Is the prediction of prognosis not improved by the seventh edition of the TNM classification for colorectal cancer? Analysis of the surveillance, epidemiology, and end results (SEER) database

Comparison of short- and long-term outcomes between laparoscopic and open multivisceral resection for clinical T4b colorectal cancer: A multicentre retrospective cohort study in China

BACKGROUND

Laparoscopic surgery is controversial for patients with clinical T4b colorectal cancer (CRC) who require multivisceral resection (MVR). This study aims to explore and compare the safety and long-term oncological outcomes of laparoscopic surgery and open surgery for patients with clinical T4b CRC.

MATERIALS AND METHODS

This study was a retrospective cohort study based on a multicentre database. According to the operation method, the patients were divided into a laparoscopic MVR group and an open MVR group. The short-term and long-term outcomes were compared.

RESULTS

From January 2010 to December 2021, a total of 289 patients in the laparoscopic MVR group and 349 patients in the open MVR group were included. After propensity score matching, patients were stratified into a laparoscopic MVR group (n = 163) and an open MVR group (n = 163). Compared with the open MVR group, the laparoscopic MVR group had less blood loss (100 vs. 200, p < 0.001), a shorter time to first flatus (3 vs. 4, P < 0.001), a shorter postoperative hospital stay (10 vs. 12, P < 0.001), and a lower incidence of surgical site infection (2.5 % vs. 8.0 %, P = 0.043). The Kaplan-Meier curves showed that the two groups had similar overall survival (P = 0.283) and disease-free survival (P = 0.152).

CONCLUSION

Compared with open MVR, laparoscopic MVR had less blood loss, fewer surgical site infection complications, faster recovery and a shorter hospital stay. The long-term survival outcome of laparoscopic MVR was not inferior to that of open MVR.

Neoadjuvant Immune Checkpoint Inhibition Improves Organ Preservation in T4bM0 Colorectal Cancer With Mismatch Repair Deficiency: A Retrospective Observational Study

BACKGROUND

Colorectal cancer with mismatch repair deficiency is usually less aggressive and associated with a lower risk of distant metastasis. Immune checkpoint inhibition, rather than traditional chemoradiotherapy, has shown great advantages in treating such patients.

OBJECTIVE

This study aimed to verify the hypothesis that locally very advanced (T4b) colorectal cancer without distant metastases might present with higher probability of mismatch repair deficiency and be more sensitive to neoadjuvant immune checkpoint inhibition.

DESIGN

This study was designed as a single-center retrospective observational study.

SETTINGS

The study was conducted in a tertiary referral center in China.

PATIENTS

The study included patients who were clinically diagnosed with T4bM0 colorectal cancer from 2008 to 2019.

MAIN OUTCOME MEASURES

Clinicopathological characteristics, mismatch repair status, and survival outcomes of patients with mismatch repair deficiency were analyzed.

RESULTS

A total of 268 patients were included. The incidence of patients with mismatch repair deficiency in the T4bM0 population was 27.6% (75/268), with 84.0% (63/75) in the colon and 16.0% (12/75) in the rectum. For tumors located in the proximal colon, 45.0% (50/111) exhibited mismatch repair deficiency, whereas the incidence of mismatch repair deficiency in sigmoid colon cancer and rectal cancer was only 15.9% (25/157). Neoadjuvant immune checkpoint inhibition significantly reduced the open surgery rate ( p = 0.000) and multivisceral resection rate ( p = 0.025). The pathological complete remission rate in the neoadjuvant immune checkpoint inhibition group was significantly higher than that in neoadjuvant chemoradiotherapy/chemotherapy group (70.0% vs 0%; p = 0.004). No tumor downstaging was observed after neoadjuvant chemotherapy. Neoadjuvant immune checkpoint inhibition provided significantly better disease-free survival ( p = 0.0078) and relatively longer overall survival ( p = 0.15) than other groups.

LIMITATIONS

This study is limited by the possible selection bias and small sample size.

CONCLUSIONS

Our data depicted the high incidence of mismatch repair deficiency in T4bM0 mismatch repair deficiency and the effectiveness of the neoadjuvant immune checkpoint inhibition group in organ preservation. Precision oncology requires identification of the protein status of mismatch repair at initial diagnosis to make a rational treatment decision for these patients. See Video Abstract at http://links.lww.com/DCR/B952 .

LA INHIBICIN DEL PUNTO DE CONTROL INMUNITARIO NEOADYUVANTE MEJORA LA PRESERVACIN DE RGANOS EN EL CNCER COLORRECTAL TBM CON DEFICIENCIA DE REPARACIN DE ERRORES DE COINCIDENCIA UN ESTUDIO OBSERVACIONAL RETROSPECTIVO

ANTECEDENTES:Los pacientes con cáncer colorrectal con deficiencia en la reparación de desajustes suelen (dMMR) ser menos agresivos y se asocian con un menor riesgo de metástasis a distancia. La inhibición del punto de control inmunitario, en lugar de la quimiorradioterapia tradicional, ha mostrado grandes ventajas en el tratamiento de estos pacientes.OBJETIVO:Este estudio tuvo como objetivo verificar nuestra hipótesis de que el CCR localmente muy avanzado (T4b) sin metástasis a distancia podría presentarse con una mayor probabilidad de dMMR y ser más sensible a la inhibición del punto de control inmunitario neoadyuvante.DISEÑO:Este estudio fue diseñado como un estudio observacional retrospectivo de un solo centro.CONFIGURACIÓN:El estudio se realizó en un centro de referencia terciario en China.PACIENTES:Se incluyeron pacientes con diagnóstico clínico de CCR T4bM0 desde 2008 hasta 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron las características clinicopatológicas, el estado de MMR y los resultados de supervivencia de los pacientes con dMMR.RESULTADOS:Se incluyeron un total de 268 pacientes. La incidencia de dMMR en la población T4bM0 fue del 27,6% (75/268), con un 84,0% (63/75) en colon y un 16,0% (12/75) en recto. Para los tumores ubicados en el colon proximal, el 45,0% (50/111) exhibió dMMR, mientras que la incidencia de dMMR en el cáncer de colon sigmoideo y el cáncer de recto fue solo del 15,9% (25/157). La inhibición del punto de control inmunitario neoadyuvante redujo significativamente la cirugía abierta y la tasa de resección multivisceral ( p = 0,000 y p = 0,025, respectivamente). La tasa de PCR en el grupo de inhibición del punto de control inmunitario neoadyuvante fue significativamente mayor que en el grupo de quimiorradioterapia/quimioterapia neoadyuvante (70,0% frente a 0%, p = 0,004). No se observó reducción del estadio del tumor después de la quimioterapia neoadyuvante. La inhibición del punto de control inmunitario neoadyuvante proporcionó una supervivencia sin enfermedad significativamente mejor ( p = 0,0078) y una supervivencia general relativamente más larga ( p = 0,15) que otros grupos.LIMITACIONES:Este estudio está limitado por el posible sesgo de selección y el pequeño tamaño de la muestra.CONCLUSIONES:Nuestros datos representan la alta incidencia de dMMR en T4bM0 CRC y la eficacia del grupo de inhibición del punto de control inmunitario neoadyuvante en la preservación de órganos. La oncología de precisión requiere la identificación del estado de la proteína MMR en el diagnóstico inicial para tomar una decisión de tratamiento racional para estos pacientes especiales. Consulte el Video Resumen en http://links.lww.com/DCR/B952 . (Traducción-Dr. Yesenia Rojas-Khalil ).

Prognostic evaluation of cancer associated fibrosis and tumor budding in colorectal cancer

Colorectal carcinoma (CRC) is the second most common cancer and third leading cause of cancer-related deaths worldwide. Although the staging system provides a standardized guidance in treatment regimens, the clinical outcome in patients with colon cancer at the same TNM stage may vary dramatically. Thus, for better predictive accuracy, further prognostic and/or predictive markers are required. Patients who underwent curative surgery for colorectal cancer in past 3 years at a tertiary care hospital were retrospectively included in this cohort study to evaluate the prognostic indicators, tumor-stroma ratio (TSR) and tumor budding (TB) on histopathological sections and correlated them with pTNM staging, histopathological grading, tumor size, and lymphovascular and perineural invasion in patients with colo-rectal cancer. TB was strongly associated with advanced stage of the disease along with lympho-vascular and peri-neural invasion and it can be used as an independent adverse prognostic factor. TSR showed a better sensitivity, specificity, PPV and NPV as compared to TB in patients having poorly differentiated adenocarcinoma than those with moderately or well differentiated.

Comprehensive Review of Biomarkers for the Treatment of Locally Advanced Colon Cancer

Despite the implementation of global screening programs, colorectal cancer (CRC) remains the second leading cause of cancer-related deaths worldwide. More than 10% of patients with colon cancer are diagnosed as having locally advanced disease with a relatively poor five-year survival rate. Locally advanced colon cancer (LACC) presents surgical challenges to R0 resection. The advantages and disadvantages of preoperative radiotherapy for LACC remain undetermined. Although several reliable novel biomarkers have been proposed for the prediction and prognosis of CRC, few studies have focused solely on the treatment of LACC. This comprehensive review highlights the role of predictive biomarkers for treatment and postoperative oncological outcomes for patients with LACC. Moreover, this review discusses emerging needs and approaches for the discovery of biomarkers that can facilitate the development of new therapeutic targets and surveillance of patients with LACC.

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

Beyond N staging in colorectal cancer: Current approaches and future perspectives

Traditionally, lymph node metastases (LNM) evaluation is essential to the staging of colon cancer patients according to the TNM (tumor–node–metastasis) system. However, in recent years evidence has accumulated regarding the role of emerging pathological features, which could significantly impact the prognosis of colorectal cancer patients. Lymph Node Ratio (LNR) and Log Odds of Positive Lymph Nodes (LODDS) have been shown to predict patients’ prognosis more accurately than traditional nodal staging and it has been suggested that their implementation in existing classification could help stratify further patients with overlapping TNM stage. Tumor deposits (TD) are currently factored within the N1c category of the TNM classification in the absence of lymph node metastases. However, studies have shown that presence of TDs can affect patients’ survival regardless of LNM. Moreover, evidence suggest that presence of TDs should not be evaluated as dichotomic but rather as a quantitative variable. Extranodal extension (ENE) has been shown to correlate with presence of other adverse prognostic features and to impact survival of colorectal cancer patients. In this review we will describe current staging systems and prognostic/predictive factors in colorectal cancer and elaborate on available evidence supporting the implementation of LNR/LODDS, TDs and ENE evaluation in existing classification to improve prognosis estimation and patient selection for adjuvant treatment.

Tumor Stroma Ratio and Its Significance in Locally Advanced Colorectal Cancer

Colorectal cancer is the third leading cause of cancer-related death, and its incidence is rising in the younger patient population. In the past decade, research has unveiled several processes (underlying tumorigenesis, many of which involve interactions between tumor cells and the surrounding tissue or tumor microenvironment (TME). Interactions between components of the TME are mediated at a sub-microscopic level. However, the endpoint of those interactions results in morphologic changes which can be readily assessed at microscopic examination of biopsy and resection specimens. Among these morphologic changes, alteration to the tumor stroma is a new, important determinant of colorectal cancer progression. Different methodologies to estimate the proportion of tumor stroma relative to tumor cells, or tumor stroma ratio (TSR), have been developed. Subsequent validation has supported the prognostic value, reproducibility and feasibility of TSR in various subgroups of colorectal cancer. In this manuscript, we review the literature surrounding TME in colorectal cancer, with a focus on tumor stroma ratio.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CANCER SURVIVORS

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

Prognostic Factors Affecting Disease-Free Survival and Overall Survival in T4 Colon Cancer

PURPOSE

It is known that as the T stage of a carcinoma progresses, the prognosis becomes poorer. However, there are few studies about factors that affect the prognosis of T4 advanced colon cancer. This study aimed to identify the prognostic factors associated with disease-free survival (DFS) and overall survival (OS) in T4 colon cancer.

METHODS

Patients diagnosed with stage T4 on histopathology after undergoing curative surgery for colon cancer between March 2009 and March 2018 were retrospectively analyzed for factors related to postoperative survival. Primary outcomes were DFS and OS.

RESULTS

Eighty-two patients were included in the study. DFS and OS of the pathologic (p) T4b group were not inferior to that of the pT4a group. Multivariate analysis showed that differentiation (hazard ratio [HR], 4.994; P = 0.005), and laparoscopic surgery (HR, 0.323; P = 0.008) were significant prognostic factors for DFS, while differentiation (HR, 7.904; P ≤ 0.001) and chemotherapy (HR, 0.344; P = 0.038) were significant prognostic factors for OS.

CONCLUSION

Tumor differentiation, laparoscopic surgery, and adjuvant chemotherapy were found to be significant prognostic factors in patients with T4 colon cancer. Adjuvant chemotherapy and curative resections by laparoscopy might improve the prognosis in these patients.

Horizontal spread of pericolic lymph node metastasis as a prognostic factor for recurrence in Stage III colorectal cancer

AIM

Main lymph node (LN) metastasis dissected with a high vascular tie at the root of the feeding artery is a poor prognostic factor in colorectal cancer (CRC). However, the effects of horizontal spread on recurrence after curative resection remain unclear. The purpose of this study is to evaluate the relationship between the horizontal spread of LN metastasis and recurrence in CRC.

METHOD

In this retrospective study, 189 CRC patients (98 men, 91 women) who underwent curative resection at our hospital from 2003 to 2018 and had only pericolic LN metastasis were divided into two groups: patients with LN metastasis beside the tumour only (T group, n = 121) and those with LN metastasis with horizontal spread (S group, n = 68) (mean follow-up period 50.9 ± 34.1 months). The primary outcome was recurrence-free survival (RFS). We investigated the correlation between clinicopathological background factors and recurrence using Cox regression analysis.

RESULTS

Fewer than three LN metastases (N1) were found in 157 patients (107 T group, 50 S group), and four or more metastases (N2a) were found in 32 patients (14 T group, 18 S group). Univariate analyses revealed significantly shorter RFS in the S group [hazard ratio (HR) 1.95, 95% CI 1.07-3.55; p = 0.03). Multivariate analyses revealed that horizontal spread is an independent risk factor for recurrence (HR 1.95, 95% CI 1.05-3.68; p = 0.03).

CONCLUSION

Although further investigation is needed, horizontal spread of LN metastasis is a prognostic factor for recurrence in Stage III CRC.

Laparoscopic approach for T4 colon cancer can be associated with poor prognosis in right-sided T4b tumours

INTRODUCTION

Although recent studies have demonstrated the safety of laparoscopic surgery in T4 colon cancer, some patients could have poor prognosis. In this study, we aimed to analyse the risk factors affecting oncologic outcome of laparoscopic surgery.

MATERIALS AND METHODS

Among the 1033 T4 colon cancer patients collected from a multicentre database (2004-2017), 584 patients (458 T4a and 126 T4b) underwent laparoscopic approach for radical surgery. Risk factors associated with 3-year disease-free survival (DFS) and overall survival (OS) were evaluated through multivariate analysis. In addition, subgroups were classified using a combination of risk factors, and the survival rate was evaluated.

RESULTS

During this period, 188 (32.2%) had recurrence, and 151 (25.9%) died. In the multivariate analysis for oncologic outcome, elevated carcinoembryonic antigen level (hazard ratio [HR] 1.37) and absence of adjuvant chemotherapy (HR 1.60) were associated with poor DFS. T4b (HR 1.56, 1.46), right-sided location (HR 1.52, 1.42), and open conversion (HR 2.70, 2.12) were independently associated with both poor DFS and OS. When four subgroups were analysed through the combination of tumour location and T stage, the DFS and OS rates were significantly lower in patients with right-sided T4b cancer than in other groups (log-rank p < 0.001).

CONCLUSION

Right-sided T4b colon cancer for laparoscopic surgery may lead to poor oncologic outcome. This approach could be a caution in suspected cases preoperatively.

PNN and KCNQ1OT1 Can Predict the Efficacy of Adjuvant Fluoropyrimidine-Based Chemotherapy in Colorectal Cancer Patients

The benefit of adjuvant chemotherapy in the early stages of colorectal cancer (CRC) is still disappointing and the prediction of treatment outcome quite difficult. Recently, through a transcriptomic approach, we evidenced a role of PNN and KCNQ1OT1 gene expression in predicting response to fluoropyrimidine-based adjuvant chemotherapy in stage III CRC patients. Thus, the aim of this study was to validate in an independent cohort of stages II–III CRC patients our previous findings. PNN and KCNQ1OT1 mRNA expression levels were evaluated in 74 formalin-fixed paraffin-embedded tumor and matched normal mucosa samples obtained by stages II–III CRC patients treated with fluoropyrimidine-based adjuvant chemotherapy. PININ, the protein encoded by PNN, was immunohistochemically evaluated in 15 tumor and corresponding normal mucosa samples, selected on the basis of a low, medium, or high mRNA expression tumor/mucosa ratio. PNN and KCNQ1OT1 mRNA mean expression levels were significantly higher in tumor compared with normal tissues. Patients with high PNN or KCNQ1OT1 tumor mRNA levels according to ROC-based cutoffs showed a shorter disease-free survival (DFS) compared with patients with low tumor mRNA gene expression. Also, patients with tumor mRNA expression values of both genes below the identified cutoffs had a significantly longer DFS compared with patients with the expression of one or both genes above the cutoffs. In a representative large cohort of stages II–III CRC untreated patients retrieved from GEO datasets, no difference in DFS was observed between patients with high and low PNN or KCNQ1OT1 gene expression levels. These data confirm our previous findings and underscore the relevance of PNN and KCNQ1OT1 expression in predicting DFS in early stages of CRC treated with fluoropyrimidine-based adjuvant chemotherapy. If further validated in a prospective case series, both biomarkers could be used to identify patients who benefit from this treatment and to offer alternative chemotherapy regimens to potential unresponsive patients. In relation to the suggested biological role of PNN and KCNQ1OT1 in CRC, they might also be exploited as potential therapeutic targets.

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.

ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX-based neoadjuvant concurrent chemoradiation

Colorectal cancer (CRC) of the clinical tumor stage T4b (cT4b) refers to advanced tumors with direct invasion of adjacent structures and the tumors are considered unresectable. Despite advancements in aggressive surgery and combination chemotherapy, the prognosis of cT4b CRC remains poor. Optimizing the therapeutic sequence administered to patients with cT4b CRC to improve clinical outcomes is crucial. In the present study, patients with unresectable cT4b and nodal stage N1-2 CRC were investigated at a single institution. A total of 20 consecutive patients were treated with pre-operative concurrent chemoradiation by using 5-fluorouracil/leucovorin/oxaliplatin (FOLFOX) since February 2015 and were regularly followed up until March 2020. Due to their poor response to concurrent chemoradiation (CCRT) with FOLFOX, the chemotherapy regimen was changed to irinotecan plus 5-fluorouracil/leucovorin (FOLFIRI) as the second-line neoadjuvant treatment. Genetic alterations, such as microsatellite instability (MSI), were documented, and the expression levels of excision repair cross-complementing group 1 (ERCC1) and ERCC2 were examined. Of the 20 patients, the tumors of 14 patients (70%) became resectable after FOLFIRI administration. The median duration between the last date of radiotherapy and surgery was 32.7 weeks (range, 10.1–59.3 weeks). Of note, 4 of the 14 patients with resectable tumors (28.6%) achieved a pathologic complete response. The median overall survival and progression-free survival were 27.5 months (range, 12–39 months) and 27.5 months (range, 8–39 months), respectively. The cancerous specimens of all of the patients (100%) exhibited ERCC2 overexpression and 18 specimens (90%) had ERCC1 overexpression. Only one tumor (5%) exhibited high MSI. The present study indicated that ERCC overexpression associated with the poor response of FOLFOX-based CCRT and FOLFIRI after FOLFOX-based CCRT failure may have a potential role in conversion to resectable tumors by neoadjuvant treatment in cT4b CRC. However, a further prospective study with more patients is required to improve the precision of the conclusions.

Diffusion tensor imaging of rectal carcinoma: Clinical evaluation and its correlation with histopathological findings

OBJECTIVE

This study sought to assess the feasibility of diffusion tensor imaging (DTI) to noninvasively evaluate histological grade and lymph node metastasis in patients with rectal carcinoma (RC).

METHODS

Thirty-seven consecutive patients with histologically confirmed RC were examined by 1.5-T MRI. DTI was performed using a single-shot echo-planar imaging sequence with b values of 0 and 1000 s/mm² and motion-probing gradients in nine noncollinear directions. Fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) maps were compared with histopathological findings.

RESULTS

The FA values (0.357 ± 0.047) of the RCs were significantly lower than those of the normal rectal wall, muscle, prostate, and uterus (P < 0.001 for all), while the AD, MD, and RD values (1.221 ± 0.131, 0.804 ± 0.075, and 0.667 ± 0.057 × 10^-3 mm²/s, respectively) were also significantly lower than their respective normal values (P < 0.001 for all). The FA, AD, MD, and RD values for RC additionally showed significant inverse correlations with histological grades (r = -0.781, r = -0.750, r = -0.718, and r = -0.682, respectively; P < 0.001 for all). Further, the FA (0.430 vs. 0.611), AD (1.246 vs. 1.608 × 10^-3 mm²/s), MD (0.776 vs. 1.036 × 10^-3 mm²/s), and RD (0.651 vs. 0.824 × 10^-3 mm²/s) (P < 0.001 for all) of the metastatic and nonmetastatic lymph nodes were significantly different.

CONCLUSIONS

DTI may be clinically useful for the noninvasive evaluation of histological grade and lymph node metastasis in patients with RC.

Surgical management and hyperthermic intraperitoneal chemotherapy for locally advanced colorectal cancer

Locally advanced colorectal cancers (CRC) pose several management challenges, including local recurrence and the development of peritoneal metastases (PM). These recurrences are associated with a poor prognosis and onerous complications. In selected patients with PM, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have shown to confer survival benefit. However, its effectiveness depends on the disease extent and this combined treatment is associated with significant morbidity. Additionally, early detection of PM is difficult even with state-of-the-art imaging techniques. Due to the high-risk of developing PM, locally advanced CRC are currently being investigated in several trials, including adjuvant HIPEC in an attempt to reduce the risk of PM. This review article sets out to examine the current data available on this topic, in an attempt to determine the suitability and effectiveness of HIPEC in the management of locally advanced CRC.

Multiple treatment lines and prognosis in metastatic colorectal cancer patients

The proportion of patients with metastatic colorectal cancer (mCRC) receiving second or further lines of treatment has not been widely studied. To shed light on this issue, we retrospectively analysed the treatments administered for metastatic disease, and investigated prognostic factors after a diagnosis of metastases, in a consecutive cohort of mCRC patients. Three hundred forty-six mCRC patients were enrolled: 173 were stage II or III (metachronous group), and 173 stage IV (synchronous group) at diagnosis. Survival was calculated between the date of metastatic disease and the date of death or last follow-up. Patients with synchronous lesions more frequently had multiple disease sites, peritoneal carcinomatosis and massive liver deposits, whereas significantly more patients with metachronous lesions developed lung metastases as the sole disease site. 97.4% patients received at least one, 62.4% two, 41.9% three and 23.7% four treatment lines. Patients with metachronous metastases more frequently underwent surgery of metastases in first-line treatment (48.5 versus 24.8%), and more of them were progression-free at the time of the analysis (44 versus 34.9%). At univariate analysis, age > 70 years, multiple disease sites and peritoneal carcinomatosis were associated with significantly decreased survival, whereas surgery of metastases and isolated lung metastases predicted better survival. At multivariate analysis, only peritoneal carcinomatosis and surgery of metastases independently affected survival. The percentage of patients who received an active treatment decreased going from first- to fourth-line treatment. However, the proportion of patients who received efficacious treatment in advanced line remained high. Surgery of metastases was the most important prognostic factors.

Recurrence pattern and outcomes in T4 colon cancer: A single institution analysis

BACKGROUND AND OBJECTIVES

Patients with T4 colon adenocarcinoma have an increased risk of locoregional and distant recurrence. This study defines the metastatic pattern, predictors of recurrence, and efficacy of adjuvant treatment in T4 colon cancer.

METHODS

A retrospective review was performed of patients with T4 colon adenocarcinoma from May 2005 to November 2015 at a tertiary care hospital. Baseline factors, follow-up, recurrence, and survival were collected and analyzed.

RESULTS

Locoregional recurrence (LR) rates for N0, N1, and N2 were 21/85 (24.7%), 14/50 (28%), and 21/46 (45.7%), respectively (P = .014). Multivariate analysis for distant recurrence was significant for positive nodes (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1-9.9). Multivariate analysis for LR was significant for the following variables: perforation (HR, 2.7; 95% CI, 1.2-6.2), lymphovascular invasion (HR, 2.7; 95% CI, 1.1-6.7), positive nodes (HR, 2.8; 95% CI, 1.2-6.9), and positive margins (HR, 5.0; 95% CI, 2.1-12.1). Multivariate analysis for overall survival was significant for: signet ring histology (HR, 2.5; 95% CI, 1.2-5.8), positive nodes (HR, 2.3; 95% CI, 1.2-4.4), and positive margin (HR, 2.8; 95% CI, 1.4-5.8).

CONCLUSION

T4 colon adenocarcinoma has a high risk of LR and mortality. Clinical trials utilizing the aforementioned high-risk features may increase the ability to demonstrate beneficial intervention.

An Immunoscore System Based On CD3+ And CD8+ Infiltrating Lymphocytes Densities To Predict The Outcome Of Patients With Colorectal Adenocarcinoma

Purpose

The aim of this study was to evaluate the Immunoscore (IS) methodology as a prognostic marker of colorectal adenocarcinoma in Tunisian population. Tumor blocks were retrospectively collected from 106 patients with sporadic colorectal cancer.

Methods

Immunohistochemical staining and images analysis software were used to quantify the density of CD3⁺ and CD8⁺ tumor-infiltrating lymphocytes in the center of the tumor and invasive margin.

Results

The density of CD3⁺ and CD8⁺ was significantly associated with 5-year overall survival (P=0.001 and P=0.00098, respectively) and 5-year disease-free survival (P=0.0006 and P=0.0056, respectively). The earlier stage and the absence of vascular emboli showed a significant association with IS analysis. Cox multivariate regression analysis revealed that Immunoscore (from I0 to I4) was more significantly correlated with overall survival (P=0.00011) and disease-free survival (P=0.0008) than Tumor-Node-Metastasis (TNM) staging (P=0.057 and P=0.039, respectively). Patients with low IS were associated with inferior disease-free survival and overall survival, contrary to patients with high IS.

Conclusion

This is the first study which evaluated the prognostic value of IS methodology in colorectal cancer in African and Arabic population. The IS methodology carries out in this study allows to estimate the risk of relapse in patients with colorectal cancer. Overall, our results support the implementation of the consensus Immunoscore as a new component for the classification of cancer, designated TNM-Immune.

Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy

Background

Neoadjuvant chemoradiation is currently standard of care in stage II-III rectal cancer, resulting in tumor downstaging for patients with treatment-responsive disease. However, the prognosis of the downstaged patient remains controversial. This work critically analyzes the relative contribution of pre- and post-therapy staging to the anticipated survival of downstaged patients.

Methods

The National Cancer Database (NCDB) was queried for patients with rectal cancer treated with transabdominal resection between 2004 and 2014. Stage II-III patients downstaged with neoadjuvant radiation were compared with stage I patients treated with definitive resection alone. Patients with positive surgical margins were excluded. Overall survival was evaluated using both Kaplan-Meier analyses and Cox proportional hazards models. All statistical tests were two-sided.

Results

A total of 44 320 patients were eligible for analysis. Survival was equivalent for patients presenting with cT1N0 disease undergoing resection (mean survival = 113.0 months, 95% confidence interval [CI] = 110.8 to 115.3 months) compared with those downstaged to pT1N0 from both cT3N0 (mean survival = 114.9 months, 95% CI = 110.4 to 119.3 months, P = .12) and cT3N1 disease (mean survival = 115.4 months, 95% CI = 110.1 to 120.7 months, P = .22). Survival statistically significantly improved in patients downstaged to pT2N0 from cT3N0 disease (mean survival = 109.0 months, 95% CI = 106.7 to 111.2 months, P < .001) and cT3N1 (mean survival = 112.8 months, 95% CI = 110.0 to 115.7 months, P < .001), compared with cT2N0 patients undergoing resection alone (mean survival = 100.0 months, 95% CI = 97.5 to 102.5 months). Multiple survival analysis confirmed that final pathologic stage dictated long-term outcomes in patients undergoing neoadjuvant radiation (hazard ratio [HR] of pT2 = 1.24, 95% CI = 1.10 to 1.41; HR of pT3 = 1.81, 95% CI = 1.61 to 2.05; HR of pT4 = 2.72, 95% CI = 2.28 to 3.25, all P ≤ .001 vs pT1; HR of pN1 = 1.50, 95% CI = 1.41 to 1.59; HR of pN2 = 2.17, 95% CI = 2.00 to 2.35, both P < .001 vs pN0); while clinical stage at presentation had little to no predictive value (HR of cT2 = 0.81, 95% CI = 0.69 to 0.95, P = .008; HR of cT3 = 0.83, 95% CI = 0.72 to 0.96, P = .009; HR of cT4 = 1.02, 95% CI = 0.85 to 1.21, P = .87 vs cT1; HR of cN1 = 0.96, 95% CI = 0.91 to 1.02, P = .19; HR of cN2 = 0.96, 95% CI = 0.86 to 1.08, P = .48 vs cN0).

Conclusions

Survival in patients with rectal cancer undergoing neoadjuvant radiation is driven by post-therapy pathologic stage, regardless of pretherapy clinical stage. These data will further inform prognostic discussions with patients.

RNA sequencing reveals PNN and KCNQ1OT1 as predictive biomarkers of clinical outcome in stage III colorectal cancer patients treated with adjuvant chemotherapy

Five-year overall survival of stage III colorectal cancer (CRC) patients treated with standard adjuvant chemotherapy (ACHT) is highly variable. Genomic biomarkers and/or transcriptomic profiles identified lack of adequate validation. Aim of our study was to identify and validate molecular biomarkers predictive of ACHT response in stage III CRC patients by a transcriptomic approach. From a series of CRC patients who received ACHT, two stage III extreme cohorts (unfavorable vs. favorable prognosis) were selected. RNA-sequencing was performed from fresh frozen explants. Tumors were characterized for somatic mutations. Validation was performed in stage III CRC patients extracted from two GEO datasets. According to disease-free survival (DFS), 108 differentially expressed genes (104/4 up/downregulated in the unfavorable prognosis group) were identified. Among 104 upregulated genes, 42 belonged to olfactory signaling pathways, 62 were classified as pseudogenes (n = 17), uncharacterized noncoding RNA (n = 10), immune response genes (n = 4), microRNA (n = 1), cancer-related genes (n = 14) and cancer-unrelated genes (n = 16). Three out of four down-regulated genes were cancer-related. Mutational status (i.e., RAS, BRAF, PIK3CA) did not differ among the cohorts. In the validation cohort, multivariate analysis showed high PNN and KCNQ1OT1 expression predictive of shorter DFS in ACHT treated patients (p = 0.018 and p = 0.014, respectively); no difference was observed in untreated patients. This is the first study that identifies by a transcriptomic approach and validates PNN and KCNQ1OT1 as molecular biomarkers predictive of chemotherapy response in stage III CRC patients. After a further validation in an independent cohort, PNN and KCNQ1OT1 evaluation could be proposed to prospectively identify stage III CRC patients benefiting from ACHT.

Prognosis Prediction of Colorectal Cancer Using Gene Expression Profiles

Background: Investigation on prognostic markers for colorectal cancer (CRC) deserves efforts, but data from China are scarce. This study aimed to build a prognostic algorithm using differentially expressed gene (DEG) profiles and to compare it with the TNM staging system in their predictive accuracy for CRC prognosis in Chinese patients. Methods: DEGs in six paired tumor and corresponding normal tissues were determined using RNA-Sequencing. Subsequently, matched tumor and normal tissues from 127 Chinese patients were assayed for further validation. Univariate and multivariate Cox regressions were used to identify informative DEGs. A predictive index (PI) was derived as a linear combination of the products of the DEGs and their Cox regression coefficients. The combined predictive accuracy of the DEGs-based PI and tumors' TNM stages was also examined by a logistic regression model including the two predictors. The predictive performance was evaluated with the area under the receiver operating characteristics (AUCs). Results: Out of 75 candidate DEGs, we identified 10 DEGs showing statistically significant associations with CRC survival. A PI based on these 10 DEGs (PI-10) predicted CRC survival probability more accurately than the TNM staging system [AUCs for 3-year survival probability 0.73 (95% confidence interval: 0.64, 0.81) vs. 0.68 (0.59, 0.76)] but comparable to a simplified PI (PI-5) using five DEGs (LOC646627, BEST4, KLF9, ATP6V1A, and DNMT3B). The predictive accuracy was improved further by combining PI-5 and the TNM staging system [AUC for 3-year survival probability: 0.72 (0.63, 0.80)]. Conclusion: Prognosis prediction based on informative DEGs might yield a higher predictive accuracy in CRC prognosis than the TNM staging system does.

Significance of lymph node metastasis in the survival of stage IV colorectal cancer by hematogenous metastasis

Purpose

Although lymph node (LN) metastasis is an important prognostic marker of colorectal cancer (CRC), the effect of LN metastasis on the survival of stage IV CRC is debated yet.

Methods

LN status and survivals as well as clinicopathological features of synchronous stage IV CRC patients, operated for 8 years, were analyzed. Patients with hematogenous metastases were included only but those with peritoneal seeding or preoperative adjuvant therapy were not included.

Results

Total 850 patients were enrolled and 77 (9.1%) were without LN metastases (N0M1). N0M1 patients were older and have favorable pathological features including lower CEA than patients with LN metastasis (N + M1). The pathologically poor features accumulated with N stage progression within N + M1. N0M1 had better 5-year overall survival (OS) and disease free survival than N + M1. And 5-year OS's within N + M1 group were stratified and different according to N stage progression, although the effect of N stage progression is different according to curative resection or not. When compared with stage III, 5-year OS of N0M1 with curative resection was comparable to that of anyTN2aM0 and was better than anyTN2bM1.

Conclusion

LN metastasis is a significant prognostic factor in stage IV by hematogenous metastasis, too. N stage progression accumulates pathologically poor prognostic factors. However, the effect on survival of each N stage progression differs depending on curative resection or not of the hematogenous metastases.

Do Patients with Second Primary Colorectal Cancer Hold the Similar Prognosis and Therapeutic Benefits as Those with Initial Primary Colorectal Cancer?

Aim

The objective is to compare the differences on prognosis and the therapeutic benefits between initial and second primary colorectal cancer (pCRC).

Methods

A dataset containing 377,271 initial pCRC cases and 18,617 second pCRC cases from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 1988-2015 was evaluated. Survival comparisons were made using the log-rank test. Cox proportional hazards models were used to assess the survival benefits.

Results

The cancer-specific survival rate of patients with initial pCRC was significantly higher than that of patients with second pCRC (5-years survival rate: 64.85% vs. 60.22%, P<0.001). The Chi-square of stratified log rank for age at diagnosis was lower than that for primary site, pTNM stage, sex, race, histology, and grade (Chi-square=86.73). There were almost no differences on therapeutic benefits between patients with initial and second pCRC except that treatments with chemotherapy were significantly associated with longer survival rate compared with treatments without chemotherapy among stage III surgical initial and second primary left-sided colon cancers patients (HR=0.764 vs. 0.581; P for interaction =0.008).

Conclusion

Patients with second pCRC have worse prognosis than those with initial pCRC primarily because of older age in the former group. The results evidenced that the therapeutic benefits on the prognosis for colorectal cancer were generally similar between patients with initial and second pCRC.

Noninferiority of three months versus six months of oxaliplatin-based adjuvant chemotherapy for resected colon cancer. How should IDEA findings affect clinical practice?

The eagerly awaited results of the multi-continental International Duration Evaluation of Adjuvant Chemotherapy (IDEA) project have recently been presented at major oncological meetings. The 3-year disease-free survival (DFS) was presented for 12,834 Stage III colon cancer patients in a pooled analysis of 6 individual noninferiority phase III randomized trials, all investigating three versus six months of oxaliplatin-based adjuvant therapy. Noninferiority (NI) could not be demonstrated for the whole population as the DFS hazard ratio (HR) of 1.07 with its 95% CI of 1.00-1.15 crossed the postulated NI boundary of 1.12. However, there was an expected reduction in the incidence of specific side effects with the three months treatment. NI could be demonstrated for the T3N1 subgroup (∼60% of patients, HR for DFS 1.01, 95% CI 0.90-1.12). Moreover, NI was also declared for the subgroup treated with the CAPOX regimen (capecitabine plus oxaliplatin, ∼40% of patients), but the CAPOX choice was physician-based and not subject to randomization. Overall, the IDEA results indicate that three months of therapy might be adequate for most of Stage III tumors; however, a small subset of these patients still have high risk of recurrence and death with short treatment duration. Precise predictors of benefit need to be identified, nonetheless tumor-intrinsic factors, such as tumor stage, might currently be considered as useful tools to inform the decision-making process.

Lymph node ratio as a valuable prognostic factor for patients with colorectal liver-only metastasis undergoing curative resection

Background

Recent studies have suggested that the lymph node ratio (LNR) is a prognostic indicator for various malignancies. However, LNR has not been evaluated in colorectal liver-only metastasis (CRLM). This study aimed to investigate the prognostic value of LNR in patients with CRLM after curative resection.

Patients and methods

We retrospectively investigated the clinicopathologic features of 154 CRLM patients who underwent curative resection between 2005 and 2015. We classified patients into low and high groups based on their LNR by using the X-tile software. Survival curves were plotted through Kaplan–Meier method and compared by log-rank test. Cox proportional hazards analysis was performed to identify the factors associated with recurrence-free survival (RFS) and overall survival (OS).

Results

The patients were divided into two groups in which 124 patients were identified as LNR ≤0.33 and 30 patients as LNR >0.33. Compared to low LNR, high LNR was significantly associated with poor 3-year RFS (47.2% vs 16.7%, P=0.001) and OS (72.8% vs 45.3%, P=0.003) rates. Multivariate analysis indicated that the LNR was an independent predictor for 3-year RFS (hazard ratio, 2.124; 95% CI, 1.339–3.368; P=0.001) and OS (HR, 2.287; 95% CI, 1.282–4.079; P=0.005). However, the node (N) stage and lymph node distribution were not significantly associated with the 3-year RFS (P=0.071, P=0.226) or OS (P=0.452, P=0.791) in patients with CRLM.

Conclusion

This study demonstrated that LNR was an independent predictor for 3-year RFS and OS in patients with CRLM who underwent curative resection and that its prognostic value was superior to that of N stage and lymph node distribution.

The tumour-stroma ratio in colon cancer: the biological role and its prognostic impact

The tumour microenvironment consists of a complex mixture of non-neoplastic cells, including fibroblasts, immune cells and endothelial cells embedded in the proteins of the extracellular matrix. The tumour microenvironment plays an active role in tumour behaviour. By interacting with cancer cells, it influences disease progression and the metastatic capacity of the tumour. Tumours with a high amount of stroma correspond to poor patient prognosis. The tumour-stroma ratio (TSR) is a strong independent prognostic tool in colon cancer and provides additional value to the current clinically used tumour-node-metastasis classification. The TSR is assessed on conventional haematoxylin and eosin-stained paraffin sections at the invasive front of the tumour. Here we review studies demonstrating the prognostic significance of the TSR in solid epithelial tumours with a focus on colon cancer. Moreover, the biological role of the tumour microenvironment during tumour progression and invasion will be discussed, as well as the attempts to target the tumour stroma for therapeutic purposes. We suggest that the TSR can be implemented with little effort and without additional costs in current routine pathology diagnostics owing to its simplicity and reliability.

Upregulation of c-mesenchymal epithelial transition expression and RAS mutations are associated with late lung metastasis and poor prognosis in colorectal carcinoma

The present study aimed to investigate whether c-mesenchymal epithelial transition factor (C-MET) overexpression combined with RAS (including KRAS, NRAS and HRAS) or BRAF mutations were associated with late distant metastases and the prognosis of patients with colorectal cancer (CRC). A total of 374 patients with stage III CRC were classified into 4 groups based on RAS/BRAF and C-MET status for comprehensive analysis. Mutations in RAS/BRAF were determined using Sanger sequencing and C-MET expression was examined using immunohistochemistry. The associations between RAS/BRAF mutations in combination with C-MET overexpression and clinicopathological variables including survival were evaluated. In addition, their predictive value for late distant metastases were statistically analyzed via logistic regression and receiver operating characteristic analysis. Among 374 patients, mutations in KRAS, NRAS, HRAS, BRAF and C-MET overexpression were observed in 43.9, 2.4, 0.3, 5.9 and 71.9% of cases, respectively. Considering RAS/BRAF mutations and C-MET overexpression, vascular invasion (P=0.001), high carcino-embryonic antigen level (P=0.031) and late distant metastases (P<0.001) were more likely to occur in patients of group 4. Furthermore, survival analyses revealed RAS/BRAF mutations may have a more powerful impact on survival than C-MET overexpression, although they were both predictive factors for adverse prognosis. Further logistic regression suggested that RAS/BRAF mutations and C-MET overexpression may predict late distant metastases. In conclusion, RAS/BRAF mutations and C-MET overexpression may serve as predictive indicators for metastatic behavior and poor prognosis of CRC.

Over-expression of AURKA, SKA3 and DSN1 contributes to colorectal adenoma to carcinoma progression

Development of colorectal cancer (CRC) involves sequential transformation of normal mucosal tissues into benign adenomas and then adenomas into malignant tumors. The identification of genes crucial for malignant transformation in colorectal adenomas (CRAs) has been based primarily on cross-sectional observations. In this study, we identified relevant genes using autologous samples. By performing genome-wide SNP genotyping and RNA sequencing analysis of adenocarcinomas, adenomatous polyps, and non-neoplastic colon tissues (referred as tri-part samples) from individual patients, we identified 68 genes with differential copy number alterations and progressively dysregulated expression. Aurora A, SKA3, and DSN1 protein levels were sequentially up-regulated in the samples, and this overexpression was associated with chromosome instability (CIN). Knockdown of SKA3 in CRC cells dramatically reduced cell growth rates and increased apoptosis. Depletion of SKA3 or DSN1 induced G2/M arrest and decreased migration, invasion, and anchorage-independent growth. AURKA and DSN1 are thus critical for chromosome 20q amplification-associated malignant transformation in CRA. Moreover, SKA3 at chromosome 13q was identified as a novel gene involved in promoting malignant transformation. Evaluating the expression of these genes may help identify patients with progressive adenomas, helping to improve treatment.

T4 Colon Cancer - Current Management

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor’s stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

Lymph Node Ratio as a Risk Factor for Recurrence After Adjuvant Chemotherapy in Stage III Colorectal Cancer

BACKGROUND

Although several markers, including the lymph node ratio (LNR), have been proposed as a clinically prognostic tool for colorectal cancer (CRC), it remains unclear which markers have the most relevance in determining recurrence following adjuvant chemotherapy for stage III CRC.

METHODS

Independent risk factors for recurrence-free survival (RFS) were retrospectively determined using the Cox proportional hazard model in 360 stage III CRC patients and validated using an independent cohort comprising 172 stage III CRC patients.

RESULTS

The LNR was independently associated with RFS (HR, 1.96; 95% CI, 1.11 to 3.28; P = 0.020). A higher LNR value was significantly associated with recurrence, microsatellite stable, and shorter time to recurrence. A combination of the LNR with pre-chemotherapy CEA and CA19-9, other independent risk factors, provided accurate risk stratification of RFS and conferred additional information on recurrence within each stage III CRC subgroup, which was then validated in an independent cohort. A beneficial effect in patients at risk of recurrence, and a reduced effect in patients at low risk, was exhibited by the addition of oxaliplatin to 5-fluorouracil-based adjuvant chemotherapy.

CONCLUSION

A higher LNR is one of the most aggressive phenotypes with recurrence risk following adjuvant chemotherapy for stage III CRC.

Combined detection of the expression of Nm23-H1 and p53 is correlated with survival rates of patients with stage II and III colorectal cancer

Molecular tumor markers hold considerable promise for accurately predicting the recurrence and progression of colorectal cancer (CRC) in patients. However, in the majority of cases, single marker analysis has been found to have low accuracy, and is of little practical use in clinical practice. The present study investigated the prognostic value of the combined detection of the protein expression of metastasis suppressor 23-H1 (Nm23-H1) and p53 using immunohistochemical analysis, and the mRNA expression levels were analyzed using reverse transcription-quantitative polymerase chain reaction in 110 cases of stage II and III CRC. The results revealed that the expression levels of Nm23-H1 in CRC tissues were lower, compared with those in normal tissues (χ²=18.249; P<0.001), and the protein expression levels of p53 were higher in the CRC tissues (χ²=23.940; P<0.001); although the mRNA expression levels of Nm23-H1 and p53 presented with the same trend. The protein expression of Nm23-H1 was correlated with lymph node metastases (χ²=11.847; P=0.001) and pathological patterns (χ²=6.911; P=0.032). However, it did not correlate with patient gender or age, or with tumor World Health Organization classification or invasive depth (P>0.05). No significant correlation was observed between the expression of p53 and clinicopathological features (P>0.05). Patients with CRC with Nm23-H1(+)/p53(−) tumors had increased survival rates, with a five-year overall survival rate of 83.8% and a five-year disease-free survival rate of 70.2%. The five-year overall survival rates in other study cohorts were lower, compared with the Nm23-H1(+)/p53(−) group (P<0.0125), and this was the same for the five-year disease-free survival rate (P<0.0125). In conclusion, the present study demonstrated that the combined detection of the protein expression of Nm23-H1 and p53 was associated with the long term survival rates of patients with stage II and III CRC; and this may offer potential for use as a predictor of survival rates in patients with CRC.

Koelreuteria Formosana Extract Induces Growth Inhibition and Cell Death in Human Colon Carcinoma Cells via G2/M Arrest and LC3-II Activation-Dependent Autophagy

Autophagy is a self-destructive process that degrades cytoplasmic constituents. In our previous study, Koelreuteria formosana ethanolic extract (KFEE), which is obtained from natural plants endemic to Taiwan, has inhibited cell metastasis in renal carcinoma cells. However, the anticancer effects of KFEE on colon cancer remain unclear. In this study, KFEE exerted a strong cytotoxic effect on DLD-1 and COLO 205 human colorectal cancer cell lines. KFEE effectively inhibited cancer cell proliferation, induced G2/M-phase arrest associated with downregulaton of cyclin E, cyclin B and cdc25C and upregulation of p21, and induced cell death by activating autophagy but did not cause apoptotic cell death. Exposed KFEE cells showed increased levels of acridine orange, autophagic vacuoles, and LC3-II proteins, which are specific autophagic markers. Bcl-2, p-Akt, and p-mTOR levels, which have been implicated in autophagic downregulation, were decreased after KFEE treatment. Autophagy inhibitor 3-methyladenosine and bafilomycin-A1 and genetic silencing of LC3 attenuated KFEE-induced growth inhibition. These findings suggested that KFEE causes cytostatic effect through autophagy. In xenograft studies, oral administration of KFEE had significantly inhibited the tumor growth in nude mice that had received subcutaneous injection of DLD-1 cells. KFEE is a promising candidate in phytochemical-based, mechanistic, and pathway-targeted cancer prevention strategies.

Case Report: Collision Tumour of Colon Leiomyosarcoma and Adenocarcinoma

The colon is an exceedingly rare site of primary leiomyosarcoma and only a few cases have been published to date. Of the reported cases of collision tumours, collision tumours that specifically occurred in the colon have consisted of combinations of adenoma or adenocarcinoma with lymphomas or neuroendocrine tumours. Here, not only do we report a case of colon leiomyosarcoma, but we report, what is to our knowledge, the first case of collision tumour consisting of colon leiomyosarcoma and adenocarcinoma. Cause, prognosis, and treatment of colon collision tumours vary and are yet to be understood.

A report of the frequency of colorectal carcinoma and involved lymph nodes in South-West Iran

Context:

The colorectal cancer (CRC) is the most common malignancy between men and women. CRC has considerable morbidity and mortality, with more than 1000,000 new cases and 500,000 annual deaths. Regional lymph nodes are most common sites of metastasis from colon cancer. Lymph node involvement is an essential factor in enabling the accurate evaluation of prognosis in CRC patients.

Aims:

In this study, we focused on the frequency of CRC and involved lymph nodes and adequacy of lymph node dissection in patients who referred to the Oncology and Radiotherapy Department of Golestan Hospital in Ahvaz City located in South-West Iran.

Setting and Design:

We conducted a retrospective study among patients receiving surgical treatment for CRC in the Department of Oncology and Radiotherapy of Golestan Hospital in Ahvaz City located in South-West Iran between 2001 and 2010.

Methods and Materials:

All patients who underwent resection for CRC by open or laparoscopic approaches were included in the study. Data were collected from patients’ medical records.

Statistical Analysis Used:

Statistical data were analyzed using SPSS 21.

Results:

A total of 585 cases with CRC aged from16 to 89 years with mean age of 53-year-old were studied. Average number of dissected nodes was 8 lymph nodes, and lymph nodes were not found in pathology specimen of 61 cases (10.4%). In 199 patients (34.01%), number of dissected lymph nodes was 12 or more and in 386 patients (65.98%), number of dissected lymph nodes was <12.

Conclusion:

This study revealed a large amount of patients that had been under over treatment with radiotherapy and the following inability. Lack of removal of sufficient tissue by the surgeon during surgery or an inadequate sample check by a pathologist might lead to an inability to correct staging of the disease as well as the inability to determine the treatment program of the patients and over treatment with radiotherapy and chemotherapy.

Overexpression of the S100A2 protein as a prognostic marker for patients with stage II and III colorectal cancer

We aimed to identify a novel prognostic biomarker related to recurrence in stage II and III colorectal cancer (CRC) patients. Stage II and III CRC tissue mRNA expression was profiled using an Affymetrix Gene Chip, and copy number profiles of 125 patients were generated using an Affymetrix 250K Sty array. Genes showing both upregulated expression and copy number gains in cases involving recurrence were extracted as candidate biomarkers. The protein expression of the candidate gene was assessed using immunohistochemical staining of tissue from 161 patients. The relationship between protein expression and clinicopathological features was also examined. We identified 9 candidate genes related to recurrence of stage II and III CRC, whose mRNA expression was significantly higher in CRC than in normal tissue. Of these proteins, the S100 calcium-binding protein A2 (S100A2) has been observed in several human cancers. S100A2 protein overexpression in CRC cells was associated with significantly worse overall survival and relapse-free survival, indicating that S100A2 is an independent risk factor for stage II and III CRC recurrence. S100A2 overexpression in cancer cells could be a biomarker of poor prognosis in stage II and III CRC recurrence and a target for treatment of this disease.

Effect of Lymph Node Count on Pathological Stage III Rectal Cancer with Preoperative Radiotherapy

Lymph node (LN) status after surgery for rectal cancer is affected by preoperative radiotherapy. The purpose of this study was to perform a population-based evaluation of the impact of pathologic LN status after neoadjuvant radiotherapy on survival. A total of 1,650 patients receiving neoadjuvant chemotherapy in Surveillance, Epidemiology, and End Results Program (SEER)-registered ypIII stage rectal cancer was analyzed. We identified the optimal cutoff for retrieved LNs as 10 (χ2 = 14.006, P < 0.001), which was validated as an independent prognosis factors in a Cox regression model. Further analysis showed that the LN count was only a prognosis factor with the number from 8 to 16(except for 13).After the number 16, the 5-year survival rate decreased gradually. Collectively, our results confirmed that the number of LNs in yp III stage rectal patients was a prognosis factor only with the numbers from 8 to 16(except for 13). Using the total mesorectal excision technique with an adequate pathologic examination, a large number of LNs retrieved (≥17) might indicate worse tumor response grade and poorer survival.

Increased number of negative lymph nodes is associated with improved cancer specific survival in pathological IIIB and IIIC rectal cancer treated with preoperative radiotherapy

Preoperative radiation significantly decreases the number of retrieved lymph nodes (LNs) in rectal cancer, but little is known with respect to the prognostic significance of negative LN (NLN) counts under these circumstances. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered ypIII stage rectal cancer patients, and patients from Fudan University Shanghai Cancer Center (FDSCC) were combined and analyzed. The results showed that the survival rate of patients with n (cutoff) or more NLNs increased gradually when n ranged from two to nine. After n reached 10 or greater, survival rates were approximately equivalent. Furthermore, the optimal cutoff value of 10 was validated as an independent prognostic factor in stage ypIIIB and ypIIIC patients by both univariate and multivariate analysis (P < 0.001); the number of NLNs could also stratify the prognosis of ypN(+) patients in more detail. Patients in the FDSCC set validated these findings and confirmed that NLN count was not decreased in the good tumor regression group relative to the poor tumor regression group. These results suggest that NLN count is an independent prognostic factor for ypIIIB and ypIIIC rectal cancer patients, and, together with the number of positive LNs, this will provide better prognostic information than the number of positive LNs alone.

Tumor deposit is a poor prognostic indicator in patients who underwent simultaneous resection for synchronous colorectal liver metastases

BACKGROUND

Tumor deposits are one of the important influencing factors among the different editions of Tumor, Node, Metastasis classification. Incidence and prognosis of tumor deposits in stage I, II, and III colorectal cancer patients has been explored. The aim of this study was to determine the prognostic value of tumor deposits in stage IV colorectal cancer patients who underwent simultaneous resection for synchronous colorectal liver metastases (SCRLM).

METHODS

Clinicopathological and outcome data of 146 consecutive SCRLM patients who underwent simultaneous R0 resection between July 2003 and July 2013 were collected from our prospectively established SCRLM database. The prognostic value of tumor deposits was evaluated by Kaplan-Meier and Cox regression analysis.

RESULTS

Tumor deposits were detected in 41.8% (61/146) of these SCRLM patients. Tumor deposits were significantly correlated with lymph node metastasis and nerve invasion of the primary tumors (P=0.002, P=0.041; respectively). The Kaplan-Meier survival analysis revealed that the overall survival (OS) and disease-free survival (DFS) of SCRLM patients with tumor deposits were significantly poorer than those with no tumor deposits (P=0.039, P=0.001; respectively). And with multivariate analysis, we found that positive tumor deposits were significantly associated with shorter DFS independent of lymph node status (P=0.002). Subgroup analysis found that of the 57 SCRLM patients with negative lymph node status, the OS and DFS of patients with positive tumor deposits were significantly shorter than those with negative tumor deposits (P=0.002 and P=0.031, respectively). Of the 89 patients with positive lymph node status, the OS of patients with tumor deposits was not significantly different than those without tumor deposits (P=0.965); however, the DFS of patients with tumor deposits was significantly shorter than those with no tumor deposits (P=0.034).

CONCLUSION

Tumor deposits may be an independent adverse prognostic factor in SCRLM patients who underwent simultaneous R0 resection.

Lymph node count after preoperative radiotherapy is an independently prognostic factor for pathologically lymph node-negative patients with rectal cancer

Recent studies indicated that preoperative radiotherapy significantly reduces the lymph nodes (LNs) harvest from patients with rectal cancer. This may weaken the prognostic value of current standard of LNs retrieval (≥12 LNs). This study investigates the prognostic impact of the LN counts on pathologically LN-negative (ypN0) after preoperative radiotherapy for patients with rectal cancer.Surveillance, Epidemiology and End Results (SEER) registered nonmetastatic rectal cancer patients diagnosed between 1998 and 2005 were included in this study. Optimal cutoff value for number of LNs retrieved was determined by X-tile program. Log-rank tests were adopted to compare the rectal cause specific survival (RCSS) for ypN0 patients using separated cutoff value of LN counting from 2 to 20. Correlation between LN count and tumor regression was investigated in an additional 221 patients from Fudan University Shanghai Cancer Center (FUSCC).The results showed that there were fewer number of LNs examined in patients with preoperative radiotherapy than those without (8.9 vs 10.9, P < 0.001). X-tile program identified the difference in survival was most significant (maximum of χ log-rank values) for the number 4. And 5-year RCSS increased accordingly with the cutoff values ranging from 4 to 15, which were confirmed as optimal cutoff and validated as independent prognostic factors in multivariate regression analysis (χ = 50.65, P < 0.001). Patients in FUSCC set were found to have fewer LNs retrieval in group of good tumor regression than in that of poor one (P = 0.01).These results confirmed the reduced number of LN retrieval in patients with rectal cancer treated with preop-RT. LN count is still an independently prognostic factor for ypN0 rectal cancer.

Combined microsatellite instability and BRAF gene status as biomarkers for adjuvant chemotherapy in stage III colorectal cancer

BACKGROUND

The clinical relevance of combined microsatellite instability (MSI) and BRAF status for adjuvant treatment in stage III colorectal cancer (CRC) remains elusive.

METHODS

In 405 patients with curatively resected stage III CRC, the prognostic value of combined MSI and BRAF status was assessed in four groups, as follows: high-levels of microsatellite instability (MSI-H) and BRAF-wild type, MSI-H and BRAF-mutation, microsatellite stable (MSS) and BRAF-wild type, and MSS and BRAF-mutation.

RESULTS

Combined MSI and BRAF status provided significant prognostic stratification of disease-free survival (DFS), and was independently associated with worse DFS. The MSI-H and BRAF-wild type group had similar outcomes to stage II CRC patients, despite no benefit from 5-FU monotherapy. Further, patients in the MSS and BRAF-wild type group with stage IIIA CRC had favorable outcomes to 5-FU monotherapy, similar to those with stage II CRC. In contrast, 5-FU monotherapy was insufficient among patients in the MSS and BRAF-wild type group with stage IIIB or IIIC CRC or patients in the MSS and BRAF-mutation group with stage III CRC.

CONCLUSIONS

The combination of MSI and BRAF status serves as both a prognostic and predictive marker and may provide much-needed guidance during the planning of therapeutic strategies.

TMPRSS4 correlates with colorectal cancer pathological stage and regulates cell proliferation and self-renewal ability

Transmembrane protease/serine 4 (TMPRSS4) is a member of the type II transmembrane serine protease (TTSP) family and it was found highly expressed in several cancers. This study aims to evaluate the expression of TMPRSS4 in colorectal cancer (CRC) and investigate its role in proliferation and self-renewal of colon cancer cells. qRT-PCR and immunohistochemistry were used to detect the mRNA and protein expression level of TMRPSS4 in CRC samples respectively. Loss of function assay was conducted with RNAi technique. Cell proliferation was done with WST-8 assay; cell apoptosis and cell cycle analysis were performed with flow cytometry; invasion and migration were done with transwell assay. Plate and soft agarose clonogenic assays were used to detect clone-formation ability. CD44 and CD133 expressions were analyzed by flow cytometry and western blot. We found that TMPRSS4 was highly expressed in CRC tissues both at mRNA and protein level and correlated with pathological stage. Knockdown of TMPRSS4 in highly expressed colon cancer cell line HCT116 resulted in inhibition of cell proliferation, induction of cell apoptosis and suppression of invasion and migration; moreover, knockdown of TMPRSS4 suppressed the in vitro clone-formation ability of HCT116 and reduced the expressions of CD44 and CD133. The findings in this research showed that TMPRSS4 was associated with CRC stage and regulated the proliferation and self-renewal ability of colon cancer cells; TMRPSS4 was involved in the development and progression of CRC.