphovascular invasion (LVI) is a high-risk feature guiding decision making for adjuvant chemotherapy. We evaluated the prognostic importance and reliability of LVI as an adjuvant chemotherapy indicator in 1634 patients with pT3N0 colorectal cancer treated with curative radical resection between 2012 and 2016. LVI and perineural invasion (PNI) were identified in 382 (23.5%) and 269 (16.5%) patients, respectively. In total, 772 patients received adjuvant chemotherapy. The five-year recurrence-free survival (RFS) and OS rates were 92% and 94.8%, respectively. Preoperative obstruction, PNI, and positive margins were significantly associated with RFS and OS; however, adjuvant chemotherapy and LVI were not. Pathologic slide central reviews of 242 patients using dual D2-40 and CD31 immunohistochemical staining was performed. In the review cohort, the diagnosis of LVI and PNI was changed in 82 (33.9%) and 61 (25.2%) patients, respectively. Reviewed LVI, encompassing small vessel invasion, lymphatic invasion, and large vessel invasion, was not an independent risk factor associated with OS but was related to RFS. The prognostic importance of LVI and adjuvant chemotherapy was not defined because LVI may be underrecognized in pathologic diagnoses using hematoxylin and eosin staining slides only, leading to low recurrence rate predictions. Using LVI as a guiding factor for adjuvant chemotherapy requires further consideration.

Postoperative chemotherapy improves survival in patients with resected high-risk Stage II colorectal cancer: results of a systematic review and meta-analysis

AIM

The aim was to assess the benefit of adjuvant chemotherapy in high-risk Stage II colorectal cancer.

METHOD

A systematic literature review and meta-analysis was performed comparing survival in patients with resected Stage II colorectal cancer and high-risk features having postoperative chemotherapy vs no chemotherapy.

RESULTS

Of 1031 articles screened, 29 were included, reporting on 183 749 participants. Adjuvant chemotherapy significantly improved overall survival [hazard ratio (HR) 0.61, P < 0.0001], disease-specific survival (HR = 0.73, P = 0.05) and disease-free survival (HR = 0.59, P < 0.0001) compared to no chemotherapy. Adjuvant chemotherapy significantly increased 5-year overall survival (OR = 0.53, P = 0.0008) and 5-year disease-free survival (OR = 0.50, P = 0.001). Overall survival and disease-free survival remained significantly prolonged during subgroup analysis of studies published from 2015 onwards (HR = 0.60, P < 0.0001; HR = 0.65, P = 0.0001; respectively), in patients with two or more high-risk features (HR = 0.59, P = 0.0001; HR = 0.70, P = 0.03; respectively) and in colon cancer (HR = 0.61, P < 0.0001; HR = 0.51, P = 0.0001; respectively). Overall survival, disease-specific survival and disease-free survival during subgroup analysis of individual high-risk features were T4 tumour (HR = 0.58, P < 0.0001; HR = 0.50, P = 0.003; HR = 0.75, P = 0.05), < 12 lymph nodes harvested (HR = 0.67, P = 0.0002; HR = 0.80, P = 0.17; HR = 0.72, P = 0.02), poor differentiation (HR = 0.84, P = 0.35; HR = 0.85, P = 0.23; HR = 0.61, P = 0.41), lymphovascular or perineural invasion (HR = 0.55, P = 0.05; HR = 0.59, P = 0.11; HR = 0.76, P = 0.05) and emergency surgery (HR = 0.60, P = 0.02; HR = 0.68, P = 0.19).

CONCLUSION

Adjuvant chemotherapy in high-risk Stage II colorectal cancer results in a modest survival improvement and should be considered on an individual patient basis. Due to potential heterogeneity and selection bias of the included studies, and lack of separate rectal cancer data, further large randomized trials with predefined inclusion criteria and standardized chemotherapy regimens are required.

Long-term outcome after one-stage surgery without preoperative decompression for stage II/III malignant colorectal obstruction: a propensity score-matched analysis

PURPOSE

Whether malignant colorectal obstruction (MCO) after one-stage curative surgery without preoperative decompression has a poor prognosis remains unclear. We assessed long-term outcomes of one-stage surgery without preoperative decompression for stage II/III MCO.

METHODS

We retrospectively enrolled patients with stage II/III colorectal cancer (CRC) between April 2011 and December 2017. Propensity score-matched (PSM) analysis was used to reduce the possibility of selection bias.

RESULTS

In total, 464 stage II/III CRC patients were identified, of which 145 (31%) had obstruction (MCO group) and 319 (69%) did not (non-MCO group). In the MCO group, 59 (40.7%) had emergency MCO (E-MCO) and 86 (59.3%) had semi-emergency MCO (SE-MCO). The median follow-up was 37.0 (range 0-86.5) months. The tumor was deeper and larger, and serum carcinoembryonic antigen level was higher (p < 0.001, respectively) in the MCO group (including E-MCO and SE-MCO). Venous invasion-positivity rate was significantly higher (MCO and SE-MCO only, p = 0.003 and 0.009, respectively) than that in the non-MCO group. Laparoscopic surgery rate was significantly lower (MCO and E-MCO only, p < 0.001) than that in the non-MCO group. Before PSM, disease-free survival (DFS) of the SE-MCO patients was worse than that of the non-MCO patients (p = 0.046). After PSM, DFS was not significantly different between the non-MCO and MCO, E-MCO, and SE-MCO groups (p = 0.619, 0.091, and 0.308, respectively).

CONCLUSIONS

Long-term prognosis in patients with stage II/III MCO after one-stage surgery without preoperative decompression was similar to that in patients without MCO.

Lymphovascular invasion is a high risk factor for stage I/II colorectal cancer: a systematic review and meta-analysis

The prognostic value of lymphovascular invasion (LVI) in stage I/II colorectal cancer (CRC) does not reach a consensus. To systematically assess prognostic significance of LVI, databases of PubMed, Web of Science, and Embase were searched from inception up to 10 Dec 2016. The pooled hazard ratio (HR) and 95% confidence intervals (CI) were used to determine the prognostic effects. Nineteen relevant studies including 9881 total patients were enrolled. Our results showed that LVI is significantly associated with poor prognosis in overall survival (OS) (HR=2.15, 95 % CI=1.72–2.68, P < 0.01) and disease-free survival (DFS) (HR=1.73, 95% CI=1.50–1.99, P < 0.01), which is similar in stage II patients. Further subgroup analysis revealed that the significance of the association between LVI and worse prognosis in CRC patients is not affected by below factors, including geographic setting, LVI positive rate, treatment, tumor site, and quality of the study. The current meta-analysis suggests that LVI may be a poor prognostic factor for stage I/II CRC patients.