Right- and left-sided stage III colon cancers present different prognostic outcomes of oxaliplatin-based adjuvant chemotherapy after curative resection

Survival trends for left and right sided colon cancer using population-based SEER database: A forty-five-year analysis from 1975 to 2019

BACKGROUND

Survival differences between left-sided colon cancer (LSCC) and right-sided colon cancer (RSCC) has been previously reported with mixed results, with various study periods not accounting for other causes of mortality.

PURPOSE

We sought to assess the trends in colon cancer cause- specific survival (CSS) and overall survival (OS) based on sidedness.

METHOD

Fine-Gray competing risk and Cox models were used to analyze Surveillance, Epidemiology, and End Results (SEER) population-based cohort from 1975 to 2019. Various interval periods were identified based on the timeline of clinical adoption of modern chemotherapy (1975-1989, interval period A; 1990-2004, B; and 2005-2019, C).

RESULTS

Of the 227,637 patients, 50.1% were female and 46.2% were RSCC. RSCC was more common for African Americans (51.5%), older patients (age ≥65; 51.4%), females (50.4%), while LSCC was more common among Whites (53.1%; p < 0.001), younger patients (age 18-49, 64.6%; 50-64, 62.3%; p < 0.001), males (58.1%; p < 0.001). The Median CSS for LSCC and RCC were 19.3 and 16.7 years respectively for interval period A (1975-1989). Median CSS for interval periods B and C were not reached (more than half of the cohort was still living at the end of the follow-up period). Adjusted CSS was superior for LSCC versus RSCC for the most recent interval period C (HR 0.89; 0.86-0.92; p < 0.001). LSCC consistently showed superior OS for all study periods. Stage stratification showed worse CSS for localized and regional LSCC in the earlier study periods, but the risk attenuated over time. However, left sided distant disease had superior CSS per stage for all interval periods. OS was better for LSCC irrespective of stage, with gradual improvement over time.

CONCLUSION

LSCC was associated with superior survival compared to right sided tumors. With the adoption of modern chemotherapy regimens, prognosis between LSCC and RSCC became more divergent in favor of LSCC. Colon cancer clinical trials should strongly consider tumor sidedness as an enrollment factor.

HLA class II polymorphisms as prognostic biomarkers for right and left-sided colon cancer

BACKGROUND

Colon cancer (CC) is one of the most common malignancies worldwide. Characterization of new prognostic biomarkers for right-sided CC (RCC) and left-sided CC (LCC) may contribute to improving early detection. An association of human leukocyte antigens class II (HLA-II) with the predisposition to CC was suggested.

AIM OF THE STUDY

We evaluated the association of DRB1 and DQB1 with the risk of LCC and RCC.

PATIENTS AND METHODS

Our study comprised 93 CC patients and 100 healthy controls. Genotyping of HLA class II alleles were performed by the Polymerase Chain Reaction Sequence-Specific Primers (PCR-SSP).

RESULTS

DRB1*03 was positively associated with CC. In contrast, DRB1*11, DRB1*13, DQB1*03, and DQB1*05 were negatively linked to CC. Haplotype analysis revealed that DRB1*04-DQB1*04 and DRB1*09-DQB1*02 were positive, while DRB1*01-DQB1*05, DRB1*04-DQB1*03, DRB1*07-DQB1*02, DRB1*11-DQB1*03, DRB1*11-DQB1*05, and DRB1*13-DQB1*06 were negatively associated with CC. For sigmoid CC, DRB1*13, DRB1*11, and DQB1*05 were negative, while DRB1*04-DQB1*02, and DRB1*07-DQB1*03 were positively associated. DRB1*03 and DRB1*04-DQB1*04 were positive, while DRB1*11 and DQB1*03 were negatively linked to RCC. According to the LCC, DRB1*07, DRB1*11, DQB1*03, DQB1*05, and DRB1*07-DQB1*02 were negative. In contrast, DRB1*09-DQB1*02 was positively associated with LCC. Stratified analysis revealed that DRB1*11 is associated with higher risk of metastasis in CC and sigmoid CC, and tolerance to treatment in RCC. DQB1*03 was associated with lymph-node invasion in CC.

CONCLUSION

DRB1 and DQB1 polymorphisms could be used as future biomarkers for the early detection of subjects at a higher risk of developing RCC and LCC, metastasis in sigmoid CC, and tolerance to treatment in RCC.

Development and validation of prognostic nomograms for early-onset colon cancer in different tumor locations: a population-based study

OBJECTIVE

The prevalence of early-onset colon cancer (EOCC) among individuals below the age of 50 has shown a marked upward trend in recent years. The embryology, clinical symptoms, incidence, molecular pathways, and oncologic outcomes differ between right-sided and left-sided colon cancers. However, the differences have not been fully researched in EOCC. Our study aims to develop and validate prognostic nomograms predicting overall survival (OS) and cancer-specific survival (CSS) for EOCC in different tumor locations based on the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Using the SEER database, a total of 5,588 patients with EOCC were extracted and divided into development and validation cohorts in a random allocation ratio of 7:3 across three groups. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors influencing OS and CSS outcomes. These factors were then utilized to construct nomogram models. The prognostic capabilities of the three models were assessed through various evaluation metrics, including the concordance index (C-index), receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and validation cohorts respectively. Additionally, survival curves of the low- and high-risk groups were calculated using the Kaplan-Meier method together with the log-rank test.

RESULTS

Significant differences in clinical features were observed between right-sided and left-sided EOCCs, particularly in terms of OS (52 months vs 54 months) as demonstrated by Kaplan-Meier curves. Transverse-sided EOCCs exhibited clinical characteristics similar to right-sided EOCCs, suggesting a potential shared tumor microenvironment and therapeutic considerations. Advanced stage, liver metastasis, poor grade, elevated pretreatment carcinoembryonic antigen (CEA) level, chemotherapy, and perineural invasion were identified as independent prognostic factors across all three tumor locations and were incorporated into the nomogram model. Nomograms were constructed to predict the probability of 3- and 5-year OS and CSS. The C-index and calibration plots showed that the established nomograms had good consistency between actual clinical observations and predicted outcomes. ROC curves with calculated area under the curve (AUC) values exceeded 0.8 for all three groups in both the development and validation cohorts, indicating robust predictive performance for OS and CSS. Furthermore, decision curve analysis (DCA) plots revealed a threshold probability range of 0.1 to 0.9, within which the nomogram model exhibited maximum benefit. Kaplan-Meier curves exhibited significant differences between the low- and high-risk groups in EOCC for all three tumor locations in OS and CSS, further validating the prognostic value of the nomogram models.

CONCLUSIONS

We successfully developed three precise nomogram models for EOCCs in different tumor locations, providing valuable support for clinicians in guiding clinical treatments and facilitating further prospective follow-up studies.

Potentially Avoidable Admissions and Prolonged Hospitalization in Patients with Suspected Colon Cancer

BACKGROUND

Suspicion of cancer in the Emergency Department (ED) may lead to potentially avoidable and prolonged admissions. We aimed to examine the reasons for potentially avoidable and prolonged hospitalizations after admissions from the ED for new colon cancer diagnoses (ED-dx).

METHODS

A retrospective, single-institution analysis was conducted of patients with ED-dx between 2017 and 2018. Defined criteria were used to identify potentially avoidable admissions. Patients without avoidable admissions were examined for ideal length of stay (iLOS), using separate defined criteria. Prolonged length of stay (pLOS) was defined as actual length of stay (aLOS) being greater than 1 day longer than iLOS.

RESULTS

Of 97 patients with ED-dx, 12% had potentially avoidable admissions, most often (58%) for cancer workup. Very little difference in demographic, tumor characteristics, or symptoms were found, except patients with potentially avoidable admissions were more functional (Eastern Cooperative Oncology Group [ECOG] score 0-1: 83% vs. 46%; p = 0.049) and had longer symptom duration prior to ED presentation {24 days (interquartile range [IQR] 7-75) vs. 7 days (IQR 2-21)}. Among the 60 patients who had necessary admissions but did not require urgent intervention, 78% had pLOS, most often for non-urgent surgery (60%) and further oncologic workup. The median difference between iLOS and aLOS was 12 days (IQR 8-16) for pLOS.

CONCLUSIONS

Potentially avoidable admissions following Ed-dx were uncommon but were mostly for oncologic workup. Once admitted, the majority of patients had pLOS, most often for definitive surgery and further oncologic workup. This suggests a lack of systems to safely transition to outpatient cancer management.

The clinical value of C-reactive protein and its association with tumour location in patients undergoing curative surgery for colorectal cancer - a ScotScan collaborative study

INTRODUCTION

The presence of preoperative systemic inflammatory response (SIR) is an established negative prognostic factor for patients diagnosed with colorectal cancer (CRC). C-reactive protein (CRP) is known to be implicated in detrimental immune responses. The biological differences between right-sided and left-sided CRC are gaining increasing attention. Our aim was to analyse the prognostic value of CRP and explore the association between tumour location and SIR.

MATERIAL AND METHODS

A total of 2059 patients treated for stage I-III CRC, identified from the prospectively sampled ScotScan Collaborative dataset, were included. The clinical and prognostic value of five CRP levels (<10/11-30/31-60/61-100/>100 mg/l) were examined. Additionally, the relationship between SIR and tumour location was explored.

RESULTS

Increasing levels of CRP were associated with impaired overall and cancer-specific outcome. Presence of SIR was independently associated with right-sided tumour location (p<0.001). However, the impact of SIR on cancer-specific survival (CSS) was greater for left-sided tumour location, even when adjusted for other clinicopathological factors.

CONCLUSIONS

This study confirms CRP as a routinely available, valid, and clinically relevant strong prognostic marker of SIR in CRC patients. Right-sided tumours were more often associated with SIR, but the prognostic impact was stronger in left-sided tumours.

Survival Benefit of Palliative Primary Tumor Resection Based on Tumor Location in Patients with Metastatic Colorectal Cancer: A Single-center Retrospective Study

Backgrounds/Aims

The molecular underpinnings of colorectal cancer (CRC) vary according to the tumor location. The advantages of a palliative primary tumor resection in patients with metastatic CRC are controversial. This study examined the survival outcomes of a palliative primary tumor resection based on the tumor location in patients with metastatic CRC.

Methods

The medical records of 600 patients diagnosed with metastatic CRC between January 2000 and June 2018 were reviewed retrospectively. Patients undergoing surgery for both the primary tumor and metastatic lesions were excluded. The clinical factors affecting the long-term outcomes were evaluated according to the primary tumor location, and the long-term survival was compared between patients with and without a palliative primary tumor resection. The data were analyzed using the Kaplan-Meier estimator and multivariate Cox regression models.

Results

The median follow-up duration was 18 months (interquartile range, 10-28). Patients with right-sided CRC had a poor overall- and progression-free survival compared to those with left-sided CRC. In multivariate Cox regression analysis, the palliative primary tumor resection was an independent prognostic factor predicting better overall survival in patients with metastatic CRC, regardless of the primary tumor location.

Conclusions

The primary tumor location influences the prognosis, and that a primary tumor resection can improve the overall survival in patients with metastatic CRC, regardless of the primary tumor location.

Feasibility Study of a Modified XELOX Adjuvant Chemotherapy for High-Recurrence Risk Patients With Operated Stage III Colon Cancer

Background

Our previous study reported the favorable efficacy and good tolerance associated with a modified XELOX adjuvant chemotherapy with eight cycles of capecitabine and six cycles of oxaliplatin for operated stage III colon cancer. The current study aimed to confirm the feasibility of modified XELOX chemotherapy for treating specific high-risk (T4, N2, or both) stage III colon cancer.

Methods

We selected 142 consecutive patients with high-risk stage III colon cancer who received colon tumor resection followed by modified XELOX or standard full-cycle XELOX chemotherapy from November 2007 to June 2016 at Sun Yat-sen University Cancer Center. Disease-free survival (DFS), overall survival (OS), and adverse events of patients treated with the two chemotherapy regimens were compared.

Results

Seventy-four (52.1%) patients received standard XELOX chemotherapy, and 68 (47.8%) received modified XELOX chemotherapy. Neurotoxicity was the most common adverse event in 99 (69.7%) patients. Grade 2-3 neurotoxicity, grade 2–4 thrombocytopenia and grade 3–4 leucopenia were the major severe adverse events related to the decision to treat patients with modified XELOX chemotherapy. After a median follow-up of 69 months, the modified XELOX group presented a comparable 5-year DFS rate (79.0 vs. 80.3%, P = 0.891) and 5-year OS rate (93.8 vs. 87.8%, P = 0.446) as those in the standard XELOX group. Univariate survival analysis indicated that poor tumor differentiation (HR: 2.381, 95% CI: 1.141–4.968, P = 0.021) was the only significant risk factor for DFS, but no significant prognostic factor was identified for OS.

Conclusions

The modified XELOX adjuvant chemotherapy presented a comparable oncologic efficacy as standard XELOX chemotherapy for high-risk stage III colon cancer. The modified XELOX adjuvant chemotherapy could be an alternative treatment for patients suffering severe adverse events, especially severe neurotoxicity.

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

BACKGROUND AND OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Plasma protein expression differs between colorectal cancer patients depending on primary tumor location

Colorectal cancer (CRC) includes tumors in the right colon, left colon, and rectum, although they differ significantly from each other in aspects such as prognosis and treatment. Few previous mass spectrometry-based studies have analyzed differences in protein expression depending on the tumor location. In this study, we have used mass spectrometry-based proteomics to analyze plasma samples from 83 CRC patients to study if differences in plasma protein expression can be seen depending on primary tumor location (right colon, left colon, or rectum). Differences were studied between the groups both regardless of and according to tumor stage (II or III). Large differences in plasma protein expression were seen, and we found that plasma samples from patients with rectal cancer separated from samples from patients with colon cancer when analyzed by principal component analysis and hierarchical clustering. Samples from patients with cancer in the right and left colon also tended to separate from each other. Pathway analysis discovered canonical pathways involved in lipid metabolism and inflammation to be enriched. This study will help to further define CRC as distinct entities depending on tumor location, as shown by the widespread differences in plasma protein profile and dysregulated pathways.

Safety and efficacy of a modified XELOX adjuvant regimen for patients with operated stage III colon cancer: a Chinese single-center experience

Background

A fixed 8-cycle oxaliplatin and capecitabine (XELOX) regimen has been the standard adjuvant therapy for patients with stage III colon cancer. However, completing the full-cycle of oxaliplatin is often associated with severe neurotoxicity. To spare patients from the toxic effects, without comprising the required efficacy, we evaluated the safety and efficacy of a modified XELOX (mXELOX) adjuvant chemotherapy regimen with 6 cycles of oxaliplatin and a full cycle of capecitabine.

Methods

We retrospectively analyzed 330 eligible patients with stage III colon cancer who underwent curative tumor resection followed by mXELOX, standard XELOX or unfinished XELOX adjuvant chemotherapy between December 2007 and April 2015. Associated prognostic factors were investigated and their disease-free survival (DFS) and overall survival (OS) rates were also determined and compared among the different regimen groups.

Results

Compared with the standard XELOX group, the mXELOX group had lower total incidence rates of neurotoxicity (39.3% vs. 76.2%, P < 0.001), leucopenia (53.6% vs. 69.8%, P = 0.017) and thrombocytopenia (38.1% vs. 56.3%, P = 0.011). The standard XELOX and mXELOX adjuvant chemotherapy regimens presented with comparable 3-year DFS rates (86.3% vs. 89.2%; P = 0.838) and 3-year OS rates (92.7% vs. 97.6%; P = 0.227). Compared to unfinished XELOX chemotherapy, the oncologic benefits of the mXELOX regimen were greater for patients with T4 tumors (3-year DFS: Hazard ratio [HR], 2.184; 95% confidence interval [CI], 1.051–4.540; P = 0.036; 3-year OS: HR, 4.529; 95% CI 1.245–16.479; P = 0.022) and for high-risk patients (3-year DFS: HR, 1.962; 95% CI 0.964–3.993; P = 0.044; 3-year OS: HR, 4.193; 95% CI 1.182–14.874; P = 0.026).

Conclusions

The mXELOX adjuvant chemotherapy presented a comparable survival benefit and lower incidence of toxicity than standard XELOX chemotherapy. It could be an alternative treatment for high-risk patients with operated stage III colon cancer.

Prognostic significance of elevated preoperative neutrophil-to-lymphocyte ratio for patients with colorectal cancer undergoing curative surgery: A meta-analysis

BACKGROUND

Preoperative neutrophil-to-lymphocyte ratio (NLR) has been suggested as a useful predictive factor for prognosis in patients with various cancers. However, the prognostic value of NLR in patients with colorectal cancer (CRC) remains controversial. Therefore, the goal of this study was to perform a meta-analysis to evaluate the prognostic value of NLR in patients with CRC undergoing curative surgery.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched to screen the relevant studies. Pooled hazard ratio (HR) with 95% confidence interval (CI) was used to assess the associations of preoperative NLR and overall survival (OS), disease-free survival (DFS), recurrence free survival (RFS) and disease specific survival (DSS) by STATA 13.0 software.

RESULTS

Sixteen studies involving 5897 patients were included in our meta-analysis. Our pooled results demonstrated that high NLR was associated with poor OS (HR: 1.66, 95%CI: 1.36-2.02, P < .001), DFS (HR = 1.54, 95%CI: 1.18-2.02, P = .002), RFS (HR = 2.31, 95%CI: 1.68-3.17, P < .001) and DSS (HR = 2.27; 95% CI: 1.75-2.96, P < .001). When the patients were stratified according to country, sample size, NLR cut-off, follow up and postoperative chemotherapy, high NLR was still significantly correlated with OS. The limitation was that the majority of enrolled studies were retrospective.

CONCLUSION

Preoperative NLR may be an effective predictive biomarker for prognosis in patients with CRC. Detection of NLR may be beneficial to identify the high-risk patients who need other antitumor therapies in addition to surgery.