Lymph node negative colorectal cancers with isolated tumor deposits should be classified and treated as stage III

Tumor Deposits as an Adverse Prognostic Indicator in Stage III Colon Cancer: A Multicenter Database Study

Objective

We explored the oncological impact of tumor deposits (TDs) on colon cancer and proposed optimal modifications to the current staging system.

Background

In the existing American Joint Committee on Cancer colon cancer staging system, TDs are incorporated into the N category as N1c. When lymph node metastases (LNMs) are present, their number is considered to determine nodal stages, such as N1a/b or N2a/b, regardless of TDs.

Methods

4212 patients with primary colon cancer who underwent surgical resection in the Seoul Colorectal Group (2010-2020) and 93,057 patients from the Surveillance, Epidemiology, and End Results*Stat database (2000-2017) were included in this study. Patients were classified according to the number of metastatic lymph nodes (LNs) (0/1-3/≥4) and the presence of TDs.

Results

TDs were significantly associated with left colon cancer, a higher T category, and vascular/perineural invasion. Patients with TDs had higher recurrence rates (23.1 vs 7.5%, P < 0.001). The TD-positive patients had notably worse overall survival (OS) and recurrence-free survival rates. The survival outcomes of TD-positive patients without LNM were inferior to those of TD-negative patients with LN1-3 (5-year OS: 78.9 vs 87.8%, P = 0.04). The survival outcomes of TD-positive patients with LN1-3 were similar to those of TD-negative patients with LN ≥4 (5-year OS: 87.0 vs 77.1%, P = 0.11). Survival outcomes obtained using the Surveillance, Epidemiology, and End Results *Stat database yielded consistent results.

Conclusions

TDs were associated with poor prognostic factors and had a significant impact on survival outcomes. The incorporation of tumor deposits into nodal classifications beyond the current N1c criteria may improve the staging system and more accurately reflect the recurrence and survival rates among patients with colon cancer. TD-positive in N1a or N1b could be categorized as N2.

Correlation Analysis Between Tumor Deposit and Clinicopathologic Characteristics and Prognosis of Gastric Cancer: A Multicenter Retrospective Study

BACKGROUND

The mechanism underlying the formation of gastric tumor deposits (TDs) is unclear. We aimed to explore the risk factors for the formation and prognostic value of TDs.

METHODS

This retrospective analysis included 781 locally advanced gastric cancer (LAGC) patients from four medical institutions in China, from June 2014 to June 2018. The risk factors for TD formation and prognostic value were determined through univariate and multivariate analyses.

RESULTS

Univariate analysis revealed that TD positivity was closely related to tumor diameter, Borrmann classification, differentiation degree, pT stage, pN stage, pTNM stage, and nerve and vascular invasion (p < 0.05). Multivariate logistic regression revealed that tumor diameter ≥ 5 cm (odds ratio [OR] 1.836, 95% confidence interval [CI] 1.165-2.894, p = 0.009) and vascular invasion (OR 2.152, 95% CI 1.349-3.433, p = 0.001) were independent risk factors for TD positivity. Multivariate Cox analysis revealed that TD positivity (OR 1.533, 95% CI 1.101-2.134, p = 0.011), tumor diameter ≥ 5 cm (OR 1.831, 95% CI 1.319-2.541, p < 0.001), pT4a stage (OR 1.652, 95% CI 1.144-2.386, p = 0.007), and vascular invasion (OR 1.458, 95% CI 1.059-2.008, p = 0.021) were independent risk factors for GC prognosis. The 5-year overall and disease-free survival of the TD-positive group showed significant effects among patients in the pT4a and pN3b stages (p < 0.05).

CONCLUSIONS

TDs are closely related to tumor diameter and vascular invasion in LAGC patients, and TD positivity is an independent prognostic factor for LAGC patients, especially those at pT4a and pN3b stages.

Tumour deposits are associated with worse survival than extranodal extension; a network meta-analysis on tumour nodules in colorectal cancer

Lymph node metastases (LNM) play a central role in the tumour-node-metastasis (TNM) classification for colorectal cancer (CRC), with extranodal extension (ENE) as an adverse feature. ENE has never been directly compared to tumour deposits (TD). The aim of this study was to perform an up-to-date systematic review, including a network meta-analysis to compare their prognostic value. A comprehensive search was conducted on PubMed, Embase, Web of Science and Cochrane databases to identify all prognostic studies on ENE and TD. A total of 20 studies were included, with 7719 cases. The primary outcome was 5-year disease-free survival (DFS); secondary outcomes were overall survival (OS) and disease-specific survival (DSS). Frequentist paired and network meta-analyses were performed using the netmeta package in R. For univariable DFS analysis, LNM + TD+ cases had a significantly worse outcome compared with LNM + ENE+ cases [hazard ratio (HR) = 1.27, 95% confidence interval (CI) = 1.06-1.53], which was no longer significant for multivariable DFS analysis (HR = 1.13, 95% CI = 0.87-1.46). All OS and multivariable DSS analyses showed a significantly worse outcome for LNM + TD+ cases compared with LNM + ENE cases. For all outcomes, both LNM + TD+ and LNM + ENE+ had a significantly increased hazard compared with LNM+ cases. This study shows that there is a trend towards worse outcome for LNM + TD+ than LNM + ENE+, not statistically significant in multivariable DFS analysis. Both groups perform significantly worse than cases with LNM only. To improve the accuracy of CRC staging, we recommend to put more emphasis on both ENE and TD in the TNM classification, with the most prominent role for TD.

Standardizing data collection in adjuvant colon cancer trials: A consensus project from the IDEA and ACCENT international consortia and national experts

BACKGROUND

Despite contributions provided by the recent clinical trials, several issues and challenges still remain unsolved in adjuvant colon cancer (CC). Hence, further studies should be planned to better refine risk assessment as well as to establish the optimal treatment strategy in the adjuvant setting. However, it is necessary to request adequate, contemporary and relevant variables and report them homogeneously in order to bring maximal information when analyzing their prognostic value.

MATERIAL AND METHODS

The project was devised to gain a consensus from experts engaged in the planning, accrual and analyses of stage II and III CC clinical trials, to identify mandatory and recommended baseline variables in order to i) harmonize future data collection worldwide in clinical trials dedicated to adjuvant treatment of CC; ii) propose guidance for Case Report Forms to be used for clinical trials in this setting. A total of 72 questions related to variables that should be reported and how to report them in adjuvant clinical trials were approved and then voted to reach a final consensus from panelists.

RESULTS

Data items on patient-related factors, histopathological features, molecular profile, circulating biomarkers and blood analyses were analyzed and discussed by the whole expert panel. For each item, we report data supporting the acquired consensus and the relevant issues that were discussed. Nineteen items were deemed to be mandatory for resected stage III patients and 24 for resected stage II disease. In addition, 9 and 4 items were judged as recommended for stage III and II, respectively.

CONCLUSION

In our opinion, these 28 variables should be used and uniformly reported in more comprehensive CRFs as research groups design future clinical trials in the field of adjuvant colon cancer.

The Relationship between Tumor Budding and Tumor Deposits in Patients with Stage III Colorectal Carcinoma

Background/Objectives: Recently, some new morphological features of colorectal cancer have been discovered as important prognostic factors; in this paper, we study the relationship between tumor budding (TB) and tumor deposits (TDs). Methods: The retrospective cohort study included 90 patients with pathohistologically confirmed stage III CRC who were treated with radical surgical resection. All hematoxylin and eosin (H and E)-stained slides from each patient were reviewed, and histological parameters were recorded. The samples were divided into two groups with similar sizes: a group without TDs (N = 51) and a control group with TDs (N = 39). The presence and TB grade were further analyzed in these groups and compared with other clinical and histological features. Results: The prevalence of TB in the investigated cohort was unexpectedly high (94.4%). Overall, there were 23 (25.6%) Bd1, 20 (22.2%) Bd2, and 47 (52.2%) Bd3 cases. The presence of TDs was significantly associated with a higher number of TB (p < 0.001, OR 16.3) and, consequently, with a higher TB grade (p = 0.004, OR 11.04). A higher TB grade (p = 0.001, HR 2.28; 95% CI 1.93-4.76) and a growing number of TDs (p = 0.014, HR 1.52; 95% CI 1.09-2.1) were statistically significantly associated with shorter survival. Conclusions: TDs appear more often in patients with higher TB grades in stage III CRC. A higher TB grade and a growing number of TDs were statistically significantly associated with shorter overall survival. These results could give additional emphasis to the importance of TB as an adverse prognostic factor since a strong relationship with TDs has been demonstrated.

Assessment of risk factors of lymph node metastasis and prognosis of Siewert II/III adenocarcinoma of esophagogastric junction: A retrospective study

Adenocarcinoma of the esophagogastric junction (AEG) has a high incidence, and the extent of lymph node dissection (LND) and its impact on prognosis remain controversial. This study aimed to explore the risk factors for lymph node metastasis (LNM) and prognosis in Siewert II/III AEG patients. A retrospective review of 239 Siewert II/III AEG patients surgically treated at Beijing Friendship Hospital from July 2013 to December 2022 was conducted. Preoperative staging was conducted via endoscopy, ultrasound gastroscopy, CT, and biopsy. Depending on the stage, patients received radical gastrectomy with LND and chemotherapy. Clinicopathological data were collected, and survival was monitored semiannually until November 2023. Utilizing logistic regression for data analysis and Cox regression for survival studies, multivariate analysis identified infiltration depth (OR = 0.038, 95% CI: 0.011-0.139, P < .001), tumor deposit (OR = 0.101, 95% CI: 0.011-0.904, P = .040), and intravascular cancer embolus (OR = 0.234, 95% CI: 0.108-0.507, P < .001) as independent predictors of LNM. Lymph nodes No. 1, 2, 3, 4, 7, 10, and 11 were more prone to metastasis in the abdominal cavity. Notably, Siewert III AEG patients showed a higher metastatic rate in nodes No. 5 and No. 6 compared to Siewert II. Mediastinal LNM was predominantly found in nodes No. 110 and No. 111 for Siewert II AEG, with rates of 5.45% and 3.64%, respectively. A 3-year survival analysis underscored LNM as a significant prognostic factor (P = .001). Siewert II AEG patients should undergo removal of both celiac and mediastinal lymph nodes, specifically nodes No. 1, 2, 3, 4, 7, 10, 11, 110, and 111. Dissection of nodes No. 5 and No. 6 is not indicated for these patients. In contrast, Siewert III AEG patients do not require mediastinal LND, but pyloric lymphadenectomy for nodes No. 5 and No. 6 is essential. The presence of LNM is associated with poorer long-term prognosis. Perioperative chemotherapy may offer a survival advantage for AEG patients.

Prognostic effect of categorized tumor deposits in gastric cancer: A single-center retrospective study

BACKGROUND

Tumor deposits are defined as all types of isolated cancer lesions without lymphocyte aggregates considered part of the lymph node. Tumor deposits have been reported as a negative prognostic factor. However, the survival significance of categorized tumor deposits is uncertain, particularly in gastric cancer. This study aimed to investigate the prognostic difference among categorized tumor deposits.

METHODS

Patients who underwent gastrectomy for gastric cancer were enrolled. All tumor deposits were categorized into irregular nodule, irregular nodule star, smooth nodule, and vascular/neural invasion. There are some cases with more than 2 categorized tumor deposits. These cases were categorized as tumor deposit complex in the following analysis. We performed survival analysis between the patients with and without tumor deposits, and compared the survival among each categorized tumor deposit.

RESULTS

Of 868 patients, there were 96 (11.1%) and 772 (88.9%) patients with and without tumor deposits. Vascular/neural invasion, smooth nodule, irregular nodule, irregular nodule star, and the tumor deposits complex was observed in 6 (6.3%), 15 (15.6%), 43 (44.8%), 1 (1.0%), and 31 (32.3%) patients. Patients with tumor deposits displayed poorer survival than those without; the 3-year overall survival: tumor deposits negative = 87.0%, tumor deposits positive = 53.2% (P < .001). Survival analysis revealed tumor deposits can be a prognostic risk factor (hazard ratio: 1.9854, 95% confidence interval: 1.393-2.830, P < .01). Irregular nodule and the tumor deposits complex demonstrated the worst prognosis (irregular nodule 3-year overall survival: 51.2%, tumor deposits complex 3-year overall survival: 41.9%, P = .001), whereas smooth nodule demonstrated better prognosis (smooth nodule 3-year overall survival: 80%).

CONCLUSION

Tumor deposits exerted a negative survival effect in gastric cancer. Irregular nodule and the tumor deposits complex displayed a strong prognostic effect.

Readjustment of nodal staging by integrating tumor deposits and positive lymph nodes in patients with stage III colon cancer: a population-based analysis

Whether tumor deposits (TDs) should be classified as lymph node metastasis or distant metastasis remains controversial. To address this predicament, we conducted this study to identify the predictive value of TDs on the survival of patients diagnosed with stage III colon cancer (CC). 12,904 eligible patients diagnosed with stage III CC between 2010 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The best cutoff point of TD quantity was determined based on the difference in survival. Cox proportional hazards model was employed to perform univariate and multivariate analyses. The Kaplan-Meier method and log-rank test were performed to calculate the differences between overall survival (OS). Our results showed that the number of TDs was a significant prognostic factor in patients with stage III CC (P < 0.0001). We added the number of TDs to the pN stage and devised a new pN stage, there were no significant differences in the survival of npN, except npN2a (P > 0.05). Upon re-staging to the same npN stage, the difference in survival between TDs+ and TDs- disappeared (P > 0.05). The median survival times for N2aTDs > 4 and N2bTDs > 4 were 33 and 37 months, respectively, which were significantly shorter than that of N2TDs- (65 months) and represented the worst survival rates among all groups. In conclusion, the number of TDs indicated a poor prognosis for patients with stage III CC. Incorporating TDs into the pN is feasible to predict prognosis.

Incorporation of perigastric tumor deposits into the TNM staging system for primary gastric cancer

BACKGROUND

The current prognostic significance of perigastric tumor deposits (TDs) in gastric cancer (GC) remains unclear.

AIM

To assess the prognostic value of perigastric TDs and put forward a new TNM staging framework involving TDs for primary GC.

METHODS

This study retrospectively analyzed the pathological data of 6672 patients with GC who underwent gastrectomy or surgery for GC with other diseases from January 1, 2012 to December 31, 2017 at the Chinese PLA General Hospital. According to the presence of perigastric TDs or not, the patients were divided into TD-positive and TD-negative groups by using the method of propensity score matching. The differences between TD-positive and TD-negative patients were analyzed using binary logistic regression modeling. The Kaplan-Meier method was used to plot survival curves. Multivariate Cox regression modeling and the log-rank test were used to analyze the data.

RESULTS

Perigastric TDs were found to be positive in 339 (5.09%) of the 6672 patients with GC, among whom 237 were men (69.91%) and 102 were women (30.09%) (2.32:1). The median age was 59 years (range, 27 to 78 years). Univariate and multivariate survival analyses indicated that TD-positive GC patients had a poorer prognosis than TD-negative patients (P < 0.05). The 1-, 3-, and 5-year overall survival rates of GC patients with TDs were 68.3%, 19.6%, and 11.2%, respectively, and these were significantly poorer than those without TDs of the same stages. There was significant variation in survival according to TD locations among the GC patients (P < 0.05). A new TNM staging framework for GC was formulated according to TD location. When TDs appear in the gastric body, the original stages T1, T2, and T3 are classified as T4a with the new framework, and the original stages T4a and T4b both are classified as T4b. When TDs appear in the lesser curvature, the previous stages N0, N1, N2, and N3 now both are classified as N3. When TDs appear in the greater curvature or the distant tissue, the patient should be categorized as having M1. With the new GC staging scheme including TDs, the survival curves of patients in the lower grade TNM stage with TDs were closer to those of patients in the higher grade TNM stage without TDs.

CONCLUSION

TDs are a poor prognostic factor for patients with primary GC. The location of TDs is associated with the prognosis of patients with primary GC. Accordingly, we developed a new TNM staging framework involving TDs that is more appropriate for patients with primary GC.

Tumor deposits are associated with a higher risk of peritoneal disease in non-metastatic colorectal cancer patients

BACKGROUND AND OBJECTIVES

Tumor deposit (TD) is a poor prognostic factor in colorectal cancer (CRC) patients. This study aimed to determine whether TD carry the same risk of peritoneal recurrence as known high-risk (HR) features in CRC patients.

METHODS

A retrospective cohort-study of stage I-III CRC patients from 2010 to 2015 was conducted. TD group was defined by the presence of TD on histopathology whereas HR group was defined by the presence of obstruction, perforation, or T4-stage.

RESULTS

A total of 151 patients with CRC were identified, of which 50 had TD and 101 had a HR feature. The overall risk of peritoneal recurrence was higher in the TD group versus HR group (36.0% vs. 19.8%, p = 0.03). The risk of peritoneum as the site of first recurrence was also higher in the TD group (22.0% vs. 12.9%, p = 0.03). Overall cancer recurrence at any site was also higher in the TD group (56.0% vs. 34.7%, p = 0.01). Median time to first recurrence was 1.2 (0.7-1.9) years in the TD group compared to 1.4 (0.8-2.1) years in the HR group (p = 0.31).

CONCLUSIONS

In non-metastatic CRC patients, TD might have a higher risk of tumor recurrence versus their HR counterparts. Alternative strategies for surveillance and treatment should be considered.

Revised Nodal Staging Integrating Tumor Deposit Counts With Positive Lymph Nodes in Patients With Stage III Colon Cancer

OBJECTIVE

We evaluated the prognostic value of tumor deposit (TD) counts and incorporated them with the number of positive lymph nodes to develop a revised nodal staging.

SUMMARY BACKGROUND DATA

The current American Joint Committee on Cancer (AJCC) staging on colon cancer includes the TDs only for nodenegative patients, as N1c, and their counts are not considered.

METHODS

We included consecutive patients with stage III colorectal cancer who underwent curative resections between January 2010 and December 2019. The patients were grouped as TD 0, TD 1, TD 2, or TD ≥3 based on their TD counts. Disease-free survival and overall survival were compared.

RESULTS

Of 2446 eligible stage III patients, 658 (26.9%) had TDs. Among them, 500 (76.0%) patients concurrently had positive lymph nodes (LNs). TD counts were significantly related to worse disease-free survival (DFS) and overall survival regardless of pT stages or the number of positive LNs. The patients were restaged based on the integrated number of TD counts and positive LNs. The N3 stage, which had ≥10 integrated TDs and positive LNs, was newly classified. Among the patients who completed 6 months of adjuvant chemotherapy, those upstaged to N2 from an initial stage of N1 experienced significantly worse DFS than those confirmed as N1 in the revised N staging. The newly N3-staged patients showed significantly worse DFS than the patients initially staged as N2.

CONCLUSIONS

Revised N staging using the integrated number of TD counts and positive LNs could predict DFS more accurately than current staging. It would also draw greater attention to the patients with high-risk stage III colon cancer staged as N3.

Risk factors predict microscopic extranodal tumor deposits in advanced stage III colon cancer patients

BACKGROUND

Colorectal cancer is a frequent cause of cancer-related mortality in patients with lymph node or distant metastases. Pericolonic tumor deposits (TDs) are considered prognostically distinct from lymph node metastases.

AIM

To investigate risk factors for extranodal TDs in stage III colon cancer.

METHODS

This was a retrospective cohort study. We selected 155 individuals diagnosed with stage III colon cancer from the database of the Cancer Registry of the Tri-Service General Hospital. The patients were allocated into the groups with/without N1c. Multivariate Cox regression analysis and Kaplan-Meier method were done. The primary outcomes investigate the association between the covariates and extranodal TDs, and prognostic significance of the covariates regarding the survival.

RESULTS

There were 136 individuals in the non-N1c group and 19 individuals in the N1c group. Patients with lymphovascular invasion (LVI) had a higher risk of TDs. Overall survival rates of patients with and without LVI were 6.64 years and 8.61 years, respectively (P = 0.027). The N1c patients without LVI had higher overall survival than those who with LVI (7.73 years vs 4.42 years, P = 0.010).

CONCLUSION

Patients having stage III colon cancer with LVI have a higher probability of having TDs than those with stage III colon cancer without LVI. Stage III colon cancer patients with TDs and LVI could have poor prognosis and outcome.

Prognostic value of tumor deposits in lymph node-negative gastric cancer: A propensity score matching study

BACKGROUND

The purpose of this study was to assess the prognostic value of TD in lymph node-negative GC.

METHODS

A retrospective study was conducted to collect the clinicopathological data from 1224 patients with lymph node-negative GC. According to their TD status, patients were categorized into TD-positive and TD-negative groups. Patients in both groups underwent a 1:1 propensity score matching analysis. Survival analysis was performed by the Kaplan-Meier method, and the differences between survival curves were measured by log-rank test. The cox proportional hazards model was used for univariate and multivariate analyses.

RESULTS

The TD-negative group had higher 5-year overall survival(OS) rate than TD-positive group(69.4%VS.36.4%,P < 0.05). Further subgroup analysis indicated that patients in the TD-negative group had higher 5-year OS rates than those in the TD-positive group in the T1-2, T3, and T4 subgroups(all with P < 0.05).The OS rates were decreased with the increase of the number of TD.The univariate Cox regression analysis demonstrated that tumor location in antrum, distal gastrectomy, perineural invasion, T4-stage,lymphovascular invasion and the number of TD were all associated with prognosis in patients undergoing curative gastric resection (P < 0.05).The multivariable analysis revealed that the number of TD, perineural invasion, lymphovascular invasion and T4 stage were independently associated with OS.

CONCLUSION

In lymph node-negative GC, TD is an independent risk factor for prognosis, regardless of T-stage, and patients with ≥3 TD have a worse prognosis.

High expression of secretory leukocyte protease inhibitor (SLPI) in stage III micro-satellite stable colorectal cancer is associated with reduced disease recurrence

Secretory leukocyte protease inhibitor (SLPI) is a pleiotropic protein produced by healthy intestinal epithelial cells. SLPI regulates NF-κB activation, inhibits neutrophil proteases and has broad antimicrobial activity. Recently, increased SLPI expression was found in various types of carcinomas and was suggested to increase their metastatic potential. Indeed, we demonstrated that SLPI protein expression in colorectal cancer (CRC) liver metastases and matched primary tumors is associated with worse outcome, suggesting that SLPI promotes metastasis in human CRC. However, whether SLPI plays a role in CRC before distant metastases have formed is unclear. Therefore, we examined whether SLPI expression is associated with prognosis in CRC patients with localized disease. Using a cohort of 226 stage II and 160 stage III CRC patients we demonstrate that high SLPI protein expression is associated with reduced disease recurrence in patients with stage III micro-satellite stable tumors treated with adjuvant chemotherapy, independently of established clinical risk factors (hazard rate ratio 0.54, P-value 0.03). SLPI protein expression was not associated with disease-free survival in stage II CRC patients. Our data suggest that the role of SLPI in CRC may be different depending on the stage of disease. In stage III CRC, SLPI expression may be unfavorable for tumors, whereas SLPI expression may be beneficial for tumors once distant metastases have established.

The Prognostic Value of Adjuvant Chemotherapy in Colon Cancer With Solitary Tumor Deposit

Purpose

The aim of this study is to investigate the survival benefit of adjuvant chemotherapy in patients with colon cancer with the solitary tumor deposit (TD).

Methods

The primary study outcomes used in this study were colon cancer–specific survival (CSS) and overall survival (OS). The differences of the distribution of categorical variables in patients with colon cancer with the solitary TD according to adjuvant chemotherapy administration were tested using the Pearson’s chi-square test. The Kaplan–Meier method was utilized to evaluate CSS and OS. Hazard ratio (HR) and 95% confidence interval (CI) were calculated on the basis of Cox regression models to assess the prognostic value of different demographic and clinicopathological characteristics.

Results

A total of 877 patients with TanyN1cM0 colon cancer with solitary TD were identified in our analysis. It was found that OS (75.4% vs. 42.8% for 5-year OS rate, p < 0.001) and CSS (82.9% vs. 69.3% for 5-year CSS rate, p < 0.001) of patients with colon cancer with adjuvant chemotherapy administration were significantly better than those without adjuvant chemotherapy administration. Multivariate Cox survival analyses revealed that the overall and colon cancer–specific mortality risks of patients with adjuvant chemotherapy administration were decreased by 64.4% (HR = 0.356, 95% CI = 0.265–0.479, p < 0.001) and 57.4% (HR = 0.426, 95% CI = 0.286–0.634, p < 0.001) compared with those without adjuvant chemotherapy administration, respectively.

Conclusions

Adjuvant chemotherapy administration could significantly improve OS and CSS in patients with colon cancer with the solitary TD. This is the first study to investigate and demonstrate the survival benefit of adjuvant chemotherapy in patients with colon cancer with the solitary TD.

Significance of tumor deposits combined with lymph node metastasis in stage III colorectal cancer patients: a retrospective multi-center cohort study from China

PURPOSE

The study aimed to explore the value of tumor deposits in stage III colorectal cancer (CRC) and verify whether patients with more tumor deposit numbers have higher risk of recurrence.

METHODS

The retrospective cohort analysis was performed at two cancer centers of China. Stage III CRC patients who underwent radical resection at the center between April 2008 and February 2019 were identified. The Univariate/Multivariate Cox regression, Kaplan-Meier analysis, and PSM were recurrence-free survival (RFS) used.

RESULTS

Total 1080 stage III CRC patients (634 [58.7%] men; median [IQR] age, 60 [50-68] years) who underwent radical surgical resection were identified for inclusion in this study. Patients with tumor deposits had a 12.8% lower 3-year RFS (n = 236 [69.9%]) than the patients without tumor deposits (n = 844 [82.7%]) (P ≤ 0.0001). The 3-year RFS of patients with stage N2 (n = 335 [61.2%]) was 18.6% lower (P ≤ 0.0001) than the original cohort of patients with stage N1 (n = 745 [79.8%]), but it was similar to the RFS of patients with 4 or more tumor deposits plus lymph node metastases (n = 58 [61.4%]) (P = 0.91). The RFS for patients with 4 or more tumor deposits plus number of lymph node metastases (n = 58 [61.4%]) was 15.8% lower than the cohort of patients with 1-3 tumor deposits + number of lymph node metastases (n = 687 [77.2%]) (P = 0.001). Multivariate analysis confirmed that patients with 4 or more tumor deposits + the number of lymph node metastases (hazard ratio [HR], 1.88; 95% CI, 1.24-2.87) were independently associated with a shorter RFS.

CONCLUSION

The number of tumor deposits is an indicator of poor postoperative prognosis. It is necessary to incorporate the number of tumor deposits combined with the number of lymph node metastases to stratify postoperative stratification of stage III CRC, which may provide a new theoretical basis for adjuvant therapy for patients with N1 stage CRC after surgery.

Prognostic value of tumor deposits for long-term oncologic outcomes in patients with stage III colorectal cancer: a systematic review and meta-analysis

PURPOSE

The presence of tumor deposits (TDs) in colorectal cancer is associated with a poor prognosis. In patients with the concomitant presence of both TDs and lymph nodes (LNs), there is no staging option except for the number of positive LNs alone. Therefore, to determine the prognostic value of TDs in patients with stage III colorectal cancer, meta-analyses of survival outcomes of patients with TDs were performed comparing different subgroups based on the lymph node status.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched. Data were pooled, and overall effect size was calculated using random-effect models. Outcome measures were 5-year overall survival (OS) and 5-year disease-free survival (DFS).

RESULTS

We included in the analysis 18 nonrandomized studies and 1 prospective study that examined 90,455 patients. N1c patients (TD + LN-) had worse 5-year DFS than TDs-negative stage III patients (TD-LN +) with a RR of 1.30 (95% CI 1.06-1.61, I² = 47%). In subgroup analysis, N1c patients had worse 5-year DFS (RR = 1.60, 95% CI = 1.25-2.05, I² = 40%) compared with TDs-negative N1 patients (TD-N1) whereas N1c patients had better 5-year OS (RR = 0.72, 95% CI = 0.62-0.83, I² = 0%) and 5-year DFS (RR = 0.75, 95% CI = 0.57-0.99, I² = 0%) compared with TDs-negative N2 patients (TD-N2).

CONCLUSIONS

These results may suggest that current nodal staging for colorectal cancer needs modification. The presence of TDs may have more adverse oncologic outcomes than TDs-negative N1 patients. More studies are warranted to further verify these results.

Sarcoidosis-like disease with pulmonary infestation, meningoencephalitis and transverse myelitis after sigmoid cancer treatment

We present the case of a 40-year-old male with recent history of moderately differentiated invasive adenocarcinoma of the sigmoid in whom both respiratory and neurological disease developed simultaneously, mimicking diffuse metastatic disease. The broad differential diagnosis and pitfalls (both diagnostic and therapeutic) are described. Pulmonary sarcoidosis as well as neurosarcoidosis occur very rarely after solid cancers.

Interobserver variation in the classification of tumor deposits in rectal cancer-is the use of histopathological characteristics the way to go?

The focus on lymph node metastases (LNM) as the most important prognostic marker in colorectal cancer (CRC) has been challenged by the finding that other types of locoregional spread, including tumor deposits (TDs), extramural venous invasion (EMVI), and perineural invasion (PNI), also have significant impact. However, there are concerns about interobserver variation when differentiating between these features. Therefore, this study analyzed interobserver agreement between pathologists when assessing routine tumor nodules based on TNM 8. Electronic slides of 50 tumor nodules that were not treated with neoadjuvant therapy were reviewed by 8 gastrointestinal pathologists. They were asked to classify each nodule as TD, LNM, EMVI, or PNI, and to list which histological discriminatory features were present. There was overall agreement of 73.5% (κ 0.38, 95%-CI 0.33–0.43) if a nodal versus non-nodal classification was used, and 52.2% (κ 0.27, 95%-CI 0.23–0.31) if EMVI and PNI were classified separately. The interobserver agreement varied significantly between discriminatory features from κ 0.64 (95%-CI 0.58–0.70) for roundness to κ 0.26 (95%-CI 0.12–0.41) for a lone arteriole sign, and the presence of discriminatory features did not always correlate with the final classification. Since extranodal pathways of spread are prognostically relevant, classification of tumor nodules is important. There is currently no evidence for the prognostic relevance of the origin of TD, and although some histopathological characteristics showed good interobserver agreement, these are often non-specific. To optimize interobserver agreement, we recommend a binary classification of nodal versus extranodal tumor nodules which is based on prognostic evidence and yields good overall agreement.

Prognostic Value of the N1c in Stage III and IV Colorectal Cancer: A Propensity Score Matching Study Based on the Surveillance, Epidemiology, and End Results (SEER) Database

The prognostic role of the N1c remains unclear in colorectal cancer (CRC). Our study aimed to determine the prognostic value of N1c.

Patients diagnosed in 2010-2015 were accessed from the Surveillance, Epidemiology, and End Results (SEER) database. COX univariate and multivariate regression analysis and the Kaplan-Meier method were used to assess the impact of the N1c stage on the cause-specific (CSS) and overall survival (OS). Propensity score matching (PSM) was used to construct a matched group with similar propensity scores.

Kaplan-Meier analysis showed that the CSS and OS rates in N1a were significantly better than N1c in stage III and IV CRCs after reducing selection bias (CSS: P < 0.001 in stage III, P = 0.041 in stage IV; OS: P < 0.001 in stage III, P = 0.0079 in stage IV). There were no statistical differences in CSS and OS between N1b and N1c (CSS: P = 0.500 in stage III, P = 0.270 in stage IV; OS: P = 0.390 in stage III, P = 0.600 in stage IV). Further, the prognostic value of N1c with only one tumor deposit (TD) is equivalent to N1a based on the comparison of CSS and OS rates (CSS: P = 0.420; OS: P = 0.310). Whereas N1c with only one TD had significantly better CSS and OS than N1b (CSS: P = 0.039; OS: P = 0.037).

The CSS and OS rates of N1c do not achieve a statistical difference with N1b in both stage III and IV CRCs. Significantly, higher CSS and OS rates were found in N1c with only one TD versus N1b stage in stage III CRC.

Development and validation of a novel prognostic nomogram including tumor deposits could better predict survival for colorectal cancer: a population-based study

Background

The number of tumor deposits (TDs) in colorectal cancer (CRC) prognosis remains debated. We evaluated whether the number of TDs affects prognosis in stage III CRC patients.

Methods

Univariate and multivariate analyses were performed with Cox proportional hazards models. The Kaplan-Meier method was used to estimate survival curves. The best cutoff was determined using X-Tile. Patients were 1:1 randomly divided into the training set or the testing set. Prognostic nomogram was established for stage III CRC patients. Concordance index (C-index) and calibration plot were used to assess Nomogram models.

Results

In total, 18,043 (84.69%) CRC patients without TDs and 3,263 (15.31%) patients with TDs were analyzed. Patients with TDs had significantly worse cancer-specific survival (CSS) rates (P<0.001). The number of TDs is an independent factor for the CSS of stage III CRC patients. CSS nomogram of stage III CRC patients was constructed based on race, age at diagnosis, tumor location, histological grade, pathological type, T, N, TDs, chemotherapy. In training set, C-index for CSS nomogram 0.762 (95% CI: 0.752–0.772). In testing set, the C-index for CSS nomogram 0.759 (95% CI: 0.749–0.768). The quality of calibration plots of nomogram models was high.

Conclusions

The presence of TDs is an independent risk prognostic factor for stage III CRC. The number of TDs had a high proportion of prognostic impact.

N1c colon cancer and the use of adjuvant chemotherapy: a current audit of the National Cancer Database

AIM

Colorectal cancer staging has evolved to define N1c as the presence of tumour deposits without concurrent positive lymph nodes. Work to date reports poor prognosis in N1c colon cancer, with Stage III categorization and adjuvant chemotherapy (AC) recommended. No study has yet evaluated the prevalence, treatment compliance or treatment-related outcomes on a national scale. We aimed to evaluate the prevalence of N1c colon cancer, use, outcomes and factors associated with AC in the USA.

METHOD

The National Cancer Database was reviewed for N1cM0 colon adenocarcinomas that underwent resection from 2010 to 2016. Cases were stratified into 'AC' or 'no AC' cohorts. The Kaplan-Meier method was used to estimate overall survival (OS) and compare the AC and no AC cohorts using the log-rank test. Multivariable logistic regression identified factors associated with AC. The main outcome measures were the prevalence and factors associated with AC use and its impact in N1c disease.

RESULTS

Of the 5684 (1.59% of 357 752) colon adenocarcinomas that were N1c, 55% (n = 3071) received AC. AC significantly improved 1-, 3- and 5-year OS compared with no AC (96.2%, 80%, 67.4% and 72.9%, 48.5%, 33.8%, respectively; P < 0.001). Compared with the no AC group, AC patients were younger, had less comorbidity, were of the male gender and received minimally invasive surgery at an academic treatment centre (all P < 0.05). Socioeconomic and procedural factors significantly impacted the use of AC.

CONCLUSION

In the USA, AC is underutilized in N1c colon cancer despite significantly improved OS. Socioeconomic and procedural factors associated with AC were identified, highlighting disparities in AC use and opportunities to improve oncological outcomes and survival.

Rectal cancer: a methodological approach to matching PET/MRI to histopathology

Purpose

To enable the evaluation of locoregional disease in the on-going RECTOPET (REctal Cancer Trial on PET/MRI/CT) study; a methodology to match mesorectal imaging findings to histopathology is presented, along with initial observations.

Methods

FDG-PET/MRI examinations were performed in twenty-four consecutively included patients with rectal adenocarcinoma. In nine patients, of whom five received neoadjuvant treatment, a postoperative MRI of the surgical specimen was performed. The pathological cut-out was performed according to clinical routine with the addition of photo documentation of each slice of the surgical specimen, meticulously marking the location, size, and type of pathology of each mesorectal finding. This allowed matching individual nodal structures from preoperative MRI, via the specimen MRI, to histopathology.

Results

Preoperative MRI identified 197 mesorectal nodal structures, of which 92 (47%) could be anatomically matched to histopathology. Of the matched nodal structures identified in both MRI and histopathology, 25% were found to be malignant. These malignant structures consisted of lymph nodes (43%), tumour deposits (48%), and extramural venous invasion (9%). One hundred eleven nodal structures (55%) could not be matched anatomically. Of these, 97 (87%) were benign lymph nodes, and 14 (13%) were malignant nodal structures. Five were malignant lymph nodes, and nine were tumour deposits, all of which had a short axis diameter < 5 mm.

Conclusions

We designed a method able to anatomically match and study the characteristics of individual mesorectal nodal structures, enabling further research on the impact of each imaging modality. Initial observations suggest that small malignant nodal structures assessed as lymph nodes in MRI often comprise other forms of mesorectal tumour spread.

Trial registration

Clinical Trials Identifier:NCT03846882.

Comparison of the efficiency of transgelin, smooth muscle myosin, and CD31 antibodies for the assessment of vascular tumor invasion and free tumor deposits in gastric, pancreatic, and colorectal adenocarcinomas

Background

This study aimed to compare CD31, smooth muscle myosin (SMM), and transgelin antibodies for their efficiency in detecting venous invasion (VI) and the nature of free tumor deposits (TDs) in gastric, pancreatic, and colorectal adenocarcinomas.

Materials and Methods

Eleven Whipple, 5 gastrectomy, and 3 colectomy specimens and 1 low anterior resection specimen were reviewed and examined, revealing 254 probable foci. Foci were reviewed and divided into 3 types: Type A, the "orphan artery" pattern; Type F, free TDs in the periorgan adipose and connective tissue without an unaccompanied artery; and Type X, a focus that could be detected only with the immunohistochemical procedures mentioned.

Results

No foci were positive for CD31. Transgelin staining was more sensitive than SMM staining in all focus types, Type A only and Type F only (P < 0.001, P = 0.001, and P = 0.10, respectively). In free TDs (Type F), 35.7% of the samples were negative for all four stains, and 64.2% of the samples were positive for SMM and transgelin. We did not make the distinction between a metastatic lymph node and VI in positive foci.

Conclusion

We conclude that hematoxylin and eosin (H and E) staining is inadequate and that smooth muscle markers, such as transgelin and/or SMM, are more effective than endothelial markers, such as CD31, in revealing VI and lymph node/large extramural invasion.

A Modified Tumor-Node-Metastasis Classification for Stage III Colorectal Cancers Based on Treating Tumor Deposits as Positive Lymph Nodes

Background: The tumor-node-metastasis classification of the American Joint Committee on Cancer classified tumor deposits (TDs) in patients with colorectal cancer (CRC) without lymph node (LN) metastasis as N1c, but the classification of TDs in patients with LN metastases remains controversial. This study investigated the probability of regarding TDs as positive LNs (pLNs) in pN stage and estimated its prognostic ability in CRC. Methods: We used the Surveillance, Epidemiology, and End Results program to analyze CRC patients who underwent surgical therapy (14,906 training cohort, 6,384 validation cohort). A modified pN stage (mpN) was identified using the number of pLNs plus TDs. Overall survival (OS) was analyzed using the Kaplan-Meier survival curves, and significant prognostic factors were identified by univariate and multivariate analyses. Prognostic ability was estimated using the area under the curve (AUC), calibration curve, and the Akaike's information criterion (AIC). Clinical benefit was measured by the decision curve analyses (DCA). The results were validated using the validation cohort. Results: Both the pN and mpN stages were independent prognostic factors in CRC according to univariate and multivariate analyses. The AUC analysis showed that the mpN stage had better prognostic discrimination for OS than the pN stage (0.612 vs. 0.605, P < 0.001). The AIC demonstrated that the mpN stage also showed superior model-fitting compared with the pN stage (49,756 vs. 49,841). The DCA further revealed that the mpN stage had better clinical benefits than the pN stage. The validation cohort showed similar findings. Conclusions: We concluded that counting TDs as pLNs may be superior to the pN stage when assessing the prognosis of CRC patients.

Prognostic Significance of Tumor Deposits in Combination with Lymph Node Metastasis in Stage III Colon Cancer: A Propensity Score Matching Study

Tumor deposits in colon cancer are related to poor prognosis, whereas the prognostic power of tumor deposits in combination with lymph node metastasis (LNM) is controversial. This study aimed to compare the overall survival between LNM alone and LNM in combination with tumor deposits, and to verify whether the number of tumor deposits can be considered LNM in patients with both LNM and tumor deposits in stage III colon cancer by propensity score matching (PSM). Patients carrying resected stage III adenocarcinoma of colon cancer were identified from the Surveillance, Epidemiology, and End Results database (2010–2015). The Kaplan-Meier method, Cox proportional hazard models and PSM were used. On the whole, 23,168 patients (20,451 (88.3%) with only LNM and 2,717 (11.7%) with both LNM and tumor deposits) were selected. After undergoing PSM, patients with both LNM and tumor deposits showed worse overall survival (hazard ratio = 1.33, 95% confidence interval: 1.20–1.47, P < 0.001). After the number of tumor deposits was added with that of positive regional lymph nodes, patients with both LNM and tumor deposits seemed to have prognostic implications similar to those with LNM alone (hazard ratio = 1.02, 95% confidence interval: 0.93–1.12, P = 0.66). The simultaneous presence of LNM and tumor deposits, as compared with the presence of only LNM, had an association with a worse outcome. Tumor deposits should be considered as LNM in patients with both tumor deposits and LNM in stage III colon cancer.

Tumor Deposits in Stage III Colon Cancer: Correlation With Other Histopathologic Variables, Prognostic Value, and Risk Stratification-Time to Consider "N2c"

Objectives:

National Comprehensive Cancer Network (NCCN) guidelines for stage III colon cancer define low-risk versus high-risk patients based on T (1 to 3 vs. 4) and N (1 vs. 2) status, with some variations in treatment. This study analyzes the impact of tumor deposits (TDs), T and N status, poor differentiation (PD), perineural invasion (PNI), and lymphovascular invasion (LVI) on survival.

Materials and Methods:

A retrospective analysis (2010-2015) of the National Cancer Database of stage III colon cancer patients treated with both surgery and chemotherapy was conducted. Data was extracted on sex, race, age at diagnosis, Charlson-Deyo Score, histopathologic variables, and survival rates. Statistical analysis used the test of proportions, log-rank test for Kaplan-Meier curves, and Cox proportional hazard models.

Results:

For the 42,901 patients analyzed, 5-year survival rates were similar for LN⁺TD⁻ (59.8%) and LN⁻TD⁺ (58.2%), but significantly worse for LN⁺TD⁺ (41.5%) (P<0.001). The presence of LN⁺TD⁺ was more often associated with T4 (36.9%), N2 (55.1%), PD⁺ (37.4%), PNI⁺ (34.5%), and LVI⁺ (69.1%), than LN⁺TD⁻ or LN⁻TD⁺ (P<0.001). The hazard ratios for each variable were: TD: 1.34; T4: 1.71; N2: 1.44; PD⁺: 1.37; PNI: 1.11; LVI⁺: 1.18. LN⁻ patients with ≥3 TD⁺ (N1c) had worse overall survival than those with 1 to 2 TD⁺ (P<0.01), but similar to ≥4 LN⁺TD⁻ (N2) and 1 to 3 LN⁺TD⁺ (N1a-b). In our model, 5-year survival ranged from 23.4% for high-risk to 78.1% for low-risk patients (P<0.001).

Conclusion:

This National Cancer Database (NCDB) analysis offers greater risk stratification and may prompt consideration of changes in American Joint Committee on Cancer (AJCC) classification (N2c, in addition to N1c) to reflect the different prognosis and guide management, as well as survivorship strategies, for TD⁺ stage III colon cancer patients.

Reconsidering the prognostic significance of tumour deposit count in the TNM staging system for colorectal cancer

Although the occurrence of tumour deposits (TDs) without metastatic lymph nodes (mLNs) is classified as “N1c” in the 8^th TNM staging system for colorectal cancer (CRC), the prognostic significance of the TD count is still controversial. A total of 39155 CRC patients were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The potential associations between baseline characteristics and TD status were evaluated using the χ² test. Cancer-specific survival (CSS) rates were calculated by using the Kaplan-Meier method, and CSS comparisons were performed by using the log-rank test. The results showed that TD count was an important prognostic factor and that the number of TDs was negatively correlated with the prognosis of CRC patients. We found that the prognostic value of one TD is equivalent to that of two mLNs based on the comparison of CSS rates. Accordingly, we proposed a novel N staging system by integrating the TD count into the N category with the ratio of TDs to mLNs being 1:2. There were no prognostic differences in patients with or without TDs in each novel N category. Weighing one TD as two mLNs in this novel TNM staging system is superior to the “N1c” classification in the 8^th TNM staging system in evaluating the prognosis of CRC patients.

Reduced RANBP9 expression is associated with poor prognosis in colorectal cancer patients

Background

Colorectal cancer (CRC) is the third most common malignancy worldwide. RANBP9 is a RAN-binding protein that has been reported to be a reliable predictor for prognosis in some human cancers. The mechanism of RANBP9 involvement in CRC carcinogenesis is unknown. This study measured RANBP9 expression levels in CRC to determine its association with clinicopathological parameters.

Methods

This study included 228 CRC patients who underwent radical resection. RANBP9 expression was determined using immunohistochemistry. Based on follow-up data, the correlation of RANBP9 expression levels with clinicopathological parameters, including disease free survival (DFS) and overall survival (OS) was evaluated.

Results

Reduced RANBP9 expression was correlated with tumor location (P=0.014), vascular invasion (P=0.057) and normal serum carcinoembryonic antigen levels (P=0.001). Patients with reduced RANBP9 expression had a 5-year DFS rate of 63.0% compared to 78.9% for patients with high expression levels of RANBP9 (P=0.015). Subgroup analysis demonstrated that reduced RANBP9 expression was significantly correlated with a worse DFS rate (P=0.037) for patients with left-sided colon cancer. RANBP9 was found to be an independent predictive factor for estimating DFS rate (P=0.029, hazard ratio: 0.580, 95% confidence interval: 0.356–0.946) and OS.

Conclusions

RANBP9 expression levels is a potential prognostic factor for estimating CRC survival rates in patients after surgery.

The unique prognostic characteristics of tumor deposits in colorectal cancer patients

Background

Both AJCC 7th and 8th TNM systems have included tumor deposits (TDs) in nodal staging when lymph nodes metastases (LNMs) are negative in colorectal cancer (CRC). However, the prognostic role of TDs has not been determined in the presence of positive LNMs.

Methods

Two independent large-scale cohorts of CRC patients from the Surveillance Epidemiology and End Results (SEER) database (n=69,178) [2010-2013] and Fudan University Shanghai Cancer Center (FUSCC) (n=3,137) [2010-2014] were retrospectively analyzed. Kaplan-Meier method was used to estimate survival curves and univariate and multivariate analyses were performed by Cox proportional hazard model.

Results

TDs were observed in 12.3% (n=8,480) and 14.8% (n=463) of patients in the SEER and FUSCC cohorts, respectively. Multivariate analysis suggested TDs were an independent adverse prognostic factors for overall survival (OS) (P<0.001). Remarkably, both cohorts showed the presence of TDs was significantly associated with OS, but not was the number of TDs (P=0.982 and P=0.252 for the SEER and FUSCC cohorts, respectively). In the presence of LNMs, positive TDs were associated with a shorter OS [hazard ratio (HR): 2.69, 95.0% confidence interval (CI): 2.597-2.778; P<0.001]. Further analysis combining TDs with LNMs demonstrated that the prognosis of patients with N1TD (N1 with positive TDs) was same as the N2 patients, and N2TD (N2 with positive TDs) patients had much worse prognosis than N2 (P<0.001).

Conclusions

Our results have shown the unique features of TDs in patients with CRC, different from LNMs. In the presence of LNMs, TDs should also be considered in TMN system.

Prognostic Significance of Tumor Deposits in Patients With Stage III Colon Cancer: A Nomogram Study

BACKGROUND

The clinical characteristics of stage III colon cancer and the prognostic significance of tumor deposits were investigated, to construct a prognostic nomogram.

METHODS

The data of patients were retrieved from the Surveillance, Epidemiology, and End Results database. Patients were randomized to a training or validation cohort. The Kaplan-Meier method was used to analyze survival rates. In the training cohort, a prognostic nomogram was established via Cox regression and then tested in the validation cohort. The accuracy and discrimination of the nomogram were assessed using concordance indices (C-indices) and calibration curves.

RESULTS

Of the 9246 patients meeting the inclusion criteria, 1788 (19.3%) had tumor deposits. Patients with tumor deposits only showed similar survival rates to those with lymph node metastases only (P = 0.83). Compared with these, patients with both tumor deposits and lymph node metastases exhibited significantly worse survival (P < 0.01). In the multivariate Cox regression analyses, the following were identified as independent prognostic indicators and adopted to formulate the nomogram: tumor deposits, age, ethnicity, T stage, the number of positive regional lymph nodes, grade, and carcinoembryonic antigen. In the training cohort, the calibration curve showed good consistency, and the concordance index of the nomogram for predicting overall survival reaches 0.727 (95% CI: 0.71524-0.73876), superior to the concordance index of the American Joint Committee on Cancer staging system (0.594, 95% CI: 0.58224-0.60576). These results are supported in the validation cohort.

CONCLUSIONS

Tumor deposits may be an independent prognostic factor for patients with stage III colon cancer after colectomy. The nomogram constructed herein accurately predicted overall survival.

Prognostic value of N1c in colorectal cancer: a large population-based study using propensity score matching

PURPOSE

We conducted this large population-based study to investigate the prognostic significance of N1c.

METHODS

Patients diagnosed with colorectal cancer from the surveillance, epidemiology, and end results (SEER) database between January 1, 2010, and December 31, 2010, were included in the sample. The primary outcome of interest used in our study was cause-specific survival (CSS). Cox proportional hazards models and Kaplan-Meier methods were used to evaluate the prognostic value of N1c. Propensity score matching (PSM) was implemented to reduce the possibility of selection bias using a logistic regression model.

RESULTS

A total of 19,991 patients diagnosed with colorectal cancer were identified from the SEER database. The median follow-up time of the whole cohort was 60 months (0-71 months). Multivariate Cox analysis showed that N1c was associated with significantly higher risk of colorectal cancer-specific mortality compared with N0 (HR = 1.962, 95%CI = 1.642 to 2.343, P < 0.001) and N1a (HR = 0.818, 95%CI = 0.678 to 0.987, P = 0.036); N1c was associated with significantly lower risk of colorectal cancer-specific mortality compared with N2a (HR = 1.296, 95%CI = 1.081 to 1.554, P = 0.005) and N2b (HR = 1.663, 95%CI = 1.391 to 1.989, P < 0.001). Yet the CSS difference between N1b and N1c did not achieve statistical difference (HR = 1.089, 95%CI = 0.909 to 1.304, P = 0.354).

CONCLUSIONS

The large population-based and propensity score-matched study with long follow-up time provides the first evidence that CSS difference between N1b and N1c does not achieve a statistical difference.

PET/MRI and PET/CT hybrid imaging of rectal cancer - description and initial observations from the RECTOPET (REctal Cancer trial on PET/MRI/CT) study

Purpose

The role of hybrid imaging using ¹⁸F-fluoro-2-deoxy-D-glucose positron-emission tomography (FDG-PET), computed tomography (CT) and magnetic resonance imaging (MRI) to improve preoperative evaluation of rectal cancer is largely unknown. To investigate this, the RECTOPET (REctal Cancer Trial on PET/MRI/CT) study has been launched with the aim to assess staging and restaging of primary rectal cancer. This report presents the study workflow and the initial experiences of the impact of PET/CT on staging and management of the first patients included in the RECTOPET study.

Methods

This prospective cohort study, initiated in September 2016, is actively recruiting patients from Region Västerbotten in Sweden. This pilot study includes patients recruited and followed up until December 2017. All patients had a biopsy-verified rectal adenocarcinoma and underwent a minimum of one preoperative FDG-PET/CT and FDG-PET/MRI examination. These patients were referred to the colorectal cancer multidisciplinary team meeting at Umeå University Hospital. All available data were evaluated when making management recommendations. The clinical course was noted and changes consequent to PET imaging were described; surgical specimens underwent dedicated MRI for anatomical matching between imaging and histopathology.

Results

Twenty-four patients have so far been included in the study. Four patients were deemed unresectable, while 19 patients underwent or were scheduled for surgery; one patient was enrolled in a watch-and-wait programme after restaging. Consequent to taking part in the study, two patients were upstaged to M1 disease: one patient was diagnosed with a solitary hepatic metastasis detected using PET/CT and underwent metastasectomy prior to rectal cancer surgery, while one patient with a small, but metabolically active, lung nodulus experienced no change of management. PET/MRI did not contribute to any recorded change in patient management.

Conclusions

The RECTOPET study investigating the role of PET/CT and PET/MRI for preoperative staging of primary rectal cancer patients will provide novel data that clarify the value of adding hybrid to conventional imaging, and the role of PET/CT versus PET/MRI.

Trial registration

NCT03846882.

Impact of extranodal tumor deposits on prognosis and N stage in gastric cancer

BACKGROUND

Extranodal tumor deposits have been reported to be associated with a poor prognosis in many malignancies and are also included in the tumor, node, and metastasis staging system for colorectal cancer.

METHODS

We reviewed retrospectively a total of 2,344 gastric cancer patients who underwent gastrectomy with curative intent at the Tianjin Medical University Cancer Institute and Hospital (Hexi District, Tianjin, China) and the First Affiliated Hospital of Hainan Medical University (Longhua District, Haikou, China). Patients were categorized into 2 groups based on extranodal tumor deposit status: a positive group, including those with extranodal tumor deposits, and a negative group composed of those with no extranodal tumor deposits. Clinicopathologic factors were correlated with extranodal tumor deposits, and their individual prognoses were analyzed. In addition, a pathologically modified node classification system was proposed by incorporating the extranodal tumor deposit status into the 8th ed of the N staging system. The superiority of prognostic prediction between the modified node classification and node stage was compared.

RESULTS

A total of 645 (27.5%) patients had extranodal tumor deposits. The presence of extranodal tumor deposits was associated with a larger tumor size, Borrmann type III and IV, a deeper depth of invasion, and an advanced node stage. In the multivariate analysis, extranodal tumor deposits were an independent prognostic factor for gastric cancer patients after curative resection. Gastric cancer patients with extranodal tumor deposits demonstrated a lesser 5-year overall survival than those with no extranodal tumor deposits (31.9% vs 61.4%, P < .001). With the strata analysis, statistically significant prognostic differences between the two groups were only observed in patients at the N0-N2 stage. The modified node classification was found to be more appropriate for predicting the overall survival of gastric cancer patients after curative resection than node stage, and the -2 log likelihood of the modified node classification (16,042.890) was smaller than the value of node stage (16,150.811).

CONCLUSION

Extranodal tumor deposits in gastric cancer patients indicate aggressive characteristics and a poorer prognosis of gastric cancer. We maintain that extranodal tumor deposits should be incorporated into the N staging system to enhance the accuracy of the prognostic prediction of patients with gastric cancer.

Tumour deposits are a significant prognostic factor in gastric cancer - a systematic review and meta-analysis

AIMS

Tumour deposits (TDs) are clusters of cancer cells in the soft tissue that are discontinuous from the primary tumour. In this review we are exploring their relevance for prognosis in patients with gastric cancer.

METHODS AND RESULTS

A literature search was performed to identify studies providing data on TDs and prognosis in gastric cancer patients. Eight papers were included in the meta-analysis, which was carried out in terms of risk ratios (RR) and hazard ratios (HR) with 95% confidence interval (95% CI). Of 7445 patients, 1551 had TDs (20.9%). TDs were associated with a decreased overall survival (OS) in univariate (HR = 2.82, 95% CI = 1.9-4.3) and multivariate analyses (HR = 1.65, 95% CI = 1.3-2.1). TDs were also associated with known prognostic factors such as synchronous metastatic disease (RR = 9.5), invasion depth (RR = 1.8), lymph node metastasis (RR = 1.7), lymphatic invasion (RR = 1.7), vascular invasion (RR = 2.6) and poor differentiation (RR = 1.2).

CONCLUSIONS

We found a strong indication that TDs are independent predictors of prognosis in patients with gastric cancer; hence, TDs should be included in the staging of gastric cancers.

Stage I-III colon cancer patients with tumor deposits behave similarly to stage IV patients. Cross-section analysis of 392 patients

BACKGROUND AND OBJECTIVES

Tumor deposits (TDs) are associated with adverse prognostic factors and decreased survival in colorectal cancer. However, controversy exists regarding their definition, evaluation, and staging categories. This study aimed to determine the survival and recurrence impact of the TD in colon adenocarcinomas; and to determine if TD patients behave similarly to stage IV patients.

METHODS

Cross-section study from 392 patients with colon adenocarcinoma from 2005 to 2012. We performed survival analysis and further stratified patients considering TD patients as a "stage IV-TD" to demonstrate if they behave similarly than stage IV patients.

RESULTS

From 392 patients, 204 (52%) were men, the mean age was 57.4 ± 13.9 years and 11.5% of cases had TD. In a multivariate analysis, TD failed to predict mortality and recurrence. Considering cases with TD as stage IV-TD, their mean survival was similar to stage IV patients (69.3 and 64.6 months, respectively) and different to those in stage III (110.5 months), II (135.7 months), and I (114.9 months) (P < 0.001).

CONCLUSIONS

TD failed to predict mortality and recurrence. Patients with TD in stage I-III shows similar mortality than stage IV patients; then, we suggest putting them into a substage IV category instead of the N1c category.

Prognostic Importance of Tumor Deposits in the Ipsilateral Axillary Region of Breast Cancer Patients

Tumor deposits (TD) are irregular discrete tumor masses in adipose tissue, discontinuous from the primary tumor, that are described in various cancers. The incidence and/or prognostic value of TD in breast carcinomas have not been studied so far. We reevaluated 145 breast cancer patients, diagnosed and treated between 2001 and 2006 at our institution for the presence and incidence of TD. Histologic type, grade, size of the primary tumor, estrogen receptor, progesterone receptor, human epidermal growth factor receptor-2 status of the tumor, and presence of peritumoral lymphovascular invasion were included in the data. TD were detected in 42 cases (29.0%). The mean age of the patients was 52.2 years (27-82). Most patients (79.3%) had either invasive carcinoma of no special type (NST) or invasive lobular carcinoma, and most tumors (86.9%) were either grade 2 or 3. After excluding TD from the number of metastatic lymph nodes, the pN status of 9 patients changed. Univariate analysis of 110 patients with follow-up information revealed that the new pN status (p = 0.036), presence of local recurrence (p = 0.016) and TD (p = 0.003) were significantly correlated with distant metastases. The median follow-up of the patients was 84 months (5-161), 10-year disease-free survival and overall survival were 67.2% and 73.7%, respectively. In multivariate analysis, presence of TD remained independently associated with distant metastasis (p = 0.002). The probability of distant metastasis was 3.3 times higher in patients with TD. These results emphasize that TD are present in breast cancer patients, and that their presence should warn the clinician in terms of possible distant metastasis. Therefore, presence of TD, the evaluation of which is neither time consuming nor require sophisticated methods, should be included in pathology reports.

Prognostic value and characteristics of N1c colorectal cancer

AIM

The presence of tumour deposits (TDs) in colorectal cancer (CRC) is associated with poor prognosis. The seventh edition of TNM subclassified a new nodal stage, N1c, characterized by the presence of TDs without any concurrent positive lymph node (LN). It is not clear if the N1c category is or is not equal to LN metastasis. We aimed to examine the prevalence, characteristics and prognostic significance of this new subcategory.

METHOD

Consecutive patients who underwent surgery for CRC in two centres (2011-2014) were analysed. N1 cM0 patients were matched against non-N1 cM0 (N0, N1a and N1b) patients for 3-year overall survival (OS) and disease-free survival (DFS).

RESULTS

We identified 1122 patients with 648 (57.8%) colonic cancers. In 57 patients (5.1%), N1c status was associated with rectal cancers [rectum = 33/57 (57.9%) vs colon = 24/57 (42.1%); P = 0.029], a higher pathological tumour stage [pT3-T4 N1c = 55/843 (6.5% vspT3-T4 non-N1c = 2/279 (0.7%); P < 0.0001] and vascular emboli [n = 35 (61.4%) vs n = 552 (51.8%); P = 0.0305]. Synchronous metastasis was observed in 23 cases (40%). After a mean follow-up of 31 months, 3-year OS for M0 patients, was 89.4%, 89.1%, 86.6% and 81.8% for N0, N1a, N1b and N1c tumours, respectively. DFS was significantly worse for N1c than for N0 (P = 0.0169), with N1c status having a significant effect on DFS in colonic cancers (P = 0.014). The presence of more than one TD was associated with a significantly worse DFS (P = 0.021).

CONCLUSION

Our results indicate that N1c CRC patients should be included among high-risk patients for whom it is widely accepted that adjuvant chemotherapy should be considered.

Impact of Tumor Deposits on Oncologic Outcomes in Stage III Colon Cancer

BACKGROUND

The prognosis of tumor deposits in stage III colon adenocarcinoma is poorly described.

OBJECTIVE

The purpose of this study was to determine the impact of tumor deposits on oncologic outcomes in patients with stage III colon cancer.

DESIGN

This was a multicenter retrospective cohort study.

SETTINGS

The 2010 to 2014 National Cancer Database was queried for patients with resected stage III colon adenocarcinoma on final pathology.

PATIENTS

Patients were divided into 3 groups: lymph nodes+tumor deposits-, lymph nodes+tumor deposits+, and lymph nodes-tumor deposits+.

MAIN OUTCOME MEASURES

The main outcome was 5-year overall survival.

RESULTS

Of 74,577 patients, there were 55,800 patients with lymph nodes+tumor deposits-, 13,740 patients with lymph nodes+tumor deposits+, and 5037 patients with lymph nodes-tumor deposits+. The groups had similar patient and facility characteristics, but patients with lymph nodes+tumor deposits+ had more advanced tumor characteristics. Patients with lymph nodes-tumor deposits+ were less likely to receive adjuvant systemic therapy (52% vs 74% lymph nodes+tumor deposits- and 75% lymph nodes+tumor deposits+, p < 0.001) and had a longer delay to initiation of adjuvant treatment (>8 weeks; 43% vs 33% lymph nodes+tumor deposits- and 33% lymph nodes+tumor deposits+, p < 0.001). Patients with lymph nodes+tumor deposits+ had the lowest 5-year overall survival (46.0% vs 63.4% lymph nodes+tumor deposits- vs 61.9% lymph nodes-tumor deposits+, p < 0.001). On multivariate analysis, patients with lymph nodes-tumor deposits+ had similar 5-year overall survival compared with patients with lymph nodes+tumor deposits- with ≤3 positive lymph nodes (HR, 0.93; 95% CI, 0.87-1.01). Patients with lymph nodes+tumor deposits+ had worse prognosis regardless of the number of involved lymph nodes (≤3 +lymph nodes: HR, 1.37; 95% CI, 1.28-1.47 and ≥4 +lymph nodes: HR, 1.30; 95% CI, 1.22-1.38). Of those not receiving adjuvant treatment, patients with lymph nodes-tumor deposits+ were younger and had more adverse tumor features than lymph node+ disease. Lymph nodes-tumor deposits+ was independently associated with less delivery of adjuvant systemic therapy (OR, 0.81; 95% CI, 0.80-0.82).

LIMITATIONS

This study was limited by its retrospective analysis of a prospective database.

CONCLUSIONS

The prognosis of patients with N1c disease is similar to nodal involvement without tumor deposits, yet these patients were less likely to receive adjuvant systemic therapy. Improvement in the delivery of appropriate care in these patients may increase survival and should be a target of future quality initiatives. See Video Abstract at http://links.lww.com/DCR/A666.

Prognostic Significance of Tumor Deposits in Stage III Colon Cancer

BACKGROUND

The American Joint Committee on Cancer includes extranodal tumor deposits in the tumor-node-metastasis classification of colon cancer. However, it is unclear how tumor deposits compare with lymph node metastases in prognostic significance. This study evaluated the survival impact of tumor deposits relative to lymph node metastases in stage III colon cancer.

METHODS

The US National Cancer Database (2010-2012) was reviewed for resectable stage III adenocarcinoma of the colon, and stratified by presence of tumor deposits and lymph node metastases. Univariate and multivariate survival analyses were performed.

RESULTS

Of 6424, 10.1% had both tumor deposits and lymph node metastases [5-year survival (5YS) 40.2%], 2.5% had tumor deposits alone (5YS 68.1%), and 87.4% had lymph node metastases alone (5YS 55.4%). Patients with lymph node metastases alone tended to have a greater number of lymph nodes retrieved (20.9 versus 18.8, p = 0.0126) and were more likely to receive adjuvant therapy (66.9 vs 58.0%, p = 0.003) than those with only tumor deposits. Patients with both had significantly worse survival at all T stages (p < 0.05, all). There was no significant difference in survival between tumor deposits alone and lymph node metastases alone at any T stage (p > 0.8, all). After controlling for patient, disease, and treatment characteristics, patients with tumor deposits alone [hazard ratio (HR) 0.56, p = 0.001] or only lymph node metastases (HR 0.64, p < 0.001) were associated with improved survival relative to patients with both.

CONCLUSIONS

Concomitant presence of tumor deposits and lymph node invasion carries poor prognostic significance. Tumor deposits alone appear to have prognostic implications similar to lymph node invasion alone.

MACROD2 expression predicts response to 5-FU-based chemotherapy in stage III colon cancer

Background

Colorectal cancer (CRC) is caused by genetic aberrations. MACROD2 is commonly involved in somatic focal DNA copy number losses, in more than one-third of CRCs. In this study, we aimed to investigate the association of MACROD2 protein expression with clinical outcome in stage II and stage III colon cancer.

Methods

Tissue microarrays (TMA) containing formalin-fixed paraffin-embedded tissue cores from 386 clinically well-annotated primary stage II and III colon cancers were stained by immunohistochemistry and evaluated for MACROD2 protein expression. Disease-free survival (DFS) analysis was performed to estimate association with clinical outcome.

Results

Loss of nuclear MACROD2 protein expression in epithelial neoplastic cells of stage III microsatellite stable (MSS) colon cancers was associated with poor DFS within the subgroup of 59 patients who received 5-fluorouracil (5-FU)-based adjuvant chemotherapy (p=0.005; HR=3.8, 95% CI 1.4-10.0).

Conclusion

These data indicate that low nuclear expression of MACROD2 is associated with poor prognosis of patients with stage III MSS primary colon cancer who were treated with 5-FU-based adjuvant chemotherapy.

Newly recognized extratumoral features of colorectal cancer challenge the current tumor-node-metastasis staging system

One of the most common malignant tumors in humans, colorectal cancer has been extensively studied during the past few decades. Staging colorectal cancer allows clinicians to obtain precise prognostic information and apply specific treatment procedures. Apart from remote metastases, the depth of tumor infiltration and lymph node involvement have traditionally been recognized as the most important factors predicting outcome. Variations in the molecular signature of colorectal cancer have also revealed differences in phenotypic aggressiveness and therapeutic response rates. This article presents a review of the extratumoral environment in colorectal surgery.

Beyond T, N and M: The impact of tumor deposits on the staging and treatment of colorectal and gastric carcinoma

This review aims to describe the results of the most recent studies on the prognostic value of TDs and highlight the impact of TDs on the staging and treatment of colorectal and gastric carcinoma. For colorectal carcinoma TDs have an adverse prognostic effect that is at least similar to that of positive regional lymph nodes. However, support is growing in favor of including of TDs in the M category, rather than the N or T categories of the TNM classification. Moreover, TDs seem to have an adverse effect on outcomes not only in patients without lymph node involvement but also in patients with nodal involvement. Although the prognostic impact of TDs in gastric cancer appears to be undeniable, the actual prognostic determinants of TDs, particularly in relation to the number, size and histological types, remain to be established. Although the 7th and 8th Edition of the TNM classification of colorectal and gastric carcinoma includes TDs in the N category, no current procedures or methods to assess preoperative or intraoperative N-status allow TD detection. After neoadjuvant treatment for advanced rectal carcinoma, the presence of TDs may indicate incomplete eradication of the main tumor and not discontinuous tumor foci. TDs have an undeniable prognostic impact but no algorithm of staging and strategy of treatment has been conformed to this prognostic factor to overcome the classical T,N, and M prognostic categories. Staging and treatment of colorectal and gastric cancers should be reconsidered in light of the emerging prognostic value of TDs.

Radiotherapy for Patients With Resected Tumor Deposit-Positive Colorectal Cancer: A Surveillance, Epidemiology, and End Results-Based Population Study

CONTEXT

- According to the American Joint Committee on Cancer's Cancer Staging Manual, 7th edition, TNM classification, tumor deposit (TD)-positive colorectal cancers (CRCs) are classified as N1c. The effects of radiotherapy and the effects of the updated American Joint Committee on Cancer 7th edition TNM N1c classification for patients with TD-positive CRC are unclear.

OBJECTIVE

- To investigate outcomes of radiotherapy in patients with resected TD-positive CRC.

DESIGN

- Resected TD-positive CRCs diagnosed from 2010 to 2014 were identified in the Surveillance, Epidemiology, and End Results 18 database. Factors associated with overall survival (OS) and cancer-specific survival (CSS) were investigated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

- We included 2712 qualified CRC patients, who either underwent adjuvant radiotherapy (n = 187; 6.9%) or received no radiotherapy (n = 2525; 93.1%). Univariate Cox proportional models showed improved CSS among all CRC patients who underwent adjuvant radiotherapy (CSS hazard ratio, 0.73; 95% CI, 0.57-0.95) and among rectal cancer patients when separated by location (hazard ratio, 0.57; 95% CI, 0.40-0.83), although these associations were attenuated in multivariable-adjusted models. There was improved OS among rectal cancer patients (hazard ratio, 0.77; 95% CI, 0.59-0.99). In subgroup analyses, radiotherapy was not associated with OS or CSS in either metastatic or nonmetastatic CRC patients. Instead, N1c category (versus N0) was associated with a worse OS (hazard ratio, 1.43; 95% CI, 1.31-1.57) but was not associated with CSS.

CONCLUSIONS

- Radiotherapy did not independently improve OS among TD-positive CRC patients. In this study, classifying TD positivity as N1c was associated with worse OS than classifying TD positivity as N0. The findings seem to challenge the benefits of radiotherapy and the new N1c classification of TD for TD-positive CRC patients.

Prognostic significance of perigastric tumor deposits in patients with primary gastric cancer

BACKGROUND

The presence and the prognostic significance of perigastric tumor deposits (TDs) in primary gastric cancer have not been extensively studied. The aim of this study was to evaluate the prognostic significance perigastric TDs in primary gastric cancer.

METHODS

From 2005 to 2010, 1250 patients underwent R0 gastrectomy at the Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China. Out of 1250 patients, 132 patients with perigastric TDs were identified. Additionally, 132 patients with staged matched gastric cancer without tumor deposits were selected as a control group.

RESULTS

Perigastric TDs were observed in 132 (10.5%) of the 1250 patients with gastric cancer who underwent R0 gastrectomy. There were 94 males (71.21%) and 38 females (28.79%) (2.47:1). The mean age was 57.21 years. Clinicopathologic characteristics between the two groups matched well. There was a significant difference in the overall survival of those with and without TDs by univariate (p<0.05) and multivariate (p < 0.05) survival analysis. The 1-, 3-and 5-year overall survival rates of patients with TDswere69.6%, 39.3%, and 24.2%, respectively, and were significantly poorer than those of the staged matched control group. There was no correlation between the number of TDs and patient survival in patients with gastric cancer (p>0.05); however, when comparing each pT tumor group with the perigastric TD group, the stage T4 survival rate was very similar to that observed in patients with TDs.

CONCLUSIONS

Perigastric TDs are an independent predictive prognostic factor for gastric cancer and may be appropriately considered a form of serosal invasion. We suggest that TDs should be included in TNM staging system for better outcomes.

Tumor deposits: markers of poor prognosis in patients with locally advanced rectal cancer following neoadjuvant chemoradiotherapy

Background

Tumor deposits (TDs) were reported to be poor prognoses in colorectal carcinoma, but the significance in locally advanced rectal cancer (LARC) (T3-4/N+) following neoadjuvant chemoradiotherapy (neo-CRT) and surgery is unclear. Since adjuvant chemotherapy showed no benefit for LARC following neo-CRT, it is of great value to investigate whether TDs can identify the subgroup of patients who may benefit from adjuvant chemotherapy.

Methods

Between 2004 and 2012, 310 LARC patients following neo-CRT and surgery were retrospectively reviewed. Overall survival (OS), disease-free survival (DFS), distant metastasis free survival (DMFS) and local recurrence free survival (LRFS) were evaluated by Kaplan-Meier method, log-rank test and Cox models.

Results

TDs-positive patients showed adverse OS, DFS and DMFS (all P≤0.001), but not LRFS (P = 0.273). In multivariate analysis, TDs continued to be associated with poor OS (HR = 2.44, 95% CI 1.32-4.4, P = 0.004) and DFS (HR = 1.99, 95% CI 1.21-3.27, P = 0.007), but not DMFS (HR = 1.77, 95% CI 0.97-3.20, P = 0.061) or LRFS (HR = 1.85, 95% CI 0.58-5.85, P = 0.298). Among TDs-positive patients, adjuvant chemotherapy significantly improved OS (P = 0.045) and DMFS (P = 0.026), but not DFS (P = 0.127) or LRFS (P = 0.862).

Conclusions

TDs are predictive of poor survival in LARC after neo-CRT. Fortunately, TDs-positive patients appear to benefit from adjuvant chemotherapy.

Tumor deposits counted as positive lymph nodes in TNM staging for advanced colorectal cancer: a retrospective multicenter study

We investigated the possibility of counting tumor deposits (TDs) as positive lymph nodes (pLNs) in the pN category and evaluated its prognostic value for colorectal cancer (CRC) patients. A new pN category (npN category) was calculated using the numbers of pLNs plus TDs. The npN category included 4 tiers: npN1a (1 tumor node), npN1b (2-3 tumor nodes), npN2a (4-6 tumor nodes), and npN2b (≥7 tumor nodes). We identified 4,121 locally advanced CRC patients, including 717 (11.02%) cases with TDs. Univariate and multivariate analyses were performed to evaluate the disease-free and overall survival (DFS and OS) for npN and pN categories. Multivariate analysis showed that the npN and pN categories were both independent prognostic factors for DFS (HR 1.614, 95% CI 1.541 to 1.673; HR 1.604, 95% CI 1.533 to 1.679) and OS (HR 1.633, 95% CI 1.550 to 1.720; HR 1.470, 95% CI 1.410 to 1.532). However, the npN category was superior to the pN category by Harrell's C statistic. We conclude that it is thus feasible to consider TDs as positive lymph nodes in the pN category when evaluating the prognoses of CRC patients, and the npN category is potentially superior to the TNM (7th edition) pN category for predicting DFS and OS among advanced CRC patients.

Tumor Deposits in Colorectal Cancer: Improving the Value of Modern Staging-A Systematic Review and Meta-Analysis

Purpose Colorectal cancer (CRC) treatment is largely determined by tumor stage. Despite improvements made in the treatment of various types of metastatic disease, staging has not been refined. The role of tumor deposits (TDs) in staging remains debated. We have assessed the relation of TDs with metastatic pattern to evaluate whether TDs might add significant new information to staging. Methods We performed a systematic literature search that was focused on the role of TDs in CRC. Studies with neoadjuvant-treated patients were excluded. Data on stage, histologic factors, and outcome were extracted. Data from four large cohorts were analyzed for the relevance of the presence of TDs, lymph node metastases (LNMs), and extramural vascular invasion (EMVI) on the pattern of metastases and outcomes. Results Of 10,106 included patients with CRC, 22% presented with TDs. TDs are invariably associated with poor outcome. Presence of TDs was associated with presence of LNMs and EMVI. In a pairwise comparison, effects of TD were stronger than those of both LNMs and EMVI. In the logistic regression model, TDs in combination with LNMs is the strongest predictor for liver (odds ratio [OR], 5.5), lung (OR, 4.3) and peritoneal metastases (OR, 7.0). Presence of EMVI adds information for liver and lung metastases, but not for peritoneal metastases. Conclusion We have shown that TDs are not equal to LNMs or EMVI with respect to biology and outcome. We lose valuable prognostic information by allocating TDs into nodal category N1c and only considering TDs in the absence of LNMs. Therefore, we propose that the number of TDs should be added to the number of LNMs to derive a final N stage.