Colorectal cancer with intestinal perforation - a retrospective analysis of treatment outcomes

Characteristics, treatment, and outcome of patients with bowel perforation after immune checkpoint inhibitor exposure

PURPOSE

Exposure to immune checkpoint inhibitors (ICIs) can predispose to immune-related adverse events (irAEs) involving the gastrointestinal tract. The association between ICIs and bowel perforation has not been well studied. We aimed to describe the clinical course, complications, treatment, and outcomes of patients experiencing bowel perforation during or after ICI treatment.

METHODS

This retrospective, single-center study included adult cancer patients with bowel perforation that occurred between the first dose of ICI treatment and up to 1 year thereafter between 1/1/2010 and 4/30/2021. Patients' clinical course, imaging, treatment, and outcomes related to bowel perforation were collected and analyzed.

RESULTS

Of the 13,991 patients who received ICIs during the study period, 90 (0.6%) met the inclusion criteria. A majority were male (54.4%), the most common cancer type was melanoma (23.3%), and most patients had received PD-1/L1 inhibitor treatment (58.8%). Onset of perforation occurred after a median of four ICI treatment cycles. The most common symptom was abdominal pain (95.5%). The colon was the most common location for the perforation (37.7%). Evidence of diverticulitis, enterocolitis, or appendicitis was seen in 32 (35.6%) patients, and 6 (6.6%) patients had luminal cancer involvement at the time of perforation. The overall hospitalization rate related to perforation was 95.5%, with mortality of 15.5% during the same admission. Antibiotics were given in 95% of our sample; 37.8% of patients also required surgical/interventional radiology intervention. Forty-six patients (51.1%) had perforation-related complications (e.g., sepsis, fistula, abscess), which were associated with a higher mortality rate (30%).

CONCLUSION

Our findings suggest a low incidence of bowel perforation after ICI treatment (0.6%), with 40% of patients having coexisting bowel inflammation as a potential contributing factor. Patients with bowel perforation had an aggressive disease course and high rates of hospitalization, complications, and mortality. Early recognition and prompt intervention is critical to improve patient outcomes. Future studies are warranted to further investigate the cause, predictive markers, and optimal treatment for this patient population.

Comparison of short-term surgical outcomes and long-term survival between emergency and elective surgery for colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to summarize relevant data from previous reports and perform a meta-analysis to compare short-term surgical outcomes and long-term oncological outcomes between emergency and elective surgery for colorectal cancer (CRC).

METHODS

A systematic literature search was performed using PubMed and Embase databases, and relevant data were extracted. Postoperative morbidity, hospital mortality within 30 days, postoperative recovery, overall survival (OS), and relapse-free survival (RFS) were compared using a fixed or random-effect model.

RESULTS

A total of 28 studies involving 353,686 participants were enrolled for this systematic review and meta-analysis, and 23.5% (83,054/353,686) of CRC patients underwent emergency surgery. The incidence of emergency presentations in CRC patients ranged from 2.7 to 38.8%. The lymph node yield of emergency surgery was comparable to that of elective surgery (WMD:0.70, 95%CI: - 0.74,2.14, P = 0.340; I² = 80.6%). Emergency surgery had a higher risk of postoperative complications (OR:1.83, 95%CI:1.62-2.07, P < 0.001; I² = 10.6%) and hospital mortality within 30 days (OR:4.62, 95%CI:4.18-5.10, P < 0.001; I² = 42.9%) than elective surgery for CRC. In terms of long-term oncological outcomes, emergency surgery was significantly associated with poorer RFS (HR: 1.51, 95%CI:1.24-1.83, P < 0.001; I² = 58.9%) and OS(HR:1.60, 95%CI: 1.47-1.73, P < 0.001; I² = 63.4%) of CRC patients. In addition, the subgroup analysis for colon cancer patients revealed a pooled HR of 1.73 for OS (95%CI:1.52-1.96, P < 0.001), without the evidence of significant heterogeneity (I² = 21.2%).

CONCLUSION

Emergency surgery for CRC had an adverse impact on short-term surgical outcomes and long-term survival. A focus on early screening programs and health education was warranted to reduce emergency presentations of CRC patients.

Large Bowel Perforation in Patients with Colorectal Cancer: A South African Perspective

Introduction

Large bowel perforation (LBP) occurs in up to 10% of colorectal cancer (CRC) patients and is a potential surgical emergency. Data on LBP in CRC patients from resource-limited countries are required to improve the management of this condition in these settings. Our study aimed to describe LBP amongst CRC patients in KwaZulu-Natal, South Africa.

Materials and Methods

This was a descriptive sub-analysis of LBP data from an ongoing CRC registry. This study explores free and contained perforations and describes LBP characteristics, surgical management, histological findings, overall survival, and CRC recurrence.

Results

Ninety-four out of 2523 CRC patients had LBP (3.7%). The median age was 53.0 years (interquartile range: 43.0-64.0). The male-to-female ratio was 1.4:1. Thirty-three patients (35.1%) had a coexisting bowel obstruction. Tumor site perforations occurred in 87 patients (92.6%) and were mostly in the sigmoid colon (36.2%). Perforations were contained in 77 patients (81.9%). Eighty-nine patients (94.7%) underwent resection (elective resection: 76/89 patients, 85.4%). The post-operative inpatient mortality rate was 2.2%. Most patients had Stage III CRC (46 patients, 48.9%) and moderately differentiated tumors (77 patients, 81.9%). Overall survival at 12 months following CRC diagnosis was 55.4%. The early recurrence rate for CRC disease was 5.4%.

Conclusion

Tumor site perforations predominated, and most were contained. Patients were younger when compared with the international literature. We reaffirm that diastatic-free and contained perforations are two distinct clinical entities.

Frequency of allogenic blood transfusion in patients with gastrointestinal cancer: a cross-sectional study in Peru

Background

Gastrointestinal cancer demands a high frequency of transfusions, and the high availability of blood products. We aimed to determine the frequency of blood transfusions and the most used blood products according to the type of gastrointestinal cancer.

Methods

A cross-sectional study was conducted in a Peruvian Type I Hemotherapy and Blood Bank Service of a Private Oncological Clinic during 2016–2018. We included patients with gastrointestinal cancer using the International Code of Diseases. The donations were made in compliance with the requirements of the Programa Nacional de Hemoterapía y Banco de Sangre and in accordance with the Standardised Operational Procedure of the clinic.

Results

We analysed 3,022 patients, of which 163 (5.4%) had gastrointestinal cancer (67.1 ± 12 years). The 80 (49.1%) men did not show significant differences with the 83 (50.9%) women (p = 0.178). The most frequent neoplasia was the colon (41.7%) and pancreas (37.4%). Three hundred and four blood products were transfused (average 1.8 ± 2.5 units (range: 1–30 units/patient)), of which 81.3% (247 units) were red blood cells concentrated, 8.6% (26 units) were fresh-frozen-plasma (FFP) and 6.6% (20 units) were cryoprecipitate. The type of cancer that most blood products demanded was colon neoplasia (41.8%), followed by pancreatic cancer (26.3%) and liver cancer (10.9%). We determined that ~55% of patients were O Rh(D)+ and in five patients we were poly-transfused.

Conclusion

Our findings suggested that patients with gastrointestinal cancer require large numbers of transfusions of blood cell concentrate and FFP. Also, we showed that cancer of the colon, pancreas and liver demanded more than 75% of blood products.

Retroperitoneal Cecal Perforation Resulting from Obstructive Ascending Colon Adenocarcinoma

Most colorectal cancer patients in the early stages of the disease do not display any alarming symptoms. A total percentage of 9-27% of colorectal cancer patients present with acute abdomen, bowel obstruction, perforation, or bleeding. Perforation as the first presentation of the disease is seen in no more than 2.6-10% of patients. Intestinal perforation may be found on either the site of the tumor or on a more proximal site, caused by distention of the bowel due to peripheral obstruction. This is a case of a 75-year-old female patient who presents in the emergency department with retroperitoneal cecal perforation due to an obstructing tumor of the ascending colon. She underwent an emergency right hemicolectomy and washout of the retroperitoneal space. The cecum is not an unusual site of distention and subsequent perforation in the case of colonic obstruction, especially in the presence of a competent ileocecal valve. While the mechanism of diastatic cecal perforation is well described, it is the first time in the literature that this does not occur on the anterior surface of the organ. In our case, cecal perforation presents as a retroperitoneal abscess without peritoneal spillage. Nonetheless, it still carries a grim prognosis and urgent surgical intervention is needed.

Nonobstetrical Acute Abdomen during Pregnancy as a Consequence of Colorectal Carcinoma Perforation: Case Report and Review of the Literature

Colorectal carcinoma is a rare but potentially fatal disease complicating pregnancy. It occurs most frequently in patients aged 50, although some studies report increasing incidence in women under the age of 40. Diagnosis of colorectal cancer during pregnancy is usually made at an advanced stage due to unspecific symptoms. We will present a case of an acute abdomen during pregnancy due to colorectal carcinoma perforation in a 33-year-old patient in her 26th week of gestation. Because of her abdominal condition, left hemicolectomy with colostomy was performed. Two hours after surgery, the patient gave birth to a male child weighing 910 g with an Apgar score of 2/6. The pathohistological finding indicated adenocarcinoma of the colon in Dukes stage B.

Outcome of colon cancer initially presenting as colon perforation and obstruction

Background

Emergency complications of colon cancer include perforation and obstruction which were recognized as poor prognostic factors. Few studies have directly compared the outcomes of these two groups. In this study, we evaluated mortality and morbidity in patients with colon cancer initially presenting as perforation and obstruction.

Methods

Newly diagnosed colon cancer cases initially presenting with perforation or obstruction at Tzu Chi General Hospital, Hualien, Taiwan, between 2009 and 2015 were included. Cases of iatrogenic perforation or perforation sites far away from the tumor sites and rectal (< 15 cm from the anal verge) cancer were excluded. Progression-free survival, local recurrence rate, distant metastasis rate, and overall survival were the evaluated outcomes.

Results

Eighty-one patients met the selection criteria; 23 and 58 patients had perforation and obstruction, respectively, as the initial symptom. The median age was 72 years. The median tumor stage was stage IIIB. The 1-year and 3-year survival rates were 83.7 and 59.7%, respectively. The perforation group (PRG) and obstruction group (OBG) did not differ significantly in intensive care unit (ICU) stay rate (p = 0.147), sex (p = 0.45), comorbidities (heart, liver, and renal diseases and diabetes mellitus), median stage (p = 0.198), and overall survival (p = 0.328). However, PRG had a higher age at diagnosis (74 vs. 64 years, p = 0.037), a higher APACHE II score (12 vs. 7, p = 0.002), lower disease-free survival (p = 0.001), a higher recurrence rate (56.5 vs. 19%, p = 0.002), a higher distant metastasis rate (39.1 vs. 13.8%, p = 0.015), and a higher local recurrence rate (43.5 vs. 5.2%, p < 0.001) than did OBG. OBG had a higher two-stage operation rate (46.6 vs. 17.4%, p = 0.022). After adjustment for the tumor stage, comorbidity (chronic renal disease), body mass index (BMI), and adjuvant chemotherapy or radiotherapy in multivariate statistics, PRG had lower disease-free survival (p = 0.005) than OBG but overall survival was identical.

Conclusion

For colon cancer initially presenting as perforation or obstruction, the PRG had poorer progression-free survival, a higher local recurrence rate, and a higher distant metastasis rate than did OBG. Overall survival did not differ between these two groups.

Outcomes in Critically Ill Patients with Cancer-Related Complications

INTRODUCTION

Cancer patients are at risk for severe complications related to the underlying malignancy or its treatment and, therefore, usually require admission to intensive care units (ICU). Here, we evaluated the clinical characteristics and outcomes in this subgroup of patients.

MATERIALS AND METHODS

Secondary analysis of two prospective cohorts of cancer patients admitted to ICUs. We used multivariable logistic regression to identify variables associated with hospital mortality.

RESULTS

Out of 2,028 patients, 456 (23%) had cancer-related complications. Compared to those without cancer-related complications, they more frequently had worse performance status (PS) (57% vs 36% with PS≥2), active malignancy (95% vs 58%), need for vasopressors (45% vs 34%), mechanical ventilation (70% vs 51%) and dialysis (12% vs 8%) (P<0.001 for all analyses). ICU (47% vs. 27%) and hospital (63% vs. 38%) mortality rates were also higher in patients with cancer-related complications (P<0.001). Chemo/radiation therapy-induced toxicity (6%), venous thromboembolism (5%), respiratory failure (4%), gastrointestinal involvement (3%) and vena cava syndrome (VCS) (2%) were the most frequent cancer-related complications. In multivariable analysis, the presence of cancer-related complications per se was not associated with mortality [odds ratio (OR) = 1.25 (95% confidence interval, 0.94-1.66), P = 0.131]. However, among the individual cancer-related complications, VCS [OR = 3.79 (1.11-12.92), P = 0.033], gastrointestinal involvement [OR = 3.05 (1.57-5.91), P = <0.001] and respiratory failure [OR = 1.96(1.04-3.71), P = 0.038] were independently associated with in-hospital mortality.

CONCLUSIONS

The prognostic impact of cancer-related complications was variable. Although some complications were associated with worse outcomes, the presence of an acute cancer-related complication per se should not guide decisions to admit a patient to ICU.