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Rong J, Deng W. Survival Benefits of Postoperative Chemotherapy in Patients With Colorectal Mucinous Adenocarcinoma: An Analysis Utilizing Propensity Score Matching From the Surveillance, Epidemiology, and End Results Database. Am Surg 2024:31348241257469. [PMID: 38849300 DOI: 10.1177/00031348241257469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
OBJECTIVE This study aimed to investigate the characteristics of patients with colorectal mucinous adenocarcinoma (MAC) who benefit from postoperative chemotherapy (POCT) and to develop effective postoperative survival nomograms for predicting overall survival (OS) in colorectal MAC patients. METHODS Data of colorectal MAC patients who underwent surgery from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2020 were collected. Patients were grouped based on POCT, and intergroup analysis was performed using 1:1 propensity score matching (PSM). Kaplan-Meier (K-M) curves were used to compare the prognosis between the 2 groups. Cox analysis was employed to identify factors associated with OS in patients with colorectal MAC who underwent POCT. The variance inflation factor (VIF) and bilateral stepwise regression were used to determine factors included in the model. Additionally, a nomogram was constructed to predict postoperative survival outcomes for patients. The discriminative ability of the nomograms was evaluated using the C-index and calibration curve analysis, the decision curve analysis (DCA) assessed the clinical utility of the nomogram, and the receiver operating characteristic (ROC) curve evaluated the nomograms' performance. RESULTS This study encompassed 6829 patients with colorectal MAC, among whom 2258 received POCT, and 4571 did not. Whether pre or post PSM, patients in the POCT group consistently exhibited a superior median OS compared to those in the postoperative non-chemotherapy group (P < .0001). For colorectal MAC patients undergoing POCT, OS was correlated with factors such as patient age, carcinoembryonic antigen levels, tumor deposits, perineural invasion (PNI), lymph node examination count, T staging, and Grade staging. Notably, a significant chemotherapy advantage was observed in patients without perineural invasion, those with lymph node examination counts exceeding 12, and patients with moderately differentiated tumors. The overall colorectal MAC patient postoperative OS predictive nomogram demonstrated a C-index of .74, with a calibration curve near the diagonal and a DCA curve indicating positive net benefits. In comparison to TNM staging, the ROC curves of the nomogram at 1 year, 3 years, and 5 years demonstrated superior predictive capabilities (AUC: .80 vs .71, .78 vs .71, .77 vs .70). CONCLUSION This study revealed the characteristics of colorectal MAC patients who benefit from POCT and established effective prognostic nomograms, which can aid clinicians in designing personalized treatment plans for individual patients and promote precision medicine.
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Affiliation(s)
- Jun Rong
- Department of Gastrointestinal Surgery, Pingxiang People's Hospital, Pingxiang, China
| | - Wensheng Deng
- Department of Gastrointestinal Surgery, Pingxiang People's Hospital, Pingxiang, China
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Pan F, Hu M, Ye T, Gan J, Ling M, Liu M. The activation of HAMP promotes colorectal cancer cell proliferation through zinc-mediated upregulation of SMAD4 expression. Transl Cancer Res 2024; 13:1493-1507. [PMID: 38617511 PMCID: PMC11009800 DOI: 10.21037/tcr-23-1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 01/23/2024] [Indexed: 04/16/2024]
Abstract
Background Colorectal cancer (CRC) poses a significant challenge in digestive system diseases, and emerging evidence underscores the critical role of zinc metabolism in its progression. This study aimed to investigate the clinical implications of genes at the intersection of zinc metabolism and CRC. Methods We downloaded CRC prognosis-related genes and zinc metabolism-related genes from public databases. Then, the overlapping genes were screened out, and bioinformatics analysis was performed to obtain the hub gene associated with CRC prognosis. Subsequently, in vitro assays were carried out to investigate the expression of this hub gene and its exact mechanism between zinc metabolism and CRC. Results HAMP was identified as the hub CRC prognostic gene from overlapping zinc metabolism-related and CRC prognostic genes. In vitro analysis showed HAMP was over-expressed in CRC, and its knockdown inhibited RKO and HCT-116 cell invasion and migration significantly. ZnSO4 induced HAMP up-regulation to promote cell proliferation, while TPEN decreased HAMP expression to inhibit cell proliferation. Importantly, we further found that ZnSO4 enhanced SMAD4 expression to augment HAMP promoter activity and promote cell proliferation in CRC. Conclusions HAMP stands out as an independent prognostic factor in CRC, representing a potential therapeutic target. Its intricate regulation by zinc, particularly through the modulation of SMAD4, unveils a novel avenue for understanding CRC biology. This study provides valuable insights into the interplay between zinc metabolism, HAMP, and CRC, offering promising clinical indicators for CRC patients. The findings present a compelling case for further exploration and development of targeted therapeutic strategies in CRC management.
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Affiliation(s)
- Fei Pan
- Department of General Medicine, Minhang Hospital, Fudan University, Shanghai, China
| | - Mengting Hu
- Department of General Medicine, Minhang Hospital, Fudan University, Shanghai, China
| | - Tao Ye
- Department of Oncology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jiaqi Gan
- Department of General Medicine, Minhang Hospital, Fudan University, Shanghai, China
| | - Meirong Ling
- Department of Emergency Medical, Minhang Hospital, Fudan University, Shanghai, China
| | - Mei Liu
- Department of General Medicine, Minhang Hospital, Fudan University, Shanghai, China
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Alshehri KA, Alsulaimani N, Alghamdi WA, Almansouri Z, Zubair SA, Zekri J, Saimeh H, Sultan S. Mucinous Differentiation in Colorectal Cancer: A 10-Year Experience Audit at King Faisal Specialist Hospital and Research Centre, Jeddah. Cureus 2024; 16:e56722. [PMID: 38646258 PMCID: PMC11032733 DOI: 10.7759/cureus.56722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Given that colorectal cancer is one of the leading causes of mortality, mucinous adenocarcinoma is one of the subtypes and is characterized by the presence of mucin-producing tumor cells with mucin components and is more challenging to manage. In Saudi Arabia, it represents approximately 10-15% of all colorectal carcinoma. The main etiological cause of mucinous adenocarcinoma is yet not well understood. The main goal of our study is to discuss the histopathology and the molecular background of mucinous colorectal adenocarcinoma and also to provide an update on its prognosis and therapeutics from recent published literature. It is a retrospective cohort study that was conducted at King Faisal Specialist Hospital, Jeddah, Saudi Arabia. The study included 68 adult patients diagnosed with mucinous colon cancer, who did surgical resection alone or with or without adjuvant chemotherapy following from January 2011 to December 2020. The mucinous subtypes are found more commonly in the proximal colon. In our study, 26 patients (38.2% of the cases) were right-sided and 35 patients (51.5%) were from the left side, but these included the rectum as well and this reflects the higher incidence of diagnosis of rectal cancer in the region. Most tumors were classified as Grade II in 56 patients (82.4%), consistent with the intermediate differentiation status often associated with the mucinous subtypes. The most common symptom at presentation was abdominal pain in 38 patients (55.9%) followed by per rectal bleeding and abdominal mass. The management in our study was in line with the standard established practice and surgical resection as expected was the primary potentially curative approach. Notably of patients presenting with locally advanced rectal cancer, six patients underwent concomitant chemoradiotherapy followed by surgery and four patients had upfront surgery. The duration of the median follow-up was 32 months. At the time of analysis, 30 patients (44.1%) were alive and remained on regular follow-up, 17 patients (25%) had succumbed to the disease, and 21 patients (30.9%) were lost to follow-up. The median overall survival was not reached, and notably, 49 patients (71.6%) remained alive at the four-year mark. Whilst our study contributes to the current understanding of mucinous adenocarcinomas of the colon, further research in molecular profiling and genomic testing and larger clinical trials with tailored treatments is necessary to refine treatment strategies and improve outcomes.
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Affiliation(s)
- Khalid A Alshehri
- Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Naif Alsulaimani
- General Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Wejdan A Alghamdi
- General Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Zuhoor Almansouri
- Anatomic Pathology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Syed A Zubair
- Medical Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Jamal Zekri
- Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
- Medicine, Al-Faisal University, Jeddah, SAU
| | - Haitham Saimeh
- General Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Sufian Sultan
- Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
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Jiang J, Tang XW, Huang S, Hu N, Chen Y, Luo B, Ren WS, Peng Y, Yang WX, Lü MH. Epidemiologic characteristics and risk factors associated with overall survival for patients with mucinous colorectal cancer: A population-based study. World J Gastrointest Oncol 2023; 15:1461-1474. [PMID: 37663939 PMCID: PMC10473928 DOI: 10.4251/wjgo.v15.i8.1461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/21/2023] [Accepted: 06/13/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Mucinous adenocarcinoma (MC) has attracted much attention as a distinct histologic subtype of colorectal cancer in recent years. However, data about its epidemiologic and prognostic characteristics are limited. Therefore, patient data extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program were collected to analyze the epidemiologic and clinicopathological characteristics of MC. AIM To determine the epidemiologic and clinicopathological characteristics of MC. METHODS The incidence trend of MC was calculated through the Joinpoint Regression Program. Cox regression analyses were performed to identify prognostic factors associated with overall survival (OS). A nomogram was established to predict the survival probability of individual patients with MC. RESULTS We found that rates of MC decreased from 4.50/100000 in 2000 to 1.54/100000 in 2018. Rates of MCs in patients aged ≤ 50 years decreased 2.27%/year during 2000-2018. The incidence of appendiceal MCs increased from 0.14/100000 in 2000 to 0.24/100000 in 2018, while the incidence in other anatomic subsites continued to decrease. On multivariable Cox analyses, age, race, tumor site, T stage, N stage, M stage, surgery, and chemotherapy were associated with OS. A nomogram was developed based on these factors, and the area under the curve for 1-year, 3-year, and 5-year OS in the training cohort was 0.778, 0.778, and 0.768, respectively. CONCLUSION Our results demonstrated that MC incidence decreased in almost all anatomic subgroups except for the appendix. A nomogram predicting the survival probability of patients with MCs showed good performance.
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Affiliation(s)
- Jiao Jiang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Xiao-Wei Tang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Shu Huang
- Department of Gastroenterology, the People’s Hospital of Lianshui, Huaian 223400, Jiangsu Province, China
| | - Nan Hu
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Yuan Chen
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Bei Luo
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Wen-Sen Ren
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Yan Peng
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Wei-Xing Yang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Mu-Han Lü
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
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New Personal Model for Forecasting the Outcome of Patients with Histological Grade III-IV Colorectal Cancer Based on Regional Lymph Nodes. JOURNAL OF ONCOLOGY 2023; 2023:6980548. [PMID: 36880007 PMCID: PMC9985509 DOI: 10.1155/2023/6980548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/27/2022] [Accepted: 11/24/2022] [Indexed: 02/27/2023]
Abstract
Background Metastases at regional lymph nodes could easily occur in patients with high-histological-grade colorectal cancer (CRC). However, few models were built on the basis of lymph nodes to predict the outcome of patients with histological grades III-IV CRC. Methods Data in the Surveillance, Epidemiology, and End Results databases were used. Univariate and multivariate analyses were performed. A personalized prediction model was built in accordance with the results of the analyses. A nomogram was tested in two datasets and assessed using a calibration curve, a consistency index (C-index), and an area under the curve (AUC). Results A total of 14,039 cases were obtained from the database. They were separated into two groups (9828 cases for constructing the model and 4211 cases for validation). Logistic and Cox regression analyses were then conducted. Factors such as log odds of positive lymph nodes (LODDS) were utilized. Then, a personalized prediction model was established. The C-index in the construction and validation groups was 0.770. The 1-, 3-, and 5-year AUCs were 0793, 0.828, and 0.830 in the construction group, respectively, and 0.796, 0.833, and 0.832 in the validation group, respectively. The calibration curves showed well consistency in the 1-, 3- and 5-year OS between prediction and reality in both groups. Conclusion The nomogram built based on LODDS exhibited considerable reliability and accuracy.
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Simultaneous analysis of tumor-infiltrating immune cells density, tumor budding status, and presence of lymphoid follicles in CRC tissue. Sci Rep 2022; 12:21732. [PMID: 36526699 PMCID: PMC9758132 DOI: 10.1038/s41598-022-26225-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Colorectal cancer (CRC) affects more than 1,000,000 people worldwide each year. Recently, the number of young patients with early-onset colorectal cancer has increased, and right-sided colorectal cancer is still often diagnosed only in advanced stages. The TNM classification is not perfect for CRC staging. This study aimed to perform, for the first time, simultaneous analysis of tumor-infiltrating immune cell density, presence of lymphoid follicles, and budding status in CRC tissue. Intraoperative samples of neoplastic tissue were collected from 195 consecutive patients who were admitted to the surgical ward for elective colorectal surgery. Histological parameters were assessed in the tissue samples: tumor budding foci, poorly differentiated clusters and areas of poorly differentiated components. Tumor-infiltrating immune cells (tumor-associated neutrophils and tumor-infiltrating lymphocytes) were detected in five randomly chosen, areas at the tumor center and at the invasive front. Additionally, the presence of lymphoid follicles in CRC tissue was assessed. Tumor budding parameters were positively correlated with colorectal cancer advancement or histologic (mucinous) type of CRC. The number of poorly differentiated clusters was higher in younger patients. Lower densities of CD3 and CD4 lymphocytes were seen in CRC with a greater depth of tumor invasion. Lower densities of CD3 and CD8 lymphocytes were found in CRC with metastases to the surrounding lymph nodes. The lower density of CD8 lymphocytes was observed in CRC with distant metastases. Lower densities of tumor-associated neutrophils and tumor-infiltrating lymphocytes (CD3 and CD8) were revealed in CRC without lymphoid follicles. The number of lymphoid follicles was higher in patients with less advanced CRCs. Three histopathology markers, such as high tumor budding, scanty lymphocyte infiltration, and the poverty of lymphoid follicles, complement each other, appear to be reliable indicators of colorectal cancer progression, and could be useful in everyday medical practice, but their widespread use requires further research. We propose to take into account these markers, in the assessment of colorectal cancer advancement, in addition to the TNM classification.
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Xu X, Wang J. Development and validation of prognostic nomograms in patients with gallbladder mucinous adenocarcinoma: A population-based study. Front Oncol 2022; 12:1084445. [PMID: 36591489 PMCID: PMC9795173 DOI: 10.3389/fonc.2022.1084445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Background Gallbladder mucinous adenocarcinoma (GBMAC) is an uncommon malignant gallbladder tumor. There are few studies on its prognosis, with the majority consisting of small series or individual cases. We sought to develop and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) in GBMAC patients. Methods The clinicopathological data of GBMAC patients from 1975 to 2019 was extracted from the Surveillance, Epidemiology, and End Results (SEER) database, and all patients were randomly divided into a training cohort (70%) and a validation cohort (30%). Using multivariate Cox regression analyses based on Akaike information criterion (AIC), prognostic and important variables for GBMAC were determined. On the basis of these factors, nomograms were developed to predict the 1-, 3-, and 5-year OS and CSS rates of patients with GBMAC. Multiple parameters, including the area under the subject operating characteristic curve (AUC), the calibration plots, and the decision curve analysis (DCA), were then used to evaluate the accuracy of nomograms. Results Following exclusion, a total of 707 GBMAC patients were enrolled, and the training cohort (490, 70%) and validation cohort (217, 30%) were randomly assigned. Grade, surgery, radiation, and SEER stage were predictive factors for patients with GBMAC, as indicated by univariate and multivariate Cox regression analyses based on AIC. We created nomograms for predicting OS and CSS in GBMAC using the four factors. The calibration curves and area under the curves (AUCs) indicated that our nomograms have a moderate degree of predictive accuracy and capability. The results of the DCA revealed that the nomogram has a high predictive value. Conclusion We established the first nomograms for predicting 1-, 3-, and 5-year OS and CSS in GBMAC patients, thereby contributing to the prognostication of patients and clinical management.
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Affiliation(s)
- Xiaoming Xu
- Department of Gastroenterology, Jining First People’s Hospital, Jining, China
| | - Jingzhi Wang
- Department of Radiotherapy Oncology, The Affiliated Yancheng First Hospital of Nanjing University Medical School, The First People’s Hospital of Yancheng, Yancheng, China,*Correspondence: Jingzhi Wang,
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Chen Q, He L, Li Y, Zuo C, Li M, Wu X, Pu C, Xu X, Tang R, Xiong Y, Li J. Risk Factors on the Incidence and Prognostic Effects of Colorectal Cancer With Brain Metastasis: A SEER-Based Study. Front Oncol 2022; 12:758681. [PMID: 35372090 PMCID: PMC8971714 DOI: 10.3389/fonc.2022.758681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 02/07/2022] [Indexed: 02/01/2023] Open
Abstract
Background Colorectal cancer (CRC) with brain metastases (BM) is uncommon and often diagnosed at a late stage. The aims of this study were to identify the clinical factors that can influence the incidence of CRC patients with BM (CRCBM) and to investigate the impact of clinical factors and therapies on the outcomes of CRCBM. Methods Between 2010 and 2018, patients with CRCBM were enrolled under the Surveillance, Epidemiology, and End Results (SEER) program. Multivariable logistic and Cox regression models were used to identify risk factors and prognostic factors of BM. Kaplan–Meier curve and log-rank test were used to evaluate overall survival (OS) and tumor-specific survival (CSS) of CRCBM patients. Results A total of 195 (0.34%) CRC patients initially diagnosed with BM were included for analysis. The positive level of CEA, pN2a-b, and additional organ metastases were positively associated with developing BM from the CRC cohort (p < 0.05). The median OS and CSS of the BM patients were both 4.0 months, while the corresponding survival time in CRC patients without BM was 14.0 and 16.0 months, respectively (HR = 2.621, 95% CI = 2.061–3.333 for CSS; HR = 2.556, 95% CI = 2.026–3.225 for OS; log rank p < 0.001, each). Only systematic treatment was independently associated with better survival (p < 0.05, each). Conclusions Although the overall prognosis of CRCBM patients was extremely poor, the positive level of CEA, pN2a-b, and distant metastases could be bad risk factors for the incidence of CRCBM. In addition, only systematic treatment was found to be a negative prognostic factor for CRCBM patients. These related factors can provide more valuable reference for clinical individualized treatments.
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Affiliation(s)
- Quan Chen
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
- Department of Stem Cell & Regenerative Medicine, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Le He
- Department of Gastroenterology, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yuhong Li
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Chenghai Zuo
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Mengxia Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiaofeng Wu
- Department of Stem Cell & Regenerative Medicine, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Chengxiu Pu
- Department of Stem Cell & Regenerative Medicine, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiang Xu
- Department of Stem Cell & Regenerative Medicine, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Rongrui Tang
- Department of Neurosurgery, University-Town Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Rongrui Tang, ; Yanli Xiong, ; Juan Li,
| | - Yanli Xiong
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
- *Correspondence: Rongrui Tang, ; Yanli Xiong, ; Juan Li,
| | - Juan Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
- *Correspondence: Rongrui Tang, ; Yanli Xiong, ; Juan Li,
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Huang A, Yang Y, Shi JY, Li YK, Xu JX, Cheng Y, Gu J. Mucinous adenocarcinoma: A unique clinicopathological subtype in colorectal cancer. World J Gastrointest Surg 2021; 13:1567-1583. [PMID: 35070064 PMCID: PMC8727185 DOI: 10.4240/wjgs.v13.i12.1567] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/02/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Mucinous adenocarcinoma (MAC) is a unique clinicopathological subtype of colorectal cancer, which is characterized by extracellular mucinous components that comprise at least 50% of the tumor tissue. The clinical characteristics, molecular features, response to chemo-/radiotherapy, and prognosis of MAC are different from that of non-MAC (NMAC). MAC is more common in the proximal colon, with larger volume, higher T-stage, a higher proportion of positive lymph nodes, poorer tumor differentiation, and a higher proportion of peritoneal implants compared to NMAC. Although biopsy is the main diagnostic method for MAC, magnetic resonance imaging is superior in accuracy, especially for rectal carcinoma. The aberrant expression of mucins, including MUC1, MUC2 and MUC5AC, is a notable feature of MAC, which may be related to tumor invasion, metastasis, inhibition of apoptosis, and chemo-/radiotherapy resistance. The genetic origin of MAC is mainly related to BRAF mutation, microsatellite instability, and the CpG island methylator phenotype pathway. In addition, the poor prognosis of rectal MAC has been confirmed by various studies, and that of colonic MAC is still controversial. In this review, we summarize the epidemiology, clinicopathological characteristics, molecular features, methods of diagnosis, and treatments of MAC in order to provide references for further fundamental and clinical research.
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Affiliation(s)
- An Huang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jing-Yi Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yu-Kun Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jing-Xuan Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yu Cheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jin Gu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
- Peking-Tsinghua Center for Life Science, Peking University International Cancer Center, Beijing 100142, China
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing 100144, China
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Yan C, Yang H, Chen L, Liu R, Shang W, Yuan W, Yang F, Sun Q, Xia L. Clinical significance of mucinous component in colorectal adenocarcinoma: a propensity score-matched study. BMC Cancer 2021; 21:1286. [PMID: 34852768 PMCID: PMC8638428 DOI: 10.1186/s12885-021-09031-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/15/2021] [Indexed: 01/12/2023] Open
Abstract
Background This study aims to investigate the clinical significance and prognostic value of mucinous component (MC) in colorectal adenocarcinoma (AC). Methods Patients with colorectal AC and AC with MC (ACMC) (1–100%) underwent surgical resection between January 2007 and February 2018 were retrospectively reviewed. Propensity score matching (PSM) was performed according to a 1:1 ratio. Receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off value of MC ratio for prognostic prediction. The clinicopathological features and 3-year overall survival (OS) of AC patients, mucinous adenocarcinoma (MAC) (MC > 50%) patients, and ACMC (1–50%) patients were compared before and after matching. Multivariable analysis was used for analyzing independent risk factors related to prognosis. Results A total of 532 patients were enrolled in this study. Patients with AC, MAC, and ACMC (1–50%) exhibited different clinicopathological features. However, their 3-year OS rates were similar (82.00% vs. 74.11% vs. 81.48%, P = 0.38). After matching, ROC curve determined 70% as the optimal cut-off value. And patients with ACMC > 70% had a much poorer 3-year OS compared with ACMC (1–70%) patients and AC patients (47.37% vs. 86.15% vs. 79.76%, P < 0.001). In addition, ACMC > 70% was revealed as a risk factor for poor survival in univariate analysis (HR = 1.643, 95%CI = 1.025–2.635, P = 0.039), though not an independent risk factor in multivariable analysis (HR = 1.550, 95%CI = 0.958–2.507, P = 0.074). Conclusions MAC is usually diagnosed at an advanced stage. MAC has a similar survival with AC and ACMC (1–50%) patients before and after matching. Patients with ACMC > 70% exhibited a much poorer OS, and should be given more clinical attention.
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Affiliation(s)
- Chuanwang Yan
- Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Weifang Medical University, Key Laboratory of Metabolism and Gastrointestinal Tumor, the First Affiliated Hospital of Shandong First Medical University, Key Laboratory of Laparoscopic Technology, the First Affiliated Hospital of Shandong First Medical University, Shandong Medicine and Health Key Laboratory of General Surgery, Weifang, 261000, Shandong, China
| | - Hui Yang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, the First Affiliated Hospital of Shandong First Medical University, Key Laboratory of Laparoscopic Technology, the First Affiliated Hospital of Shandong First Medical University, Shandong Medicine and Health Key Laboratory of General Surgery, Jinan, 250000, Shandong, China
| | - Lili Chen
- Department of Pathology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, 250000, Shandong, China
| | - Ran Liu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, the First Affiliated Hospital of Shandong First Medical University, Key Laboratory of Laparoscopic Technology, the First Affiliated Hospital of Shandong First Medical University, Shandong Medicine and Health Key Laboratory of General Surgery, Jinan, 250000, Shandong, China
| | - Wei Shang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, the First Affiliated Hospital of Shandong First Medical University, Key Laboratory of Laparoscopic Technology, the First Affiliated Hospital of Shandong First Medical University, Shandong Medicine and Health Key Laboratory of General Surgery, Jinan, 250000, Shandong, China
| | - Wenguang Yuan
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, the First Affiliated Hospital of Shandong First Medical University, Key Laboratory of Laparoscopic Technology, the First Affiliated Hospital of Shandong First Medical University, Shandong Medicine and Health Key Laboratory of General Surgery, Jinan, 250000, Shandong, China
| | - Fei Yang
- Department of Pathology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, 250000, Shandong, China.
| | - Qing Sun
- Department of Pathology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pathology, Shandong Lung Cancer Institute, Shandong Institute of Nephrology, Jinan, China.
| | - Lijian Xia
- Department of Pathology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, 250000, Shandong, China.
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11
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Jia X, Li B, Wang H, Yan Z. Clinical Features, Molecular Alterations and Prognosis of Colorectal Adenocarcinoma With Mucinous Component in Chinese Patients. Appl Immunohistochem Mol Morphol 2021; 29:765-772. [PMID: 34081634 DOI: 10.1097/pai.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
Mucinous adenocarcinoma (MAC) is conventionally diagnosed by WHO definition when the extracellular mucin is >50% of the tumor area, while tumors with <50% mucin are designated as having a mucinous component. The study is aimed at analyzing the clinicopathologic characteristics, mutation spectrum, and prognosis of colorectal adenocarcinoma with mucinous component (CAWMC). Mutation analyses for exon 2 to 4 of KRAS gene and exon 15 of BRAF gene were performed by Sanger sequencing. Expression of DNA mismatch repairs and P53 proteins were evaluated by immunohistochemistry. Density of tumor-infiltrating lymphocyte (TIL) status was scored. We also evaluated the percentage of glands producing mucin and the morphology of the different tumor cell types in mucin pools. We retrospectively analyzed the prognosis of 43 patients with stage II/III. The overall frequencies of KRAS and BRAF mutations were 36% and 8%, respectively. Patients with MAC exhibiting high levels of mucin were related to the increase of tumor diameter (P=0.038) but were not associated with any of the other clinicopathologic parameters. The proportion or variable morphology of mucinous component did not stratify progression-free survival in stage II/III cases. TIL was the most significant predictor of progression-free survival among stage II/III CAWMC. It is interesting to note that signet ring cell carcinoma does not portend a worse prognosis for patients with high TIL levels. Combining use the grade of TIL status with the WHO grade of the entire tumor can help identify patients with a high risk of recurrence more accurately.
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Affiliation(s)
| | | | - Hui Wang
- Surgery, ZhongShan-XuHui Hospital, FuDan University, Shanghai, China
| | - Zhe Yan
- Surgery, ZhongShan-XuHui Hospital, FuDan University, Shanghai, China
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12
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Koseki Y, Kamimura K, Tanaka Y, Ohkoshi-Yamada M, Zhou Q, Matsumoto Y, Mizusawa T, Sato H, Sakamaki A, Umezu H, Yokoyama J, Terai S. Rapid progression of colonic mucinous adenocarcinoma with immunosuppressive condition: A case report and review of literature. World J Clin Cases 2021; 9:9182-9191. [PMID: 34786403 PMCID: PMC8567511 DOI: 10.12998/wjcc.v9.i30.9182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/29/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal mucinous adenocarcinoma is a rare subtype of colorectal cancer and is characterized by an abundance of mucin in the tumor. In addition, the colorectal mucinous adenocarcinoma often demonstrates poor differentiation in the histology of tumor cells and poor prognosis compared with those with adenocarcinoma. Here, we present the case of a young woman with colonic mucinous adenocarcinoma showing significantly rapid progression within four months of immunosuppressant therapy for Henoch–Schönlein purpura.
CASE SUMMARY Here we report a rare case of ascending colon mucinous adenocarcinoma with lymph node and liver metastases which developed and progressed rapidly within four months during the treatment of Henoch–Schönlein purpura using corticosteroids. The systemic screening examinations showed no tumors before the immunosuppressant therapy. Fortunately, the patient was successfully treated with chemotherapy.
CONCLUSION While no direct evidence that the immunosuppressants accelerated the tumor development, the case presenta tion and review of the literature demonstrated that surveillance for malignancies before and during treatment with immunosuppressive agents is essential.
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Affiliation(s)
- Youhei Koseki
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
- Department of General Medicine, Niigata University, Niigata 9518510, Japan
| | - Yuto Tanaka
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Marina Ohkoshi-Yamada
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Qiliang Zhou
- Department of Medical Oncology, Niigata University, Niigata 9518510, Japan
| | | | - Takeshi Mizusawa
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Hajime Umezu
- Division of Pathology, Niigata University, Niigata 9518510, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University, Niigata 9518510, Japan
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13
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Huang Q, Zou MH, Wei JC, Jiang Y, Chen ZP, Wang Q, Li WL, Cao J. Risk Factors for Recurrence of Radically Resected Mucinous Colorectal Adenocarcinoma. Cancer Manag Res 2021; 13:4777-4790. [PMID: 34168497 PMCID: PMC8216659 DOI: 10.2147/cmar.s313627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Mucinous adenocarcinoma (MA) is a subtype of colorectal cancer (CRC) associated with a higher incidence of local extension and worse survival compared to non-mucinous adenocarcinoma, but few studies have investigated surgery-related predictors for recurrence of MA. Therefore, we aimed to elucidate the predictors for local recurrence and remote metastasis of MA after surgery. Patients and Methods This study retrospectively analyzed 162 patients with mucinous colorectal adenocarcinoma (MAC) after radical resection. Analysis variables included demographics, clinical indicators, pathologic stage, surgical procedure, adjuvant therapy, and recurrence. Univariate and multivariate analyses were performed to investigate the risk factors for local and distant tumor relapse. Results A total of 162 patients (86 male) with a mean age of 58.26 years were included; 70.37% of patients had colonic tumors, and 29.63% had rectal tumors. The 5-year disease-free survival (DFS) rates for these patients were as follows: 100% for TNM stage I, 71.2% for stage II, and 47.8% for stage III. Five-year DFS rates of MAC, colonic and rectal MA were 62.0%, 65.8%, and 51.7%, respectively. Local recurrence occurred in 38 patients and distant metastasis in 33 patients. In univariate analysis, predictors for local recurrence of MAC were intraoperative blood loss, intraoperative transfusion, and N2 stage; and predictors for distant metastasis were male sex, CA199, CEA, intraoperative blood loss, T4 stage, and N2 stage. In multivariate analysis, predictors for local recurrence of MAC were intraoperative transfusion (P=0.04, OR=4.175) and N2 stage (P=0.000, OR=5.291), and predictors for distant metastasis were male sex (P=0.049, OR=2.410), CA199 (P=0.02, OR=1.003), and T4 stage (P=0.007, OR=4.006). Conclusion Intraoperative transfusion and N2 stage were significant predictors for local recurrence. Male sex, CA199, and T4 stage were significant predictors for distant metastasis. Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to treatment and follow-up of MAC.
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Affiliation(s)
- Qing Huang
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
| | - Min-Hong Zou
- Department of Ultrasound, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jian-Chang Wei
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
| | - Ye Jiang
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhuan-Peng Chen
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
| | - Qiang Wang
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
| | - Wang-Lin Li
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
| | - Jie Cao
- Department of Gastrointestinal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, The Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, People's Republic of China
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14
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Liao YC, Ying HQ, Huang Y, Luo YR, Xiong CF, Nie RW, Li XJ, Cheng XX. Role of Chronic Inflammatory Ratios in Predicting Recurrence of Resected Patients with Stage I-III Mucinous Colorectal Adenocarcinoma. Cancer Manag Res 2021; 13:3455-3464. [PMID: 33907468 PMCID: PMC8068493 DOI: 10.2147/cmar.s303758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022] Open
Abstract
Background Cancer-related inflammation is the main cause of the progression of mucinous colorectal adenocarcinoma (MCA). Circulating fibrinogen-to-pre-albumin ratio (FPR) is associated with the clinical outcome in colorectal cancer (CRC). However, the prognostic role of FPR and which is the best inflammatory prognostic biomarker within MCA remain unknown. Methods We enrolled 157 patients with stage I–III MCA in this study. Kaplan-Meier curve, Cox regression, and time-dependent receiver operation characteristic curve analysis were performed to assess the prognostic value and efficacy of the neutrophil-to-albumin ratio (NAR), neutrophil-to-pre-albumin ratio (NPAR), albumin-to-alkaline phosphatase ratio (AAPR), albumin-to-globulin ratio (AGR), albumin-to-fibrinogen ratio (AFR), and FPR in these patients. Results We found that NAR, NPAR, and FPR were significantly associated with unsatisfactory recurrence-free survival (RFS) in patients with stage I–III MCA, and the predicted efficacy of FPR was superior to that of the other two inflammatory biomarkers. Moreover, patients with a high combined TNM-CA199-FPR score had worse outcomes, with a high predicted efficacy of up to 0.779 (0.703–0.856). Using FPR, the patient was monitored for the recurrence up to two months earlier than that achieved using the common imaging techniques (4 vs 6 median months) in stage I–III MCA patients undergoing radical resection. Conclusion FPR is the preferred inflammatory biomarker and commonly used for predicting and monitoring recurrence in stage I–III MCA patients. The combined TNM-CA199-FPR score is an economical, simple, effective, and independent prognostic factor for localized disease.
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Affiliation(s)
- Yu-Cui Liao
- School of Public Health; Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Hou-Qun Ying
- Department of Nuclear Medicine, Jiangxi Province Key Laboratory of Laboratory Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Ying Huang
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, People's Republic of China
| | - Yan-Ran Luo
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, People's Republic of China
| | - Cui-Fen Xiong
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, People's Republic of China
| | - Ruo-Wei Nie
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, People's Republic of China
| | - Xiao-Juan Li
- Department of Clinical Laboratory, Kunming Children's Hospital, Kunming, Yunnan, 650500, People's Republic of China
| | - Xue-Xin Cheng
- School of Public Health; Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
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15
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Ayhan M, Turan N, Köstek O, Tufan G, Tataroğlu Özyükseler D, Odabas H, Sakin A, Turan M, Sürmeli H, Yıldırım ME. Does the efficacy of regorafenib differ in chemotherapy refractory metastatic colorectal cancer patients who had mucinous pathology compared to those who had non-mucinous pathology? Curr Probl Cancer 2020; 45:100670. [PMID: 33129567 DOI: 10.1016/j.currproblcancer.2020.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/29/2020] [Accepted: 10/15/2020] [Indexed: 12/09/2022]
Abstract
PURPOSE To investigate the importance of mucinous histopathology on the assessment of tumor response in patients with metastatic colorectal cancer (mCRC) receiving regorafenib. MATERIALS AND METHOD All patients diagnosed with histologically confirmed mCRC in 2 oncology centers between 2013 and 2018 were retrospectively analyzed. Among 678 patients diagnosed with mCRC, 103 patients were treated with regorafenib. Ninety-four of these patients who had used at least 2 cycles of regorafenib and evaluable for treatment response were included in the analysis. Histopathologically, 18 patients with mucinous adenocarcinoma and 76 patients with nonmucinous adenocarcinoma were compared in terms of response rate and survival durations. RESULTS Median follow-up duration of 6 months, median age of the patients was 61 (34-77) years. While 19.1% of the patients had mucinous histology, 80.9% had nonmucinous histology. The overall response rate was significantly lower in the mucinous subgroup than the nonmucinous subgroup (5.6% vs 43.4%, respectively, P = 0.003). Similarly, both progression-free survival (3.0 vs 4.0 months, respectively, P = 0.011) and overall survival duration were shorter in the mucinous subgroup (3.0 vs 7.0 months, P = 0.016, respectively) compared with the nonmucinous subgroup. CONCLUSION The histological subgroup may predict tumor response in mCRC patients receiving regorafenib. Its efficacy on nonmucinous histology had significantly more favorable than mucinous subtype.
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Affiliation(s)
- Murat Ayhan
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey.
| | - Nedim Turan
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
| | - Osman Köstek
- Department of Medical Oncology, Edirne Sultan 1. Murat State Hospital, Edirne, Turkey
| | - Gülnihal Tufan
- Department of Medical Oncology, Health Science University Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Deniz Tataroğlu Özyükseler
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
| | - Hatice Odabas
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
| | - Abdullah Sakin
- Department of Medical Oncology, YuzuncuYil University Faculty of Medicine, Van, Turkey
| | - Merve Turan
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
| | - Heves Sürmeli
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
| | - Mahmut Emre Yıldırım
- Department of Medical Oncology, Health Science University Kartal Dr. LütfiKırdar Training and Research Hospital, İstanbul, Turkey
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