Use of surgery among elderly patients with stage IV colorectal cancer

Primary Tumor Resection Before Systemic Therapy in Patients With Colon Cancer and Unresectable Metastases: Combined Results of the SYNCHRONOUS and CCRe-IV Trials

PURPOSE

Chemotherapy is established as primary treatment in patients with stage IV colorectal cancer and unresectable metastases. Data from nonrandomized clinical trials have fueled persistent uncertainty if primary tumor resection (PTR) before chemotherapy prolongs survival. We investigated the prognostic value of PTR in patients with newly diagnosed stage IV colon cancer who were not amenable to curative treatment.

PATIENTS AND METHODS

Patients enrolled in the multicenter, randomized SYNCHRONOUS and CCRe-IV trials were included in the analysis. Patients with colon cancer with synchronous unresectable metastases were randomly assigned at 100 sites in Austria, Germany, and Spain to undergo PTR or up-front chemotherapy (No PTR group). The chemotherapy regimen was left at discretion of the local team. Patients with tumor-related symptoms, inability to tolerate surgery and/or systemic chemotherapy, and history of another cancer were excluded. The primary end point was overall survival (OS), and the analyses were performed with intention-to-treat.

RESULTS

A total of 393 patients were randomly assigned to undergo PTR (n = 187) or no PTR (n = 206) between November 2011 and March 2017. Chemotherapy was not administered to 6.4% in the No PTR group and 24.1% in the PTR group. The median follow-up time was 36.7 months (95% CI, 36.6 to 37.3). The median OS was 16.7 months (95% CI, 13.2 to 19.2) in the PTR group and 18.6 months (95% CI, 16.2 to 22.3) in the No PTR group (P = .191). Comparable OS between the study groups was further confirmed on multivariate analysis (hazard ratio, 0.944 [95% CI, 0.738 to 1.209], P = .65) and across all subgroups. Patients with serious adverse events were more common in the No PTR group (10.2% v 18.0%; P = .027).

CONCLUSION

Among patients with colon cancer and synchronous unresectable metastases, PTR before systemic chemotherapy was not associated with prolonged OS.

Treatment of primary cancer in metastatic hormone-sensitive prostate cancer

PURPOSE OF REVIEW

Recently, there has been emerging interest in the treatment of primary tumours in metastatic prostate cancer based on major trials that have provided evidence for radiation therapy and cytoreductive radical prostatectomy. Preclinical studies have further established the molecular features of metastatic disease that provide a rationale for primary treatment.

RECENT FINDINGS

Several randomised controlled trials and other prospective studies have demonstrated a benefit in overall survival, predominantly in low-volume disease. Advancements in precision medicine also offer insight into improving selection, staging and monitoring.

SUMMARY

In this review, the authors highlight and review recent data on emerging and established treatment options and shift towards personalised medicine for hormone-sensitive metastatic prostate cancer.

Development and validation of a clinical survival model for young-onset colorectal cancer with synchronous liver-only metastases: a SEER population-based study and external validation

Background

The morbidity and mortality of young-onset colorectal cancer (YO-CRC) patients have been increasing in recent years. Moreover, YO-CRC patients with synchronous liver-only metastases (YO-CRCSLM) have various survival outcomes. Therefore, the purpose of this study was to construct and validate a prognostic nomogram for patients with YO-CRCSLM.

Methods

The YO-CRCSLM patients were rigorously screened from the Surveillance, Epidemiology, and End Results (SEER) database in January 2010 and December 2018 and then assigned to a training and validation cohort randomly (1488 and 639 patients, respectively). Moreover, the 122 YO-CRCSLM patients who were enrolled in The First Affiliated Hospital of Nanchang University were served as a testing cohort. The variables were selected using the multivariable Cox model based on the training cohort and then developed a nomogram. The validation and testing cohort were used to validate the model's predictive accuracy. The calibration plots were used to determine the Nomogram's discriminative capabilities and precision, and the decision analysis (DCA) was performed to evaluate the Nomogram's net benefit. Finally, the Kaplan-Meier survival analyses were performed for the stratified patients based on total nomogram scores classified by the X-tile software.

Results

The Nomogram was constructed including ten variables: marital status, primary site, grade, metastatic lymph nodes ratio (LNR), T stage, N stage, carcinoembryonic antigen (CEA), Surgery, and chemotherapy. The Nomogram performed admirably in the validation and testing group according to the calibration curves. The DCA analyses showed good clinical utility values. Low-risk patients (score<234) had significantly better survival outcomes than middle-risk (234-318) and high-risk (>318) patients (P < 0.001).

Conclusion

A nomogram predicting the survival outcomes for patients with YO-CRCSLM was developed. In addition to facilitating personalized survival prediction, this nomogram may assist in developing clinical treatment strategies for patients with YO-CRCSLM who are undergoing treatment.

Primary tumor resection in colorectal cancer patients with unresectable distant metastases: a minireview

Colorectal cancer (CRC) is the second most common cause of cancer-related death among both men and women worldwide and the third most common cancer overall. About 20% of patients diagnosed with CRC were discovered to have distant metastatic lesions, the majority of which were located in the liver. For the optimum treatment of CRC patients with hepatic metastases, interventional radiologists, medical oncologists, and surgeons must all collaborate. The surgical excision of the primary tumor is an important part of CRC treatment since it has been found to be curative in cases of CRC with minimal metastases. However, given the evidence to date was gathered from retrospective data, there is still controversy over the effectiveness of primary tumor resection (PTR) in improving the median overall survival (OS) and quality of life. Patients who have hepatic metastases make up a very tiny fraction of those who are candidates for resection. With a focus on the PTR, this minireview attempted to review the current advancements in the treatment options for hepatic colorectal metastatic illness. This evaluation also included information on PTR's risks when performed on individuals with stage IV CRC.

Survival nomograms for colorectal carcinoma patients with lung metastasis and lung-only metastasis, based on the SEER database and a single-center external validation cohort

Background

We analysed the survival of colorectal cancer (CRC) patients with lung metastasis and lung-only metastasis and determined the risk factors for lung metastasis in CRC patients.

Methods

Data from colorectal cancer patients with lung metastasis diagnosed from 2010 to 2015 were obtained from the SEER database. Survival was analysed using the Kaplan–Meier method and log-rank test, the Cox proportional hazards regression model, and a competing risk model. The predictive ability of the nomgram was assessed by the concordance index (C-index) and calibration curves. The data from the SEER database for the period 2016–2019 was used as an external validation set. The characteristics of 70 CRC patients treated at Shanghai East Hospital between 2016 and 2019 were retrospectively analysed and data from China was chosen as an external validation set.

Results

The median survival time for colorectal cancer patients with lung metastasis was 12 months, while this value was 24 months in patients with lung-only metastasis. Among all CRC patients with lung metastasis, age, grade, T stage, N stage, presence of liver, brain or bone metastasis, anatomic site and surgery were related to overall survival (OS). In CRC patients with lung-only metastasis, age, T stage, marital status, chemotherapy and surgery were independent prognostic factors affecting OS. Two nomograms predicting OS were established, with great discrimination (C-index between 0.67 and 0.81) and excellent calibration. Factors including age, race, sex, tumour grade, T stage, N stage, presence of liver, brain or bone metastasis, marital status, insurance status and anatomic location were related to the occurrence of lung metastasis in CRC patients.

Conclusion

We developed two reliable clinical prediction models among CRC patients to predict the OS rates in patients with lung metastasis and lung metastasis only.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02547-9.

Subtilisin from Bacillus amyloliquefaciens induces apoptosis in breast cancer cells through ubiquitin-proteasome-mediated tubulin degradation

To search for novel proteases from environmental isolates which can induce apoptosis in cancer cells, we have purified subtilisin from Bacillus amyloliquefaciens and studied its anti-cancer properties. Subtilisin induced apoptosis in colon (HT29) and breast (MCF7) cancer cells but showed no effect on mouse peritoneal macrophages and normal breast cells (MCF10A). Western blot analysis showed that Bax, Bcl-2 level remained unchanged but tubulin level decreased significantly. Subtilisin does not induce the intrinsic pathway of apoptosis, rather it induced tubulin degradation in MCF-7 cells, whereas in normal cells (MCF-10A) tubulin degradation was not observed. Subtilisin activates ubiquitination and proteasomal-mediated tubulin degradation which was completely restored in presence of proteasome inhibitor MG-132. We further observed PARKIN, one of the known E3-ligase, is overexpressed and interacts with tubulin in subtilisin treated cells. Knockdown of PARKIN effectively downregulates ubiquitination and inhibits degradation of tubulin. PARKIN activation and tubulin degradation lead to ER-stress which in turn activates caspase-7 and PARP cleavage, thus guiding the subtilisin treated cells towards apoptosis. To our knowledge this is the first report of subtilisin induced apoptosis in cancer cells by proteasomal degradation of tubulin.

Metallic Nanoparticles for the Modulation of Tumor Microenvironment; A New Horizon

Cancer is one of the most critical human challenges which endangers many people’s lives every year with enormous direct and indirect costs worldwide. Unfortunately, despite many advanced treatments used in cancer clinics today, the treatments are deficiently encumbered with many side effects often encountered by clinicians while deploying general methods such as chemotherapy, radiotherapy, surgery, or a combination thereof. Due to their low clinical efficacy, numerous side effects, higher economic costs, and relatively poor acceptance by patients, researchers are striving to find better alternatives for treating this life-threatening complication. As a result, Metal nanoparticles (Metal NPs) have been developed for nearly 2 decades due to their important therapeutic properties. Nanoparticles are quite close in size to biological molecules and can easily penetrate into the cell, so one of the goals of nanotechnology is to mount molecules and drugs on nanoparticles and transfer them to the cell. These NPs are effective as multifunctional nanoplatforms for cancer treatment. They have an advantage over routine drugs in delivering anticancer drugs to a specific location. However, targeting cancer sites while performing anti-cancer treatment can be effective in improving the disease and reducing its complications. Among these, the usage of these nanoparticles (NPs) in photodynamic therapy and sonodynamic therapy are notable. Herein, this review is aimed at investigating the effect and appliances of Metal NPs in the modulation tumor microenvironment which bodes well for the utilization of vast and emerging nanomaterial resources.

Treatment of Stage IV Colon Cancer in the United States: A Patterns-of-Care Analysis

BACKGROUND

National guidelines recommend chemotherapy as the mainstay of treatment for stage IV colon cancer, with primary tumor resection (PTR) reserved for patients with symptomatic primary or curable disease. The aims of this study were to characterize the treatment modalities received by patients with stage IV colon cancer and to determine the patient-, tumor-, and hospital-level factors associated with those treatments.

METHODS

Patients diagnosed with stage IV colon cancer in 2014 were extracted from the SEER Patterns of Care initiative. Treatments were categorized into chemotherapy only, PTR only, PTR + chemotherapy, and none/unknown.

RESULTS

The total weighted number of cases was 3,336; 17% of patients received PTR only, 23% received chemotherapy only, 41% received PTR + chemotherapy, and 17% received no treatment. In multivariable analyses, compared with chemotherapy only, PTR + chemotherapy was associated with being married (odds ratio [OR], 1.9), having bowel obstruction (OR, 2.55), and having perforation (OR, 2.29), whereas older age (OR, 5.95), Medicaid coverage (OR, 2.46), higher T stage (OR, 3.51), and higher N stage (OR, 6.77) were associated with PTR only. Patients who received no treatment did not have more comorbidities or more severe disease burden but were more likely to be older (OR, 3.91) and non-Hispanic African American (OR, 2.92; all P<.05). Treatment at smaller, nonacademic hospitals was associated with PTR (± chemotherapy).

CONCLUSIONS

PTR was included in the treatment regimen for most patients with stage IV colon cancer and was associated with smaller, nonacademic hospitals. Efforts to improve guideline implementation may be beneficial in these hospitals and also in non-Hispanic African American and older populations.

Surgical resection and survival outcomes in metastatic young adult colorectal cancer patients

Background

The incidence of colorectal cancer in adults younger than age 50 has increased with rates expected to continue to increase over the next decade. The objective of this study is to examine the survival benefit of surgical resection (primary and/or metastatic) versus palliative therapy in this patient population.

Methods

We identified 6708 young adults aged 18–45 years diagnosed with metastatic colorectal cancer (mCRC) from 2004 to 2015 from the SEER database. Overall survival (OS) was analyzed using Kaplan–Meier estimation, log rank test, and multivariate Cox proportional hazards model.

Results

Sixty‐three percent of patients in our study underwent primary tumor resection (PTR), with 40% undergoing PTR alone and 23% undergoing both resection of primary disease and metastasectomy. The median OS for patients who underwent both PTR and metastasectomy was 36 months, compared to 13 months for those who did not receive any surgical intervention. The multivariate analysis showed significant OS benefit of receiving both PTR and metastasectomy (HR 0.34, 95% CI: 0.31–0.37, p < 0.001) compared to palliative therapy. Undergoing PTR only and metastasectomy only were also associated with improved OS (HR 0.46, 95% CI: 0.43–0.49, p < 0.001 and HR 0.64, 95% CI: 0.55–0.76, p < 0.001, respectively).

Conclusion

This is the largest observational study to evaluate survival outcomes in young‐onset mCRC patients and the role of surgical intervention of the primary and/or metastatic site. Our study provides evidence of statistically significant increase in OS for young mCRC patients who undergo surgical intervention of the primary and/or metastatic site.

Survival outcomes of elderly patients referred to the lower gastrointestinal 2-week wait service

AIM

The benefit to elderly patients (≥80 years old) of referral to the resource-intensive lower gastrointestinal 2-week wait (LGI-2WW) pathway is unknown. The aim of this study was to investigate the survival outcome of elderly patients referred to a LGI-2WW service.

METHOD

This study comprised a retrospective analysis of a prospectively gathered database of patients referred to a single-centre LGI-2WW service and conformed to STROBE guidelines. The primary outcome was all-cause mortality. Statistical analysis was performed with the chi-square test and Kaplan-Meier survival curves compared with the generalized log-rank test.

RESULTS

A total of 10 155 patients referred to the LGI-2WW service between 1 January 2015 and 31 December 2018 were analysed; median follow-up was 37.0 months (range 0-66 months). Six hundred and ninety one cancers were diagnosed (6.8% detection rate); 551 (80%) of these were lower GI cancers (LGICas) [517 (75%) colorectal; 34 (5%) anal]. Forty per cent of LGICas were diagnosed via the LGI-2WW service. Patients aged ≥80 years with LGICa were more likely to be treated with palliative intent [age <80 years, 92/360 (26%) vs. age ≥80 years, 105/191 (55%); p < 0.001]. LGICa patients aged <85 years had a survival difference between those treated with curative intent (LGICa-Cur) or palliative intent (LGICa-Pal) (median survival for patients aged 80-84 years: LGICa-Cur 57 months vs. LGICa-Pal 15 months; p < 0.001). Patients aged ≥85 years did not have any survival difference by treatment intent (median survival for patients aged 85-89 years: LGICa-Cur 31 months vs. LGICa-Pal 16 months; p = 0.062; median survival for patients aged ≥90 years: LGICa-Cur 14 months vs. LGICa-Pal 16 months; p = 0.703).

CONCLUSION

Patients with LGICa aged ≥85 years have similar survival whether treated with curative or palliative intent. This can inform management discussions with patients and LGI-2WW referral pathway prioritization approaches.

Clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer: a population-based study

The aim of this study was to evaluate the clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer. Patients diagnosed with metastatic pancreatic cancer between 2004 and 2014 were identified from the Surveillance Epidemiology and End Results database. Clinical characteristics and prognostic factors in elderly patients with metastatic pancreatic cancer were examined. A total of 10784 metastatic pancreatic cancer patients between 65 and 80 years old were included and divided into three age groups. Elderly metastatic pancreatic cancer patients differed from younger patients in many aspects, including marital status, race, sex, T stage, N stage, treatment regimen, prognosis, cause of death, and metastatic characteristics (P<0.001). An analysis of prognostic factors showed that chemotherapy, as the main treatment for elderly patients, can significantly improve prognosis, while surgery can improve the prognosis of patients between 65 and 80 years old. Other factors, including sex, marital status, T stage, and site of metastasis, had different effects on patients in different age groups. Elderly patients with metastatic pancreatic cancer are a special group of individuals whose clinical characteristics and prognostic factors are different from those of younger patients, and these patients require special treatment and attention.

The clinical features, management, and survival of elderly patients with colorectal cancer

Background

As the population ages, the number of elderly patients with colorectal cancer is increasing year by year. However, older people have rarely been the focus of studies on colorectal cancer. Therefore, in the present study, we aimed to carry out a retrospective analysis of this patient subgroup.

Methods

A retrospective study of clinical data of patients aged over 80 years who died from colorectal cancer in our hospital between 1993 and 2020 was performed. Logistic regression, the Kaplan-Meier method, and a multivariate Cox proportional hazards model were used to analyze the overall survival and treatment outcomes of the patients.

Results

A total of 87 patients were included in the study. The overall median survival was 45 months. In most patients, the primary lesion was located in the right colon. One-quarter of the patients refused to accept any treatment. Patients with stage IV tumors, who accounted for the largest proportion of the study population, displayed a higher rate of abandoning treatment than did patients of other stages. Almost all patients with stages II and III accepted surgery. Patients who underwent surgery to treat their colorectal cancer had longer survival than those who did not.

Conclusions

Old age should not be a reason for giving up treatment for colorectal cancer. The treatment of colorectal cancer patients aged 80 years and above requires individualized evaluation and more aggressive treatment to achieve greater benefits.

Comparison of Urban-Rural Readmission Rates After Colorectal Cancer Surgery: Findings From a Privately Insured Population

OBJECTIVES

We assessed the 30-day readmission rate of a privately insured population diagnosed with colorectal cancer (CRC) who had primary tumor resection in rural and urban communities.

METHODS

Claims data of people aged <65 with a diagnosis of CRC between 2012 and 2016 and enrolled in a private health plan administered by BlueCross BlueShield of Nebraska were analyzed. Readmission was defined as the number of discharged patients who were readmitted within 30 days, divided by all discharged patients. Multivariate logistic regression was used to estimate the factors associated with readmission.

RESULTS

The urban population had a higher readmission rate (11%) than the rural population (8%). Although the adjusted odds ratio showed that there is no difference in readmission between rural and urban residents, patients with a Charlson Comorbidity Index (CCI) of >1 were more likely than those without CCI to be readmitted (OR 3.59, 1.41-9.11). Patients with open vs. laparoscopic surgery (OR 2.80, 1.39-5.63) and those with an obstructed or perforated colon vs. none (OR 7.17, 3.75-13.72) were more likely to be readmitted.

CONCLUSIONS

Readmission after CRC surgery occurs frequently. Interventions that target the identified risk factors should reduce readmission rates in this privately insured population.

Impact of Time to Castration Resistance on Cytoreductive Radiotherapy in Metastatic Castration-Resistant Prostate Cancer

Background

The role of local radiotherapy in metastatic castration-resistant prostate cancer (mCRPC) remains undefined. This study aimed to identify the value of local radiotherapy and potential candidates for mCRPC.

Methods

A total of 215 patients with mCRPC treated with or without cytoreductive radiotherapy (CRT) between June 2011 and February 2019 were analyzed. Overall survival (OS) was calculated from the onset of mCRPC. The receiver-operating characteristic (ROC) curve was used to find the cutoff point for time to castration resistance (TCR).

Results

One-hundred and fifty-five (72.1%) patients received abiraterone after mCRPC, and 54 (25.1%) patients received CRT. The median TCR was 14.9 months. After a median follow-up of 31.7 months, the median OS was 33.3 months. The Eastern Cooperative Oncology Group (ECOG) performance scores 0-1, oligometastases, abiraterone after mCRPC, CRT, and TCR ≥9 months were independent prognostic factors for better OS. Stratified analyses showed improved survival when CRT was applied to patients treated with abiraterone (HR 0.44; 95% CI 0.23-0.83; P = 0.012) and TCR ≥9 months (HR 0.39; 95% CI 0.21-0.74; P = 0.004). The percentage of PSA response after radiotherapy was higher in patients with TCR ≥9 months compared to those with TCR <9 months. No grade 3 or worse adverse events after radiotherapy were reported.

Conclusions

ECOG performance score, oligometastases, abiraterone application, TCR and CRT were independent prognostic factors for OS in patients with mCRPC. Patients with a short duration of response to primary androgen deprivation therapy were less likely to benefit from CRT.

Anticancer Drug Discovery from Microbial Sources: The Unique Mangrove Streptomycetes

Worldwide cancer incidence and mortality have always been a concern to the community. The cancer mortality rate has generally declined over the years; however, there is still an increased mortality rate in poorer countries that receives considerable attention from healthcare professionals. This suggested the importance of the prompt detection, effective treatment, and prevention strategies. The genus Streptomyces has been documented as a prolific producer of biologically active secondary metabolites. Streptomycetes from mangrove environments attract researchers' attention due to their ability to synthesize diverse, interesting bioactive metabolites. The present review highlights research on mangrove-derived streptomycetes and the production of anticancer-related compounds from these microorganisms. Research studies conducted between 2008 and 2019, specifically mentioning the isolation of streptomycetes from mangrove areas and described the successful purification of compound(s) or generation of crude extracts with cytotoxic activity against human cancer cell lines, were compiled in this review. It is anticipated that there will be an increase in prospects for mangrove-derived streptomycetes as one of the natural resources for the isolation of chemotherapeutic agents.

The factors related to failure of Enhanced Recovery after Surgery (ERAS) in colon cancer surgery

PURPOSE

Enhanced Recovery after Surgery has been proven effective for patients with gastrointestinal cancer. But radical enhanced recovery could also lead to adverse clinical outcomes. Compared with reports on the estimation of successful implementation of enhanced recovery, studies on risk factors of enhanced recovery failure are still lacking.

METHODS

A retrospective analysis was carried out on 102 patients in ERAS who underwent elective colon cancer surgery. This study included 102 patients with colon cancer between 2015 and 2019, defining enhanced recovery failure as postoperative length of stay over 10 days, stay in ICU over 24 h after surgery, reoperation, death, or unplanned readmission within 30 days after surgery. Univariate and multivariate analyses were performed to explore potential risk factors of failure.

RESULTS

Aged ≥ 75, open operation, number of drainage tube over 1, re-urethral catheterization, and Clavien-Dindo grade over 2 were associated with ERAS failure, according to univariate analysis. Multivariate analysis showed that age ≥ 75 [OR 7.231; P = 0.009]; open operation (OR 3.599; P = 0.021); and number of drainage tube over 1 (OR 3.202; P = 0.020) were independent risk factors for ERAS failure.

CONCLUSIONS

We found age ≥ 75, open operation, and number of drainage tube over 1 are independent risk factors associated with ERAS failure after colon cancer surgery.

Metastatic pancreatic adenocarcinomas could be classified into M1a and M1b category by the number of metastatic organs

Background

With the improvement of treatment and prognosis for patients with late malignant diseases, certain malignancies with distant metastasis (M1 category) have been further classified into M1a (single metastatic site) and M1b (multiple metastatic sites) category in the staging system. We aimed to assess the feasibility of sub-classifying metastatic pancreatic adenocarcinoma (mPA) into M1a and M1b category depending on the number of metastatic organs.

Methods

Patient records were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2010–2015). Univariable and multivariable analyses were performed using the Cox regression model. Then survival analysis was determined using the Kaplan–Meier method.

Results

A total of 11,885 patients were included in this analysis, including 9425 patients with single metastasis and 2460 patients with multiple metastases. Multivariable analysis showed that gender, age, marital status, grade, surgery, chemotherapy, and radiotherapy were independent prognostic factors for patients with single metastasis; gender, age, marital status, grade, chemotherapy and radiotherapy were independent prognostic factors for patients with multiple metastases. Notably, surgery was an independent prognostic factor for patients with single metastasis (P < 0.001) but not for patients with multiple metastases (P = 0.134). Kaplan–Meier analysis showed that patients with single metastasis (M1a) had better survival outcomes than patients with multiple metastases (M1b) (P < 0.001).

Conclusions

PA patients with M1 diseases could be divided into M1a (single metastasis) category and M1b (multiple metastases) category by the number of metastatic organs. The subclassification would facilitate individualized treatment for late PA patients. Surgery was associated with lower mortality in M1a patients but not significantly in M1b patients.

Colonic stent vs surgical resection of the primary tumor. Effect on survival from stage-IV obstructive colorectal cancer

BACKGROUND AND OBJECTIVES

the impact of surgical primary tumor resection on survival of obstructive metastatic colorectal cancer remains controversial. The primary goal of this study was to analyze survival in patients with obstructive metastatic colorectal cancer after treatment with either resection surgery or a colonic stent.

MATERIAL AND METHODS

a prospective study was performed of all patients with stage-IV colorectal cancer and obstructive manifestations, diagnosed from 2005 to 2012 and managed with either resection surgery or a colonic stent. Cases with a perforation, abscess, right colon or distal rectal malignancy, multiple colorectal cancer or derivative surgery were excluded.

RESULTS

a total of 95 patients were included, 49 were managed with resection surgery and 46 with a colonic stent. The colonic stent group had a higher Charlson index (9.5 ± 2.1 vs 8.6 ± 1.5, p = 0.01), a shorter time to oral intake (0.9 ± 1.1 vs 16.4 ± 53.5 days, p = 0.05), a shorter hospital stay (4 ± 4.8 vs 16.7 ± 15.5 days, p = 0.0001), less need for stomata (11.1 % vs 32.7 %, p = 0.01), fewer early complications (4.3 % vs 46.9 %, p = 0.0001) and more late complications (33.3 % vs 6.4 %, p = 0.001). Undergoing chemotherapy (p = 0.008) was the only independent factor related to increased survival. In the subgroup of patients managed with chemotherapy, surgical primary tumor resection was an independent factor associated with increased survival.

CONCLUSION

both treatments are effective for resolving obstructive manifestations in patients diagnosed with stage-IV obstructive colorectal cancer. Resection surgery has no positive impact on survival and thus cannot be recommended as a therapy of choice.

Clinical complete regression after local radiotherapy combined with chemotherapy for stage IV rectal cancer: A case report

Colorectal cancer is the fourth most common type of cancer worldwide with about 0.8 million new cases annually. Improving patient survival remains a challenge for clinicians. Observation waiting method provides improved quality of life compared with direct surgery. This case report suggested that colorectal cancer patients could choose active observation waiting method for treatment. A 59-year-old male patient, with rectal bleeding and an Eastern Cooperative Oncology Group (ECOG) performance status score of 0, was admitted to the hospital due to increased fecal blood volume. The electronic colonoscopy revealed multiple polyps in colon and rectum, whereas the pathological biopsy indicated poorly differentiated rectal adenocarcinoma. The clinical stage was defined as T3N2M1a according to the TNM classification of the American Joint Committee on Cancer (AJCC) staging manual (version 8). In addition, positron emission tomography/computed tomography (PET/CT) examination showed non-regional lymph node metastasis (subclavian). Subsequently, the expression of PD-L1 (-), NRAS (-), KRAS (-), HRAS (-), BRAF (-) (-, negative) and the microsatellite stability (MSS) were detected in the rectal cancer lesion using molecular pathological examination. Patients with primary rectal cancer and pelvic lymph node metastasis were treated with three-dimensional conformal radiotherapy (3D-CRT; dose, 60 Gy/30 Fr) and XELOX chemotherapy (200 mg oxaliplatin at day 1 plus 1.5 g capecitabine twice a day from day 1-14 for a total of 5 cycles). PET/CT scan revealed that the metabolism levels of the lesion returned to normal. In addition, the routine re-examination showed progressive improvement of tumor lesions. Until recently, the carcinoembryonic antigen (CEA) level of the male patient has been within normal range. The observation waiting method rather than the direct sequential surgical resection of the primary lesion in patients with advanced rectal cancer who achieved complete clinical remission (CCR) may provide a novel treatment method for rectal cancer. Thus, overall survival (OS) and quality of survival (QoS) differences between the two strategies need to be further verified by multicenter clinical trials.

Harnessing the potential of multimodal radiotherapy in prostate cancer

Radiotherapy in combination with androgen deprivation therapy (ADT) is a standard treatment option for men with localized and locally advanced prostate cancer. However, emerging clinical evidence suggests that radiotherapy can be incorporated into multimodality therapy regimens beyond ADT, in combinations that include chemotherapy, radiosensitizing agents, immunotherapy and surgery for the treatment of men with localized and locally advanced prostate cancer, and those with oligometastatic disease, in whom the low metastatic burden in particular might be treatable with these combinations. This multimodal approach is increasingly recognized as offering considerable clinical benefit, such as increased antitumour effects and improved survival. Thus, radiotherapy is becoming a key component of multimodal therapy for many stages of prostate cancer, particularly oligometastatic disease.

Predicting Overall Survival in Patients with Metastatic Rectal Cancer: a Machine Learning Approach

BACKGROUND

A significant proportion of patients with rectal cancer will present with synchronous metastasis at the time of diagnosis. Overall survival (OS) for these patients are highly variable and previous attempts to build predictive models often have low predictive power, with concordance indexes (c-index) less than 0.70.

METHODS

Using the National Cancer Database (2010-2014), we identified patients with synchronous metastatic rectal cancer. The data was split into a training dataset (diagnosis years 2010-2012), which was used to build the machine learning model, and a testing dataset (diagnosis years 2013-2014), which was used to externally validate the model. A nomogram predicting 3-year OS was created using Cox proportional hazard regression with lasso penalization. Predictors were selected based on clinical significance and availability in NCDB. Performance of the machine learning model was assessed by c-index.

RESULTS

A total of 4098 and 3107 patients were used to construct and validate the nomogram, respectively. Internally validated c-indexes at 1, 2, and 3 years were 0.816 (95% CI 0.813-0.818), 0.789 (95% CI 0.786-0.790), and 0.778 (95% CI 0.775-0.780), respectively. External validated c-indexes at 1, 2, and 3 years were 0.811, 0.779, and 0.778, respectively.

CONCLUSIONS

There is wide variability in the OS for patients with metastatic rectal cancer, making accurate predictions difficult. However, using machine learning techniques, more accurate models can be built. This will aid patients and clinicians in setting expectations and making clinical decisions in this group of challenging patients.

Comparison of Treatment, Cost, and Survival in Patients With Metastatic Colorectal Cancer in Western Washington, United States, and British Columbia, Canada

PURPOSE

Few studies have directly compared health care utilization, costs, and outcomes between patients treated in the US multipayer health system and Canada's single-payer system. Using cancer registry and claims data, we assessed treatment types, costs, and survival for patients with metastatic colorectal cancer (mCRC) in Western Washington State (WW) and British Columbia (BC).

MATERIALS AND METHODS

Patients age ≥ 18 years diagnosed with mCRC in 2010 and later were identified from the BC Cancer database and a regional database linking WW SEER to claims from Medicare and two large commercial insurers. Demographics, treatment characteristics, costs of systemic therapy, and survival data were obtained from these databases and compared between the two regions.

RESULTS

A total of 1,592 patients from BC and 901 from WW were included in the study. Median age was similar (BC, 66 years; WW, 63 years), but patients in BC were more likely to be male (57.1% v 51.2%; P ≤ .01) and to have de novo metastatic disease (61.0% v 38.3%; P ≤ .01). The use of radiation therapy was similar between regions (BC, 31.2%; WW, 33.9%; P = .18), but primary tumor resection was more common in BC (74.1% v 66.3%; P ≤ .01) as was hepatic metastasectomy (12.4% v 2.3%; P ≤ .01). Similar percentages of patients received systemic therapy (BC, 68.8%; WW, 67.1%; P = .40), but costs were significantly higher for first-line systemic therapy in WW ($6,226 v $15,792 per patient per month; P ≤ .01). Median overall survival was similar (BC, 16.9 months; WW, 18 months).

CONCLUSION

Cost of systemic therapy for mCRC was significantly higher for patients in WW than in BC, but this did not translate to a difference in overall survival.

The cytoreductive prostatectomy in metastatic prostate cancer: what the individual trials are hoping to answer

OBJECTIVE

To review the ongoing randomised trials of cytoreductive prostatectomy (CRP) in de novo hormone-sensitive metastatic prostate cancer (HSPC) in order to identify their goals and assess their strengths and weaknesses.

METHODS

PubMed, MEDLINE and clinical trials websites searches were performed to identify currently ongoing trials of CRP in de novo HSPC.

RESULTS

Nine randomised clinical trials in CRP were identified and included: Southwest Oncology Group (SWOG) 1802, Surgery in Metastatic Carcinoma of Prostate (SIMCAP), Adjuvant Treatments to the Local Tumour for Metastatic Prostate Cancer: Assessment of Novel Treatment Algorithms (IP2-ATLANTA), Testing Radical prostatectomy in men with prostate cancer and oligoMetastases to the bone (TRoMbone), Impact of Radical Prostatectomy as Primary Treatment in Patients with Prostate Cancer with Limited Bone Metastases (g-RAMPP), Cytoreductive Prostatectomy vs Cytoreductive Prostate Irradiation as a Local Treatment Option for Metastatic Prostate Cancer: a Multicentric Feasibility Trial (LoMP II), Androgen-Deprivation Therapy or Androgen-Deprivation Therapy Plus Definitive Treatment (Radiation or Surgery) (FUSCC-OMPCa), and the Testing Radical Prostatectomy in Chinese Men with Prostate Cancer and oligoMetastases to the Bone study. Each study was different; assessing various primary outcome measures including overall survival (OS), progression-free survival and feasibility to randomise between standard therapy and CRP or between radiation therapy and CRP in the metastatic setting. In the oligometastatic setting, the trials assess OS, feasibility to randomise and time to castration resistance. Similarly, a number of secondary endpoints ranging from cancer-specific outcomes to quality-of-life outcomes are being investigated. The inclusion criteria in these trials also varied in terms of volume of metastatic disease (oligometastatic to high-volume metastatic disease), diagnosis of metastases (imaging based vs biopsy confirmed), imaging modalities used (conventional to newer modalities), as well as outcomes and follow-up regimes.

CONCLUSION

While there are differences in each protocol, each trial aims to address different aspects of CRP in de novo HSPC. Therefore, the specific goals of each study and the limitations have to be taken into consideration when interpreting the results of these trials.

Role of surgery in oligometastatic prostate cancer

Androgen deprivation therapy as single modality therapy was the standard management for oligometastatic prostate cancer (PCa). Current paradigm shifts toward a multimodality therapy approach, targeting all sites of disease, including treatment of the primary in the form of radical prostatectomy or radiation therapy. The objective of this article was to reveiw the literature regarding the role of surgery in oligometastatic PCa. PubMed and MEDLINE electronic databases were queried for English language articles from January 1, 1980 to March 31, 2019. Keywords use included oligometastatic PCa, metastatic prostate cancer (mPCa), radical prostatectomy, and cytoreductive prostatectomy. Preclinical, prospective, and retrospective studies were included. There is no published randomized controlled trials, evaluating the role of surgery in mPCa. Preclinical and retrospective data suggest benefit of primary tumor treatment in mPCa. Current literature supports the concept of cytoreductive surgery as it can prevent late symptomatic local progression, has acceptable complications, and may prolong survival in patients with mPCa. Surgery is a feasible procedure in mPCa which may improve outcome in mPCa. However, there is no Level 1 evidence, yet that support the role of surgery in mPCa. The results from well-organized prospective, randomized controlled trials are awaited before performing radical prostatectomy for mPCa in clinical practice.

Treatment Patterns Among De Novo Metastatic Cancer Patients Who Died Within 1 Month of Diagnosis

Background

Little is known about patterns of and factors associated with treatment for de novo metastatic cancer patients who die soon after diagnosis. In this study, we examine treatment patterns for patients newly diagnosed with metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis.

Methods

We identified 100 848 adult patients in the National Cancer Database with de novo metastatic lung, colorectal, breast, and pancreatic cancer, diagnosed between 2004 and 2014 and who died within 1 month. We performed descriptive and multivariable logistic regression analyses to examine receipt of surgery, chemotherapy, radiation, and hormonal therapy by cancer type, adjusting for sociodemographic and clinical variables.

Results

Treatment substantially varied by cancer type, over time, age, insurance, and facility type. Surgery ranged from 0.4% in pancreatic to 28.3% in colorectal cancer (CRC) patients, chemotherapy from 5.8% among CRC to 11% in lung and breast cancer patients, and radiotherapy from 1.3% in pancreatic to 18.7% in lung cancer patients. Use of some treatments (eg, surgery for CRC and breast cancer) progressively declined between 2004 and 2014. Compared with lung cancer patients treated at National Cancer Institute-designated cancer centers, those treated at community cancer centers had 48% lower odds of radiation.

Conclusions

Treatment of patients diagnosed with imminently fatal de novo metastatic cancer varied markedly by cancer type and patient/facility characteristics. These variations warrant more research to better identify patients with imminently fatal de novo metastatic cancer who may not benefit from aggressive and expensive therapies.

High Serum CA19-9 Concentration Predicts Poor Prognosis in Elderly Patients with Stage IV Colorectal Cancer

BACKGROUND/AIM

The optimal treatment strategy for elderly patients with stage IV colorectal cancer (CRC) remains controversial due to limited research data. The purpose of this study was to evaluate treatment results and to clarify the prognostic factors, especially poor prognosis factors, in elderly patients with stage IV CRC.

METHODS

We retrospectively reviewed the data of 82 elderly patients (aged ≥75 years) with stage IV CRC who underwent surgical treatment at our hospital between April 2001 and March 2017. Factors that affected prognosis and the ability to undergo treatment were analyzed via multivariate analysis.

RESULTS

The median overall survival (OS) in the patients with high pretreatment serum carbohydrate antigen 19-9 (CA19-9) concentration (> 370 U/mL) was significantly worse than in those with lower serum CA19-9 concentration (0-370 U/mL) (8.5 vs. 19.2 months, p = 0.0059). In univariate analysis, age (≥80 years) (p = 0.014), performance status of 1-3 (p = 0.028), and high pretreatment serum CA19-9 concentration (p = 0.014) were significant prognostic factors for poor OS. By contrast, resection of the primary tumor (p = 0.024), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0005) were significant prognostic factors for favorable OS. Multivariate analysis showed that a high pretreatment serum CA19-9 concentration was an independent prognostic factor for poor OS (p = 0.01). Meanwhile, resection of the primary tumor (p = 0.033), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0008) were prognostic factors for favorable OS.

CONCLUSIONS

A high pretreatment serum CA19-9 concentration (> 370 U/mL) was a reliable predictive factor for poor prognosis, and aggressive treatments should be performed carefully in these patients. Moreover, various treatments, including surgery and chemotherapy, might improve OS in elderly patients with stage IV CRC.

Managing Synchronous Liver Metastases in Colorectal Cancer

The most common site of blood-borne metastases from colorectal cancers (CRC) is the liver. Resection of (liver) metastases is a part of standard treatment of metastatic colorectal cancer. Hepatic resection is the first-line treatment of liver metastases, with 5-year survival rates between 25 and 58%. The enhanced efficacy of systemic chemotherapeutic regimens has increased tumor response rates and improved the progression-free and overall survival of patients with these malignancies. In approximately 20% of patients with initially unresectable liver metastases, the metastases may become resectable after administration of neoadjuvant chemotherapy. Unresectable liver metastases can be managed with systemic therapy and/or a variety of liver-directed techniques such as radiofrequency ablation, hepatic artery infusion, or yttrium-90 radioembolization. Our examination of the literature led us to propose a new patient-oriented algorithm to guide clinicians' decisions on the best choice of upfront therapy for CRC and synchronous liver metastases. The need for multidisciplinary consensus has become especially important for metastatic CRC.

More Extensive Lymph Node Dissection Improves Survival Benefit of Radical Cystectomy in Metastatic Urothelial Carcinoma of the Bladder

BACKGROUND

Radical cystectomy (RC) may occasionally be performed in individuals with metastatic urothelial carcinoma of the bladder (mUCB). However, the role of lymph node dissection (LND) for such cases is unknown. Thus, we tested the effect of RC on cancer-specific mortality (CSM) and overall mortality in mUCB patients and the effect of LND and its extent on CSM.

PATIENTS AND METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2013), we identified patients with mUCB who underwent RC with or without LND or non-RC management. Kaplan-Meier analyses and multivariable Cox regression models (CRMs) were used, after propensity score matching. The number of removed nodes best predicting CSM was identified using cubic splines and then was tested in multivariable CRMs.

RESULTS

Of 2314 patients, 319 (13.8%) underwent RC. After 2:1 propensity score matching, CSM-free survival was 14 versus 8 months (P < .001), and overall mortality-free survival was 12 versus 7 months (P < .001) for, respectively, RC and non-RC patients. In multivariable CRMs, lower CSM (hazard ratio = 0.48; P < .001) and lower overall mortality (hazard ratio = 0.49; P < .001) rates were recorded in RC patients. LND status did not affect CSM-free survival (13 vs. 10 months; P = .1). Cubic splines-derived cutoff of ≥ 13 number of removed nodes showed better CSM-free survival (20 vs. 11 months; P = .02) and reduced CSM in CRMs (hazard ratio = 0.67; P = .02).

CONCLUSION

Our study validates the survival benefit of RC in mUCB and highlights the importance of more extensive LND. These findings may corroborate the hypothesis of potential cytoreductive effect of surgery in the context of metastatic disease.

To resect or not to resect: The hamletic dilemma of primary tumor resection in patients with asymptomatic stage IV colorectal cancer

Primary tumor resection (PTR) in advanced asymptomatic colorectal cancer (CRC) has been a matter of intense debate for long time. With the advances in systemic treatments, this practice has decreased over the years, although it remains still pervasive. Although the removal of primary tumor has been extensively interrogated both in retrospective and prospective studies, it still remains a clinical conundrum. There are many arguments for and against PTR in CRC both from the preclinical and the clinical point of view. Two scoring models have been published aiming at identifying patients who are suitable candidate for PTR, but they deserve further investigations in larger datasets. While awaiting the results of ongoing randomized clinical trials (RCTs) on this controversial topic, both upfront systemic treatment and PTR followed by chemotherapy should be considered valid options in patients with asymptomatic mCRC. Clinical selection and a shared-decision making approach are the keys to success.

Effect on Survival of Androgen Deprivation Therapy Alone Compared to Androgen Deprivation Therapy Combined with Concurrent Radiation Therapy to the Prostate in Patients with Primary Bone Metastatic Prostate Cancer in a Prospective Randomised Clinical Trial: Data from the HORRAD Trial

BACKGROUND

The cornerstone of standard treatment for patients with primary bone metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT). Retrospective studies suggest a survival benefit for treatment of the primary prostatic tumour in mPCa, but to date, no randomised-controlled-trials (RCTs) have been published addressing this issue.

OBJECTIVE

To determine whether overall survival is prolonged by adding local treatment of the primary prostatic tumour with external beam radiation therapy (EBRT) to ADT.

DESIGN, SETTING, AND PARTICIPANTS

The HORRAD trial is a multicentre RCT recruiting 432 patients with prostate-specific antigen (PSA) >20ng/ml and primary bone mPCa on bone scan between 2004 and 2014.

INTERVENTION

Patients were randomised to either ADT with EBRT (radiotherapy group) or ADT alone (control group).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary endpoint was overall survival. Secondary endpoint was time to PSA progression. Crude and adjusted analyses were applied to evaluate treatment effect.

RESULTS AND LIMITATIONS

Median PSA level was 142ng/ml and 67% of patients had more than five osseous metastases. Median follow up was 47 mo. Median overall survival was 45 mo (95% confidence interval [CI], 40.4-49.6) in the radiotherapy group and 43 mo (95% CI: 32.6-53.4) in the control group (p=0.4). No significant difference was found in overall survival (hazard ratio [HR]: 0.90; 95% CI: 0.70-1.14; p=0.4). Median time to PSA progression in the radiotherapy group was 15 mo (95% CI: 11.8-18.2), compared with 12 mo (95% CI: 10.6-13.4) in the control group. The crude HR (0.78; 95% CI: 0.63-0.97) was statistically significant (p=0.02).

CONCLUSIONS

The current RCT comparing ADT to ADT with EBRT to the prostate in patients with primary bone mPCa did not show a significant difference in overall survival, although the CI cannot exclude a substantial survival benefit. Further research is needed to confirm our findings.

PATIENT SUMMARY

This study investigated the effect of adding radiation therapy to the prostate to hormonal therapy in prostate cancer patients with metastasis to the bone at diagnosis. In our patient group, additional radiotherapy did not improve overall survival. Further research is needed to confirm our findings.

TWITTER SUMMARY

Adding radiotherapy to the prostate in patients with bone metastatic prostate cancer does not improve overall survival.

Randomized controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post hoc cost analysis

AIM

In view of the increasing burden on the healthcare system, this study aims to perform a cost-effectiveness analysis of the management of incurable large bowel obstruction comparing the cost of a stent vs surgery.

METHOD

A prospective randomized controlled trial was conducted at two major teaching hospitals in Australia between September 2006 and November 2011. Fifty-six patients with malignant incurable large bowel obstruction were randomized to stent insertion or surgical decompression, of whom 52 were included in the final analysis. Data were collected at all points during the patient journey and quality of life data were obtained by patient surveys. All data points were analysed and a cost-effectiveness study was performed to compare the costs between the two treatment groups.

RESULTS

Stenting as a procedure was significantly more expensive than surgery (A$4462.50 vs A$3251.50; P < 0.001). Post-procedure stay for stented patients was significantly lower (median 7 vs 11 days; P = 0.03). Combined costs of stent group ward stay, multidisciplinary team discussion and complication management were significantly lower (P = 0.013). Overall cost difference between the two treatment groups was A$3902.44 (P = 0.101). European Quality of Life - 5 Dimensions (EQ-5D) scores for the first 4 weeks gave mean area under the curve adjusted weeks of 2.411 vs 2.271 for the stent and surgery groups respectively (P = 0.603). The incremental cost-effectiveness ratio between the surgery and the stent group was $22 955.53 in favour of stenting.

CONCLUSIONS

Treatment with stenting is cheaper than open surgery and provides quicker discharge from hospital.

Direct site-specific treatment of skin cancer using doxorubicin-loaded nanofibrous membranes

Doxorubicin (DOX) is widely used in cancer therapy. However, its application is sometimes limited by its adverse cardiotoxicity and delivery pathways. In our study, we prepared a topical implantable delivery device for controlled drug release and site-specific treatment. The core region consisted of poly (lactic co-glycolic acid) and poly-caprolactone, whereas the shell region was composed of cross-linked gelatin. DOX was enclosed in the core region of a core-shell nanofiber obtained by electrospinning. This implantable delivery device was implanted on the top of the melanoma in a mouse model, which had shown a DOX-controlled release profile with sustained and sufficient local concentration against melanoma growth in mice with negligible side effects. Compared with the traditional intravenous administration, the implantable device allows precisely localized treatment and therefore can reduce the dose, decrease the injection frequency, and ensure antitumor efficacy associated with lower side effects to normal tissues. Using a coaxial electrospinning process, it is promising to deliver different hydrophobic or hydrophilic drugs for direct tumor site-specific therapy without large systemic doses and minimized systemic toxicity.

Loco-regional treatment for castration-resistant prostate cancer: Is there any rationale? A critical review from the AFU-GETUG

Emerging evidence from population-based and retrospective series suggests a potential improvement of clinical outcomes in metastatic prostate cancer. Moreover, metastasis-directed treatment has shown encouraging results in this setting. There is an increasing interest in exploring the potential of local therapies in advanced prostate cancer, but this has rarely been specifically addressed in the castration-resistant state, whether non-metastatic or metastatic. A review of relevant articles was performed on the oncologic benefit of local treatment of the primary tumor or metastasis-targeted treatment in castration-resistant prostate cancer patients. The main goal of this strategy is to delay introduction of a new systemic agent to maintain quality of life and potentially to limit resistance. Further investigation is required to provide high-level evidence for the oncologic benefit of this treatment modality.

Post prostatectomy outcomes of patients with high-risk prostate cancer treated with neoadjuvant androgen blockade

BACKGROUND

Patients with high-risk prostate cancer have an increased likelihood of experiencing a relapse following radical prostatectomy (RP). We previously conducted three neoadjuvant androgen-deprivation therapy (ADT) trials prior to RP in unfavorable intermediate and high-risk disease.

METHODS

In this analysis, we report on the post-RP outcomes of a subset of patients enrolled on these studies. We conducted a pooled analysis of patients with available follow-up data treated on three neoadjuvant trials at three institutions. All patients received intense ADT prior to RP. The primary endpoint was time to biochemical recurrence (BCR). BCR was defined as a PSA ≥ 0.2 ng/mL or treatment with radiation or androgen-deprivation therapy for a rising PSA < 0.2 ng/mL.

RESULTS

Overall, 72 patients were included of whom the majority had a Gleason score ≥ 8 (n = 46, 63.9%). Following neoadjuvant therapy, 55.7% of patients (n = 39/70) had pT3 disease, 40% (n = 28) had seminal vesicle invasion, 12.9% (n = 9) had positive margins, and 11.4% (n = 8) had lymph node involvement. Overall, 11 (15.7%) had tumor measuring ≤ 0.5 cm, which included four patients (5.7%) with a pathologic complete response and seven (10.0%) with residual tumor measuring 0.1-0.5 cm. Compared to pretreatment clinical staging, 10 patients (14.3%) had pathologic T downstaging at RP. The median follow-up was 3.4 years. Overall, the 3-year BCR-free rate was 70% (95% CI 57%, 90%). Of the 15 patients with either residual tumor ≤ 0.5 cm or pathologic T downstaging, no patient experienced a recurrence.

CONCLUSION

In this exploratory pooled clinical trials analysis, we highlight that neoadjuvant therapy prior to RP in unfavorable intermediate and high-risk patients may potentially have a positive impact on recurrence rates. Larger studies with longer follow-up periods are warranted to evaluate the impact of neoadjuvant hormone therapy on pathologic and long-term outcomes.

Meta-analysis of outcomes following resection of the primary tumour in patients presenting with metastatic colorectal cancer

BACKGROUND

It is not clear whether resection of the primary tumour (when there are metastases) alters survival and/or whether resection is associated with increased morbidity. This systematic review and meta-analysis assessed the prognostic value of primary tumour resection in patients presenting with metastatic colorectal cancer.

METHODS

A systematic review of MEDLINE/PubMed was performed on 12 March 2016, with no language or date restrictions, for studies comparing primary tumour resection versus conservative treatment without primary tumour resection for metastatic colorectal cancer. The quality of the studies was assessed using the MINORS and STROBE criteria. Differences in survival, morbidity and mortality between groups were estimated using random-effects meta-analysis.

RESULTS

Of 37 412 initially screened articles, 56 retrospective studies with 148 151 patients met the inclusion criteria. Primary tumour resection led to an improvement in overall survival of 7·76 (95 per cent c.i. 5·96 to 9·56) months (risk ratio (RR) for overall survival 0·50, 95 per cent c.i. 0·47 to 0·53), but did not significantly reduce the risk of obstruction (RR 0·50, 95 per cent c.i. 0·16 to 1·53) or bleeding (RR 1·19, 0·48 to 2·97). Neither was the morbidity risk altered (RR 1·14, 0·77 to 1·68). Heterogeneity between the studies was high, with a calculated I² of more than 50 per cent for most outcomes.

CONCLUSION

Primary tumour resection may provide a modest survival advantage in patients presenting with metastatic colorectal cancer.

Surgical resection of a primary tumor improves survival of metastatic pancreatic cancer: a population-based study

INTRODUCTION

Pancreatic cancer is a lethal disease with a very poor prognosis. This study investigates survival of patients diagnosed with metastatic pancreatic cancer (mPC) based on local treatment of the primary tumor.

METHODS

Patients diagnosed with stage IV mPC between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Results (SEER) database. Cancer-specific survival (CSS) and overall survival (OS) were examined. CSS and OS were examined by using the Kaplan-Meier method with the log-rank test. Multivariable survival analyses of CSS and OS were conducted using the Cox proportional hazard model.

RESULTS

A total of 28918 patients with mPC were included in this analysis. There were 467 patients who received surgical resection (1.6%) and 28451 patients who did not (98.4%). Patients who were younger than 70 years (odds ratio [OR]=1.45, 95% CI=1.04-2.03, p=0.03), diagnosed from 2004 to 2008 (OR=1.49, 95% CI=1.25-1.80, p<0.001), female (OR=1.31, 95% CI=1.08-1.58, p<0.001), married (OR=1.56, 95% CI=1.27-1.90, p<0.001), at T3 stage (OR=3.53, 95% CI=1.10-11.37, p=0.035), at N1 stage (OR=2.05, 95% CI=1.68-2.50, p<0.001), presenting histological types other than adenocarcinoma (OR=2.04, 95% CI=1.43-2.94, p<0.001), and with tumor of the pancreatic head (OR=1.90, 95% CI=1.27-2.82, p=0.002) were more likely to be treated with surgical resection. The results of multivariate analysis showed that surgical resection of the primary tumor was associated with CSS (hazard ratio [HR]=0.58, 95% CI=0.52-0.64, p<0.001) and OS (HR=0.59, 95% CI=0.53-0.65, p<0.001) benefits. In addition, not receiving chemotherapy (HR=2.33, 95% CI=2.27-2.39, p<0.001), age >50 years (HR=1.25, 95% CI=1.09-1.42, p=0.001), male (HR=1.121, 95% CI=1.09-1.15, p<0.001), black ethnicity (HR=1.11, 95% CI=1.1-1.15, p<0.001), unmarried (HR=1.20, 95% CI=1.17-1.23, p<0.001), histological type of adenocarcinoma (HR=1.18, 95% CI=1.14-1.22, p<0.001), and primary site other than the pancreatic head (HR=1.08, 95% CI=1.05-1.11, p<0.001) are factors associated with poor survival.

CONCLUSION

This study reveals that local treatment has the primary benefit of both CSS and OS in patients with mPC. These results may guide the management of this patient population.

A comparative study of short-term outcomes of colorectal cancer surgery in the elderly population

BACKGROUND

Colorectal Cancer (CRC) is a disease of the elderly, and with an ageing population, oncological surgical procedures for CRC in the elderly is expected to increase. However, the balance between surgical benefits and risks associated with age and comorbidities in elderly patients is obscure.

MATERIALS AND METHODS

A retrospective database of consecutive patients who received CRC surgery was used to compare short-term surgical and oncological outcomes between patients aged ≥75 and <75 years old undergoing CRC resection.

RESULTS

There were 54 patients (63.5%) in the <75 group and 31 patients (36.5%) in the ≥75 group. Overall, there were no differences between the <75 and ≥75 groups in postoperative HDU/ITU stay, median hospital LOS or 30-day mortality rates. Patients ≥75 had a higher preoperative performance status (25.9% versus 71.0%, p < .001), but no difference in ASA Grade and referral pattern, proportion of emergency operations, cancer staging, resection margins, achievement of curative resection or median lymph node yield. There was a significantly higher use of adjuvant chemotherapy in the <75 age group (48.1% versus 25.8%, p = .043).

CONCLUSIONS

With adequate patient selection, CRC resection in elderly patients is not associated with higher postoperative mortality or worse short-term oncological benefits.

Effect on Overall Survival of Locoregional Treatment in a Cohort of De Novo Metastatic Prostate Cancer Patients: A Single Institution Retrospective Analysis From the Royal Marsden Hospital

BACKGROUND

The optimal management of the primary tumor in metastatic at diagnosis (M1) prostate cancer (PCa) patients is not yet established. We retrospectively evaluated the effect of locoregional treatment (LRT) on overall survival (OS) hypothesizing that this could improve outcome through better local disease control and the induction of an antitumor immune response (abscopal effect).

PATIENTS AND METHODS

M1 at diagnosis PCa patients referred to the Prostate Targeted Therapy Group at the Royal Marsden between June 2003 and December 2013 were identified. LRT was defined as either surgery, radiotherapy (RT) or transurethral prostatectomy (TURP) administered to the primary tumor at any time point from diagnosis to death. Kaplan-Meier analyses generated OS data. The association between LRT and OS was evaluated in univariate (UV) and multivariate (MV) Cox regression models.

RESULTS

Overall 300 patients were identified; 192 patients (64%) experienced local symptoms at some point during their disease course; 72 patients received LRT (56.9% TURP, 52.7% RT). None of the patients were treated with prostatectomy. LRT was more frequently performed in patients with low volume disease (35.4% vs. 16.2%; P < .001), lower prostate-specific antigen (PSA) level at diagnosis (median PSA: 75 vs. 184 ng/mL; P = .005) and local symptoms (34.2% vs. 4.8%; P < .001). LRT was associated in UV and MV analysis with longer OS (62.1 vs. 55.8 months; hazard ratio [HR], 0.74; P = .044), which remained significant for RT (69.4 vs. 55.1 months; HR, 0.54; P = .002) but not for TURP. RT was associated with better OS independent of disease volume at diagnosis.

CONCLUSION

These data support the conduct of randomized phase III trials to evaluate the benefit of local control in patients with M1 disease at diagnosis.

Phase II study on early start of chemotherapy after excising primary colorectal cancer with distant metastases (Pearl Star 02)

Initiating chemotherapy usually requires a delay of more than 4 weeks after surgically resecting colorectal cancer. However, there is little evidence regarding the required delay interval. We have previously reported a pilot study to determine the safety and feasibility of early initiation of chemotherapy after resecting primary colorectal cancer with distant metastases. We aimed to determine the safety and efficacy of early initiation of chemotherapy after resecting colorectal cancer with distant metastases.

This phase II study (trial number UMIN000006310) was a prospective, single-arm trial. A total of 20 patients (men, 15 and women, 5) were enrolled. They underwent XELOX therapy (130 mg/m² oxaliplatin on day 1+1000 mg/m² capecitabine twice daily on days 1-4) on postoperative day 7 and XELOX+bevacizumab (7.5 mg/kg bevacizumab on day 1) after the second chemotherapy cycle.

Baseline characteristics included a median age of 64 (range, 43-72) years. Surgical procedures included right hemicolectomy in six patients, sigmoidectomy in three, anterior resection in five, and Hartmann procedure in six. All patients started chemotherapy on postoperative day 7. Median progression-free survival was 14.9 months; overall response rate was 80%. Disease control rate was 100%. Grade 3 or higher hemotoxicity and grade 3 or higher non-hematological toxicity was noted in 5.0% and 25.0% of patients, respectively. Postoperative complications were observed in two patients (superficial incisional surgical site infection and ileus).

Early initiation of chemotherapy after surgery is feasible. These findings suggest future changes of the start time of chemotherapy after surgery.

The role of metastasis-directed therapy and local therapy of the primary tumor in the management of oligometastatic prostate cancer

Oligometastasis has been proposed as an intermediate stage of cancer spread between localized disease and widespread metastasis. Oligometastatic malignancy is now being diagnosed more frequently as the result of improvements in diagnostic modalities such as functional imaging. The importance of oligometastasis in managing metastatic prostate cancer is that it is possible to treat with a curative aim by metastasis-directed or local therapy in selected patients. Many studies have shown that these aggressive treatments lead to improved survival in other oligometastatic malignancies. However, few studies have shown definitive benefits of metastasis-directed or local therapy in oligometastatic prostate cancer. Review of the available studies suggests that stereotactic radiotherapy (RT) of metastatic lesions in oligorecurrent disease is a feasible and safe modality for managing oligometastatic prostate cancer. Also, stereotactic RT can delay the start of androgen deprivation therapy. Many retrospective studies of metastatic prostate cancer have shown that patients undergoing local therapy seem to have superior overall and cancer-specific survival compared with patients not receiving local therapy. Ongoing prospective randomized trials would be helpful to evaluate the role of local therapy in oligometastatic prostate cancer.