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

Prognostic Value of Tumor Deposits in Patients with Colorectal Cancer

Tumor nodules or tumor deposits (TDs) are a histopathological prognostic factor that are associated with a negative evolutionary course in patients with colorectal cancer (CRC). There are still controversial aspects of TDs, including how they should be integrated into the TNM classification system. The objective of this study was to analyze the predictive value of TDs for cancer-related survival (CRS) and time-to-recurrence survival (TTR) and to evaluate the prognostic value of TDs in patients whose tumors also presented lymph node metastasis (LNM). In this retrospective observational study, all patients treated for CRC between January 2010 and December 2020 at the same hospital were included. CRS and TTR were classified by tumor stage. The results were compared between patients whose tumors had TDs and patients whose tumors did not. A total of 1426 patients met the criteria for inclusion in the analysis. TDs were detected in 178 patients (12.5%): 60 had tumors without LNM, and 118 had LNM. Patients with TD tumors had a lower CRS at 60 months after diagnosis (42% vs. 82%; p < 0.001) and a shorter TTR (34% vs. 79%; p < 0.001). Cox multiple regression analysis revealed that the presence of TD was associated with an increased risk of death from CRC (HR: 1.820; 95% CI: 1.327-2.496) and an increased risk of recurrence (HR: 2.315; 95% CI: 1.743-3.073). In each N stage category, the CRS was significantly lower in the subgroup with TD+: in patients with N1a tumors, the CRS was 44% when TD+ vs. 70% when TD- (p = 0.019); in the N1b group it was 36% vs. 66% (p < 0.001); in the N2a group it was 34% vs. 58% (p = 0.012); and in N2b tumors it was 23% vs. 53% (p = 0.031). The present study shows that the information on the presence of TDs is complementary to that provided by LNM and allows the identification of subgroups of patients in each N stage determined by two metrics, CRS and TTR. TDs should be included in the definition of TNM system categories in patients who simultaneously present with LNM.

Prognostic and predictive value of tumor deposits in advanced signet ring cell colorectal cancer: SEER database analysis and multicenter validation

BACKGROUND

Colorectal signet-ring cell carcinoma (SRCC) is a rare cancer with a bleak prognosis. The relationship between its clinicopathological features and survival remains incompletely elucidated. Tumor deposits (TD) have been utilized to guide the N staging in the 8th edition of American Joint Committee on Cancer (AJCC) staging manual, but their prognostic significance remains to be established in colorectal SRCC.

PATIENTS AND METHODS

The subjects of this study were patients with stage III/IV colorectal SRCC who underwent surgical treatment. The research comprised two cohorts: a training cohort and a validation cohort. The training cohort consisted of 631 qualified patients from the SEER database, while the validation cohort included 135 eligible patients from four independent hospitals in China. The study assessed the impact of TD on Cancer-Specific Survival (CSS) and Overall Survival (OS) using Kaplan-Meier survival curves and Cox regression models. Additionally, a prognostic nomogram model was constructed for further evaluation.

RESULTS

In both cohorts, TD-positive patients were typically in the stage IV and exhibited the presence of perineural invasion (PNI) (P < 0.05). Compared to the TD-negative group, the TD-positive group showed significantly poorer CSS (the training cohort: HR, 1.87; 95% CI, 1.52-2.31; the validation cohort: HR, 2.43; 95% CI, 1.55-3.81; all P values < 0.001). This association was significant in stage III but not in stage IV. In the multivariate model, after adjusting for covariates, TD maintained an independent prognostic value (P < 0.05). A nomogram model including TD, N stage, T stage, TNM stage, CEA, and chemotherapy was constructed. Through internal and external validation, the model demonstrated good calibration and accuracy. Further survival curve analysis based on individual scores from the model showed good discrimination.

CONCLUSION

TD positivity is an independent factor of poor prognosis in colorectal SRCC patients, and it is more effective to predict the prognosis of colorectal SRCC by building a model with TD and other clinically related variables.

Tumour deposits are independently associated with recurrence in colon cancer

AIM

Tumour deposits are focal aggregates of cancer cells in pericolic fat and mesentery, distinct from vessels, nerves and lymphatics. Their presence upstages lymph node negative patients but is ignored in lymph node positive patients. We investigated the clinicopathological factors associated with tumour deposits and their impact on recurrence in lymph node positive and negative patients.

METHOD

Clinicopathological variables were collected from the medical records of patients with Stage I-III colon cancer who underwent resection in 2017-2019. Pathology was reviewed by a gastrointestinal pathologist. Patients with rectal cancer, metastasis, and concurrent malignancy were excluded.

RESULTS

Tumour deposits were noted in 69 (9%) of 770 patients. They were associated with the presence of lymph node metastasis, advanced T category, poorly differentiated tumours, microsatellite stable subtype and lymphovascular and perineural invasion (p < 0.05). The presence of tumour deposits (hazard ratio 2.48, 95% CI 1.49-4.10) and of lymph node metastasis (hazard ratio 3.04, 95% CI 1.72-5.37) were independently associated with decreased time to recurrence. There was a weak correlation (0.27) between the number of tumour deposits and the number of positive lymph nodes.

CONCLUSION

Tumour deposits are associated with more advanced disease and high-risk pathological features. The presence of tumour deposits and lymph node metastasis were found to be independent risk factors for decreased time to recurrence. A patient with both lymph node metastasis and tumour deposits is more than twice as likely to have recurrence compared with a patient with only lymph node metastasis. Tumour deposits independently predict recurrence and should not be ignored in lymph node positive patients.

Presence of tumor deposits is a strong indicator of poor outcome in patients with stage III colorectal cancers undergoing radical surgery

BACKGROUND

Tumor deposits (TDs) are emerging as an adverse prognostic factor in colorectal cancers (CRCs). However, TDs are somewhat neglected in the current staging system. It has been proposed either to add the TD count to the number of metastatic lymph nodes or to consider TDs as distant metastases; however, the scientific basis for these proposals seems questionable. This study aimed to investigate a new staging system.

METHODS

A total of 243 consecutive patients with stage III CRC who were undergoing curative resection and adjuvant chemotherapy were included. Each substage of stage III TNM was split according to the absence or presence of TDs. Receiver operating characteristic (ROC) curves and bootstrap methods were used to compare the current vs the new competing staging system in terms of oncologic outcome prediction.

RESULTS

A high rate of TDs was recorded (124 cases [51%]). TDs were correlated with other adverse prognostic indicators, particularly vascular and perineural invasions, and showed a negative correlation with the number of removed lymph nodes, suggesting a possible multimodal origin. In addition, TDs were confirmed to have a negative impact on oncologic outcome, regardless of their counts. Compared with the current staging system, the new classification displayed higher values at survival ROC analysis, a significantly better stratification of patients, and effective identification of patients at high risk of recurrence.

CONCLUSIONS

TDs negatively affect the prognosis in CRCs. A revision of the staging system could be useful to optimize treatments. The proposed new classification is easy to implement and more accurate than the current one. This study was registered online on the ClinicalTrials.gov website under the following identifier: NCT05923450.

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.

Clinical significance of tumor deposits in gastric cancer after radical gastrectomy: a propensity score matching study

OBJECTIVE

The value of tumor deposits (TDs) in the prognosis and staging of gastric cancer (GC) is still under debate. This study aims to evaluate the prognostic value of TDs and the best ways to incorporate TDs in the TNM classification of GC.

METHODS

Patients (n = 3460) undergoing curative gastrectomy for GC in the West China Hospital from 2005 to 2017 were retrospectively reviewed and divided into two groups according to the TD status (positive vs. negative). Later, clinicopathological features and overall survival (OS) between the two groups were compared. Thereafter, the associations between the presence of TD and other clinicopathological factors were evaluated through logistic regression. In addition, univariate and multivariate Cox regression were conducted for determining prognostic factors. The possibility of selection bias was reduced through conducting the 1:1 propensity score matching (PSM) analysis. The modified classification systems proposed previously that incorporated TDs into the TNM staging system were assessed.

RESULTS

There were 10.5% of patients (362/3460) diagnosed with TDs. TDs were significantly related to unfavorable factors such as advanced T stage and N stage and independently associated with poor prognosis. The 5-year OS of patients with TDs was significantly lower than that of patients without TDs (31.0% vs. 60.9%, P < 0.001), whereas higher than that of patients with peritoneal metastasis (31.0% vs. 5.0%, P < 0.001). In patients receiving chemotherapy, the 5-year OS of patients with TDs was also significantly lower than that of patients without TDs (42.0% vs. 50.9%, P = 0.026). Moreover, the system incorporating TDs in the TNM classification as metastatic lymph nodes outperformed others.

CONCLUSIONS

TDs are related to the aggressive characteristics and are an independent prognostic factor for GC. Incorporating TDs in the TNM classification as the metastatic lymph nodes increases the accuracy in predicting prognosis.

Evaluation of Predictive and Prognostic Importance of Lung Immune Prognostic Index in Locally Advanced Rectal Cancer Patients Treated With Neoadjuvant Chemoradiotherapy

OBJECTIVE

The systemic inflammatory response (SIR) is known as an important factor associated with tumorigenesis and tumor progression, and can be reflected by inflammatory markers. One of the markers that reflect this is the lung immune prognostic index (LIPI). It is based on a derived neutrophil-to-lymphocyte ratio (dNLR) and lactate dehydrogenase (LDH) level. We aimed to investigate the significance of LIPI in locally advanced rectal cancer (LARC) patients treated with neoadjuvant chemoradiotherapy (NACRT).

METHODS

In this retrospective study, we stratified the patients according to LIPI score as good LIPI and intermediate (int)/poor LIPI. According to pathological response to NACRT, we divided the patients into two groups as those with complete response (CR) or near-CR, and those with partial response (PR) or poor/no response. We classified CR and near-CR as good response. We evaluated the predictive and prognostic significance of LIPI for NACRT response, disease-free survival (DFS), and overall survival (OS) by univariate and multivariate analyses.

RESULTS

We included 137 patients in the results, with 72 (52.6%) having good LIPI and 65 (47.4%) having int/poor LIPI. The median follow-up period was 44.7 months (range: 10-105 months). Thirteen patients (18.0%) in the good LIPI group and 22 patients (34.0%) in the int/poor LIPI group achieved good response. In multivariate analysis, we found only the LIPI score as an independent risk factor (hazard ratio (HR): 2.4, p = 0.04) for NACRT response. Median DFS was 89.2 months (95% CI: 11.4-167.0) in the int/poor LIPI group; however, the DFS of all study populations and patients in the good LIPI group did not reach the median value. In multivariate analysis for DFS, we identified abdominoperineal resection (APR) (HR: 2.21, p = 0.02), presence of tumor deposit (HR: 2.96, p = 0.003), and int/poor LIPI score (HR: 2.07, p = 0.02) as separate risk variables. OS of all study populations and the patients in the LIPI groups did not reach the median value. In multivariate analysis for OS, we identified APR (HR: 2.74, p = 0.02), surgical margin positivity (HR: 12.94, p < 0.001), and adjuvant CT (HR: 0.20, p = 0.002) as separate risk variables for OS.

CONCLUSION

This is the first study investigating the predictive and prognostic significance of LIPI in LARC patients treated with NACRT. The results revealed that int/poor LIPI was associated with a higher rate of good response but shorter DFS compared to good LIPI. The baseline LIPI score serves as an easily accessible and useful prognostic index, and it has significant potential for making appropriate treatment decisions in LARC.

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.

Tumor deposits in colorectal cancer: Refining their definition in the TNM system

Tumor deposits (TDs) are discontinuous tumor spread in the mesocolon/mesorectum which is found in approximately 20% of colorectal cancer (CRC) and negatively affects survival. We have a history of repeated revisions on TD definition and categorization in the tumor-node-metastasis (TNM) system leading to stage migration. Since 1997, TDs have been categorized as T or N factors depending on their size (TNM5) or contour (TNM6). In 2009, TNM7 provided the category of N1c for TDs in a case without positive lymph nodes (LNs), which is also used in TNM8. However, increasing evidence suggests that these revisions are suboptimal and only "partially" successful. Specifically, the N1c rule is certainly useful for oncologists who are having difficulty with TDs in a case with no positive LNs. However, it has failed to maximize the value of the TNM system because of the underused prognostic information of individual TDs. Recently, the potential value of an alternative staging method has been highlighted in several studies using the "counting method." For this method, all nodular type TDs are individually counted together with positive LNs to derive the final pN, yielding a prognostic and diagnostic value that is superior to existing TNM systems. The TNM system has long stuck to the origin of TDs in providing its categorization, but it is time to make way for alternative options and initiate an international discussion on optimal treatment of TDs in tumor staging; otherwise, a proportion of patients end up missing an opportunity to receive the optimal adjuvant treatment.

Identifying the long-term survival beneficiary of chemotherapy for stage N1c sigmoid colon cancer

Sigmoid colon cancer often has an unsatisfactory prognosis. This study explored the effect of tumor deposits (TDs) on survival, and whether their presence/absence influence individualized treatment. Data of postoperative patients with sigmoid colon cancer were extracted from the Surveillance, Epidemiology, and End Results database. Overall survival (OS) was calculated using the Kaplan-Meier method and prognostic factors were identified using Cox regression analysis and random forest (RF). The nomogram's discrimination performance was evaluated using a concordance index (C-index), integrated discrimination improvement (IDI), calibration curves, and decision-curve analysis. The N1c group showed a worse prognosis than the N0 group. For N1c patients, a combination of surgery and chemotherapy prolonged survival, compared to surgery alone; however, the chemotherapy-surgery combination did not affect the OS of patients younger than 70 years, in stage T1-2, and/or of black race. Multivariable analysis and RF presented Age, T stage, and N stage were the most important predictors for OS. The novel nomogram had superiority to the TNM staging system with improved C-index and IDI, as well as good consistency and higher clinical benefit. TDs are associated with poor survival from sigmoid colon cancer, and considering TDs can inform the formulation of individual treatment regimens. The nomogram shows satisfactory prediction ability for OS.

Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection

Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.

Prognostic Value of Tumor Deposit Counts in Patients with Stage III Colorectal Cancer: A Population-Based Study

OBJECTIVE

To investigate the prognostic value of tumor deposits (TDs) counts in stage III colorectal cancer (CRC) patients and develop a prognostic nomogram.

METHODS

Data on stage III CRC patients from 2010 to 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The Kaplan-Meier analysis was used to assess differences in survival outcomes among patients. The Cox regression analysis was performed to establish the independent prognostic factors for cancer-specific survival and to establish a nomogram. The nomograms' performance was evaluated by calibration plots and concordance index (C-index). Decision curve analysis (DCA) was used to assess the clinical utility of the prediction model.

RESULTS

A total of 23,345 CRC patients were included in this study, and 3,578 (15.3%) had TDs. Cox multivariate regression analyses revealed that age, race, histological tumor grade, the administered chemotherapy, pathological type, T-stage, CEA, N-stage, peripheral nerve invasion, and TDs were independent prognostic factors. Patients with many TDs (=0/1-4, HR: 1.325,/≥5 HR: 2.223) had poorer cancer-specific survival. The prognostic value of the number of TDs was comparable to that of lymph node metastasis. The C-indices of the nomogram were superior to TNM staging in training (0.730 vs 0.646) and validation (0.714 vs 0.636) groups. DCA revealed that the nomogram had a higher clinical net benefit compared to TNM staging.

CONCLUSIONS

TDs count is an adverse prognostic factor for stage III CRC patients. Furthermore, the TDs-based nomogram can accurately predict the prognostic outcomes for stage III CRC.

The value of tumor deposits in evaluating colorectal cancer survival and metastasis: a population-based retrospective cohort study

Background

The role of tumor deposits (TDs) in TNM staging of colorectal cancer is controversial, especially the relationship with distant metastasis.

Purpose

This study aimed to determine the effect of TDs on the survival of colorectal cancer and the occurrence of distant metastasis and to determine whether TDs (+) patients behaved similarly to stage IV patients.

Methods

A retrospective analysis of CRC patients from two large independent cohorts from the Surveillance Epidemiology and End Results (SEER) database (n = 58775) and the First Affiliated Hospital of Dalian Medical University (n = 742).

Results

Univariate logistic analyses revealed that TDs are an independent predictor of liver metastasis [p < 0.001; odds ratio (OR): 5.738; 95% confidence interval (CI): 3.560–9.248] in the First Affiliated Hospital of Dalian Medical University’s patients. Meanwhile, TDs are also an independent predictor of isolated organ metastasis [p <0.001; odds ratio (OR): 3.028; 95% confidence interval (CI): 2.414–3.79; multiple organ metastases [p < 0.001; odds ratio (OR): 4.778; 95% confidence interval (CI): 4.109–5.556]; isolated liver metastasis [p < 0.001; odds ratio (OR): 4.395; 95% confidence interval (CI): 4.099–4.713] and isolated lung metastasis [p < 0.001; odds ratio (OR): 5.738; 95% confidence interval (CI): 3.560–9.248] in the SEER database. Multivariate analyses suggested TDs are an independent poor prognostic factor for distant metastasis (p <0.001).

Conclusions

Our results have shown that compared with patients with negative TDs, CRC patients with positive TDs are more likely to develop distant metastasis. Patients categorized as T4aN2bM0 TDs (+) and T4bN2M0 TDs (+) have a similar prognosis as those with stage IV, and hence these patients should be classified as stage IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02501-9.

Preoperative Absolute Lymphocyte Count to Carcinoembryonic Antigen Ratio Is a Superior Predictor of Survival in Stage I to III Colorectal Cancer

Background:

Preoperative absolute lymphocyte count (ALC) and carcinoembryonic antigen (CEA) are useful prognostic indicators in colorectal cancer (CRC); however, the role of the ALC-to-CEA ratio (LCR) has been less addressed.

Methods:

A total of 189 stage I to III CRC patients who underwent radical resection were enrolled retrospectively. The significance of the LCR in predicting disease-free survival (DFS) and overall survival (OS) was calculated and compared with other markers based on ALC. The DFS and OS differences among the low- and high-LCR subgroups and risk factors for the outcome were estimated by Kaplan–Meier analysis and the Cox proportional hazards model, respectively.

Results:

Taking 0.28 as the cutoff point, the LCR has a sensitivity and a specificity of 75.60% and 77.00%, respectively, in predicting OS. The prognostic efficacy of LCR was significantly superior to that of other markers based on ALC for predicting DFS and OS. A total of 34.92% (66/189) of patients displayed a low LCR (<0.28), and these patients were more likely to present poor cell differentiation (P = .03), tumor deposits (P < .01) and advanced T (P < .01) and liver metastasis (P = .02). Patients with a low LCR had significantly worse DFS (Log Rank = 34.98, P < .01) and OS (Log Rank = 43.17, P < .01) than those with a high LCR. The LCR was an independent prognostic factor for both DFS (hazard ratio (HR) = 0.35, 95% confidence interval (CI): 0.20-0.62, P < .01) and OS (HR = 0.18, 95% CI: 0.08-0.37, P < .01).

Conclusions:

The LCR is a superior predictor of survival in stage I to III CRC, and patients with a low LCR have an inferior outcome; however, additional studies are required to validate its prognostic role.

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.

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.

[Tumour deposition (TD), a probably underestimated poor prognostic criterion, to be taken into account in the therapeutic management of patients with stage III colon cancer]

The management of colorectal cancer (CRC) relies heavily on TNM staging. In order to improve this staging, it is essential to identify all histological markers bearing a significant prognostic value. Among these, tumor deposits (TDs), defined as tumor foci in the pericolonic or perirectal adipose tissue with no residual lymph node tissue, have been shown to be associated with poor prognosis in cohort studies leading to their individualization in the TNM7 classification as pN1c. However, TDs are only considered in the absence of lymph node metastases. There is no consensus on this particular way of integrating TDs in the TNM classification. Indeed, at the time when the choice of the type of adjuvant treatment and its duration in stage III colon cancers (i.e. with lymph node metastases) is based on pT and pN criteria, taking into account TDs only in the absence of concomitant lymph node metastases is potentially responsible for a misclassification of some patients and wrong therapeutic decisions. In addition, many questions concerning the true definition of TDs, their origin, their prognostic value and the optimization of their consideration remain open. The objective of this review is to provide a synthesis of current knowledge on TDs in CRC, in view of their prognostic importance, their biological complexity and the scientific interest they are currently the subject of.

A Modified Pathological N Stage Including Status of Tumor Deposits in Colorectal Cancer With Nodal Metastasis

Background

The American Joint Committee on Cancer 8th classification states that colorectal cancer (CRC) is classified as N1c stage when regional lymph nodes (LNs) are negative and tumor deposits (TDs) are positive. However, how to classify TDs when regional LNs are positive remains unclear. The current study aimed to investigate the possibility of combining positive LNs and positive TDs to develop a modified pathological N (mpN) stage for CRC.

Methods

We retrospectively analyzed 9,198 patients with stage III CRC from the Surveillance, Epidemiology, and End Results program who underwent surgery (6,440 in the training cohort and 2,758 the validation cohort). The combination of positive LNs and TD status was defined as mpN stage. Overall survival (OS) according to mpN and pathological N (pN) stages was analyzed by the Kaplan–Meier method. The area under the curves (AUCs) and Akaike’s information criterion (AIC) were applied to assess the predictive discrimination abilities and goodness-of-fit of the model. The clinical benefits were measured using decision curve analyses. The validation cohort was used to validate the results.

Results

AUC analysis showed that the prognostic discrimination of mpN stage (AUC = 0.628, 95% confidence interval (CI), 0.616–0.640) was better than that of pN stage (AUC = 0.618, 95% CI, 0.606–0.630, p = 0.006) for OS. The AIC demonstrated that mpN stage (AIC = 30,217) also showed superior model-fitting compared with pN stage (AIC = 30,257) and decision curve analyses revealed that mpN stage had better clinical benefits than pN stage. Similar results were found in the validation cohort.

Conclusions

Among patients with CRC and LN metastasis, mpN stage might be superior to pN stage for assessing prognosis and survival, suggesting that TD status should be included in the pN stage.

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.

MRI for Rectal Cancer Primary Staging and Restaging After Neoadjuvant Chemoradiation Therapy: How to Do It During Daily Clinical Practice

PURPOSE

To provide a practical overview regarding the state-of-the-art of the magnetic resonance imaging (MRI) protocol for rectal cancer imaging and interpretation during primary staging and restaging after neoadjuvant chemoradiation therapy (CRT), pointing out technical skills and findings that radiologists should consider for their reports during everyday clinical activity.

METHOD

Both 1.5T and 3.0T scanners can be used for rectal cancer evaluation, using pelvic phased array external coils. The standard MR protocol includes T2-weighted imaging of the pelvis, high-resolution T2-weighted sequences focused on the tumor and diffusion-weighted imaging (DWI). The mnemonic DISTANCE is helpful for the interpretation of MR images: DIS, for distance from the inferior part of the tumor to the anorectal-junction; T, for T staging; A, for anal sphincter complex status; N, for nodal staging; C, for circumferential resection margin status; and E, for extramural venous invasion.

RESULTS

Primary staging with MRI is a cornerstone in the preoperative workup of patients with rectal cancer, because it provides clue information for decisions on the administration of CRT and surgical treatment. Restaging after CRT is crucial for treatment planning, and findings on post-CRT MRI correlate with the patient's prognosis and survival. It may be useful to remember the mnemonic word "DISTANCE" to check and describe all the relevant MRI findings necessary for an accurate radiological definition of tumor stage and response to CRT.

CONCLUSIONS

"DISTANCE" assessment for rectal cancer staging and treatment response estimation after CRT may be helpful as a checklist for a structured reporting.

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.

Preoperative prediction of tumour deposits in rectal cancer by an artificial neural network-based US radiomics model

OBJECTIVE

To develop a machine learning-based ultrasound (US) radiomics model for predicting tumour deposits (TDs) preoperatively.

METHODS

From December 2015 to December 2017, 127 patients with rectal cancer were prospectively enrolled and divided into training and validation sets. Endorectal ultrasound (ERUS) and shear-wave elastography (SWE) examinations were conducted for each patient. A total of 4176 US radiomics features were extracted for each patient. After the reduction and selection of US radiomics features , a predictive model using an artificial neural network (ANN) was constructed in the training set. Furthermore, two models (one incorporating clinical information and one based on MRI radiomics) were developed. These models were validated by assessing their diagnostic performance and comparing the areas under the curve (AUCs) in the validation set.

RESULTS

The training and validation sets included 29 (33.3%) and 11 (27.5%) patients with TDs, respectively. A US radiomics ANN model was constructed. The model for predicting TDs showed an accuracy of 75.0% in the validation cohort. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and AUC were 72.7%, 75.9%, 53.3%, 88.0% and 0.743, respectively. For the model incorporating clinical information, the AUC improved to 0.795. Although the AUC of the US radiomics model was improved compared with that of the MRI radiomics model (0.916 vs. 0.872) in the 90 patients with both ultrasound and MRI data (which included both the training and validation sets), the difference was nonsignificant (p = 0.384).

CONCLUSIONS

US radiomics may be a potential model to accurately predict TDs before therapy.

KEY POINTS

• We prospectively developed an artificial neural network model for predicting tumour deposits based on US radiomics that had an accuracy of 75.0%. • The area under the curve of the US radiomics model was improved than that of the MRI radiomics model (0.916 vs. 0.872), but the difference was not significant (p = 0.384). • The US radiomics-based model may potentially predict TDs accurately before therapy, but this model needs further validation with larger samples.

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.

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.

Development and validation of an immunity-related classifier of nine chemokines for predicting recurrence in stage I-III patients with colorectal cancer after operation

Introduction

Chemokines are closely related with tumor immunity, progression, and metastasis. We aimed to construct a multi-RNA classifier of chemokine family genes for predicting tumor recurrence in stage I-III patients with colorectal cancer (CRC) after operation.

Patients and methods

By analyzing microarray data, the Cox regression analysis was conducted to determine survival-related chemokine family genes and develop a multi-RNA classifier in the training set. The prognostic value of this multi-RNA classifier was further validated in the internal validation and external independent sets. Receiver operating characteristic curves were used to compare the prediction ability of the combined model of this multi-RNA classifier and stage, and this multi-RNA classifier and stage alone.

Results

Nine survival-related chemokines were identified in the training set. We identified a nine-chemokine classifier and classified the patients as high-risk or low-risk. Compared with CRC patients with high-risk scores, CRC patients with low-risk scores had longer disease-free survival in the training (HR=2.353, 95% CI=1.480-3.742, P<0.001), internal validation (HR=2.389, 95% CI=1.428-3.996, P<0.001), and external independent (HR=3.244, 95% CI=1.813-5.807, P<0.001) sets. This nine-chemokine classifier was an independent prognostic factor in these datasets (P<0.05). The combined model of this nine-chemokine classifier and tumor stage may tend to have higher accuracy than stage alone in the training (area under curve 0.727 vs 0.626, P<0.01), internal validation (0.668 vs 0.584, P=0.03), and external independent (0.704 vs 0.678, P>0.05) sets. This nine-chemokine classifier may only be applied in Marisa's C2, C5, and C6 subtypes patients.

Conclusion

Our nine-chemokine classifier is a reliable prognostic tool for some specific biological subtypes of CRC patients. It might contribute to guide the personalized treatment for high-risk patients.

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.

Novel lymph node ratio predicts prognosis of colorectal cancer patients after radical surgery when tumor deposits are counted as positive lymph nodes: a retrospective multicenter study

The lymph node ratio (LNR), defined as the relation of tumor-infiltrated to resected lymph nodes, has been identified as an independent prognostic factor for colorectal cancer (CRC) after radical surgery. Recently, new guidelines propose counting tumor deposits (TDs) as positive lymph nodes (pLNs). The aim of this study was to investigate whether a novel LNR (nLNR) that considers TDs as pLNs can be used to accurately predict the long-term outcome of CRC patients. In this multicenter retrospective study, clinicopathological and outcome data from 2,051 stage III CRC patients who underwent R0 resection were collected between January 2004 and December 2011. Disease-free survival (DFS) and overall survival (OS) according to the nLNR category were analyzed using Kaplan-Meier survival curves. Univariate and multivariate analyses were performed to determine significant prognostic factors, and ROC curves were computed to measure the predictive capacity of the nLNR category. The 5-year DFS rates of nLNR1-4 were 68.3%, 48.4%, 33.3% and 16.5%, respectively (P<0.0001), and the 5-year OS rate of nLNR1-4 were 71.8%, 60.1%, 42.7% and 21.8%, respectively (P<0.0001). The area of under curve (AUC) of the nLNR was 0.686 (95% CI 0.663-0.710) and 0.672 (95% CI 0.648-0.697) for predicting DFS and OS. Our results demonstrate that the nLNR predicted long-term outcomes better than the LNR, npN and pN, using the cutoff points 0.250, 0.500 and 0.750.

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.

An integrated lncRNA, microRNA and mRNA signature to improve prognosis prediction of colorectal cancer

Although the outcome of patients with colorectal cancer (CRC) has improved significantly, prognosis evaluation still presents challenges due to the disease heterogeneity. Increasing evidences revealed the close correlation between aberrant expression of certain RNAs and the prognosis. We envisioned that combined multiple types of RNAs into a single classifier could improve postoperative risk classification and add prognostic value to the current stage system. Firstly, differentially expressed RNAs including mRNAs, miRNAs and lncRNAs were identified by two different algorithms. Then survival and LASSO analysis was conducted to screen survival-related DERs and build a multi-RNA-based classifier for CRC patient stratification. The prognostic value of the classifier was self-validated in the TCGA CRC cohort and further validated in an external independent set. Finally, survival receiver operating characteristic analysis was used to assess the performance of prognostic prediction. We found that the multi-RNA-based classifier consisted by 12 mRNAs, 1miRNA and 1 lncRNA, which could divide the patients into high and low risk groups with significantly different overall survival (training set: HR 2.54, 95%CI 1.67-3.87, p<0.0001; internal testing set: HR 2.54, 95%CI 1.67-3.87, p<0.0001; validation set: HR 5.02, 95% CI 2.2–11.6; p=0·0002). In addition, the classifier is not only independent of clinical features but also with a similar prognostic ability to the well-established TNM stage (AUC of ROC 0.83 versus 0.74, 95% CI = 0.608-0.824, P =0.0878). Furthermore, combination of the multi-RNA-based classifier with clinical features was a more powerful predictor of prognosis than either of the two parameters alone. In conclusion, the multi-RNA-based classifier may have important clinical implications in the selection of patients with CRC who are at high risk of mortality and add prognostic value to the current stage system.