Perioperative detection of disseminated tumour cells is an independent prognostic factor in patients with colorectal cancer

Oncological impact of perioperative blood transfusion in bladder cancer patients undergoing radical cystectomy: Do we need to consider storage time of blood units, donor age, or gender matching?

BACKGROUND

The oncological impact of perioperative blood transfusions (PBTs) of patients undergoing radical cystectomy (RC) because of bladder cancer (BCa) has been a controversial topic discussed in recent years. The main cause for the contradictory findings of existing studies might be the missing consideration of the storage time of red blood cell units (BUs), donor age, and gender matching.

STUDY DESIGN AND METHODS

We retrospectively analyzed BCa patients who underwent RC in our department between 2004 and 2021. We excluded patients receiving BUs before RC, >10 BUs, or RC in a palliative setting. We assessed the effect of blood donor characteristics and storage time on overall survival (OS) and cancer-specific survival (CSS) through univariate and multivariable Cox regression analysis. We also performed a propensity score matching with patients who received BUs and patients who did not on a 1:1 ratio.

RESULTS

We screened 1692 patients and included 676 patients for the propensity score matching. In the multivariable analysis, PBT was independently associated with worse OS and CSS (p < .001). Postoperative transfusions were associated with better OS (p = .004) and CSS (p = .008) compared to intraoperative or mixed transfusions. However, there was no influence of blood donor age, storage time, or gender matching on prognosis.

DISCUSSION

In our study of BCa patients undergoing RC, we demonstrate that PBT, especially if administered intraoperatively, is an independent risk factor for a worse prognosis. However, storage time, donor age, or gender matching did not negatively affect oncological outcomes. Therefore, the specific selection of blood products does not promise any benefits.

Blood Transfusion is Associated With Adverse Outcomes in Pediatric Solid Tumor Oncology Patients Following Tumor Resection

BACKGROUND

Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown.

METHODS

We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection.

RESULTS

Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P =0.031).

CONCLUSIONS

Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused.

LEVEL OF EVIDENCE

Level III.

The immune response to major gastrointestinal cancer surgery and potential implications for adjuvant immunotherapy

The perioperative period theoretically is a critical time of opportunity for the progression of pre-existing tumour micrometastasis. Therefore,the timing of introducing cancer therapies including chemotherapy, radiation therapy and immunotherapies in the postoperative period is important. A thorough exploration of the perioperative immune events at a cellular level in combination with an intricate review of available clinical rials was conducted to extrapolate the effects of oncological surgery on the perioperative immune milieu.This is timely in view of the recently published Checkmate-577 trial which demonstrated significant disease-free survival in carcinoma of the gastroesophageal junction with the use of adjuvant anti-programmed cell deathprotein 1(PD-1) immunotherapy.This review focusing in particular on perioperative immunosuppression, identifies potential modifiable factors, the effects of perioperative conditioning and optimisation, the most recent trials in the curative setting for Gastrointestinal malignancies and the new treatment avenues possible in the context of the combination of immunotherapy and major oncological gastrointestinal surgery.

Tumor cell E-selectin ligands determine partialefficacy of bortezomib on spontaneous lung metastasis formation of solid human tumors in vivo

Extravasation of circulating tumor cells (CTCs) is critical for metastasis and is initiated by adhesive interactions between glycoligands on CTCs and E-selectin on endothelia. Here, we show that the clinically approved proteasome inhibitor bortezomib (BZM; Velcade) counteracts the cytokine-dependent induction of E-selectin in the lung mediated by the primary tumor, thereby impairing endothelial adhesion and thus spontaneous lung metastasis in vivo. However, the efficacy of BZM crucially depends on the tumor cells' E-selectin ligands, which determine distinct adhesion patterns. The canonical ligands sialyl-Lewis A (sLeA) and sLeX mediate particularly high-affinity E-selectin binding so that the incomplete E-selectin-reducing effect of BZM is not sufficient to disrupt adhesion or metastasis. In contrast, tumor cells lacking sLeA/X nevertheless bind E-selectin, but with low affinity, so that adhesion and lung metastasis are significantly diminished. Such low-affinity E-selectin ligands apparently consist of sialylated MGAT5 products on CD44. BZM no longer has anti-metastatic activity after CD44 knockdown in sLeA/X-negative tumor cells or E-selectin knockout in mice. sLeA/X can be determined by immunohistochemistry in cancer samples, which might aid patient stratification. These data suggest that BZM might act as a drug for inhibiting extravasation and thus distant metastasis formation in malignancies expressing low-affinity E-selectin ligands.

Blood transfusion had no influence on the 5-year biochemical recurrence after robot-assisted radical prostatectomy: a retrospective study

Background

Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot-assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Methods

This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence.

Results

A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4–5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5–3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8–3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5–2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence.

Conclusions

RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Comparison of prognostic impact between positive intraoperative peritoneal and lavage cytologies in colorectal cancer

BACKGROUND

The prognostic value of positive intraoperative peritoneal cytology and lavage cytology, including the differences in their prognostic impact, in colorectal cancer is controversial. We aimed to investigate the prognostic values of positive peritoneal cytology and lavage cytology findings for colorectal cancer and compare their prognostic impact.

METHODS

We retrospectively evaluated 592 clinical stage II-IV colorectal cancer patients who underwent peritoneal cytology (n = 225) or lavage cytology (n = 367) between November 1993 and December 2018. The prognostic factors for cancer-specific survival were identified, and the differences in cancer-specific survival were examined between the patients.

RESULTS

The cytology-positive rate was 10.8% (64/592), 17.8% (40/225), and 6.5% (24/367) in the overall, peritoneal cytology, and lavage cytology groups, respectively. Both positive peritoneal cytology (hazard ratio: 2.196) and lavage cytology (hazard ratio: 2.319) were independent prognostic factors. The peritoneal cytology-positive group showed significantly poorer cancer-specific survival than the cytology-negative group (5-year: 3.5% vs. 59.5%; 10-year: 3.5% vs. 46.1%, p < 0.001). Similar results were obtained for lavage cytology (5-year: 14.1% vs. 73.9%; 10-year: 4.7% vs. 63.5%, p < 0.001). The cancer-specific survival was not significantly different between the peritoneal cytology-positive and lavage cytology-positive groups (p = 0.058). Both positive peritoneal and lavage cytology were associated with poorer cancer-specific survival across all colorectal cancer stages.

CONCLUSIONS

Positive peritoneal and lavage cytology are associated with worse cancer-specific survival in colorectal cancer. The prognostic impact was comparable between positive lavage and peritoneal cytology. Thus, cytology should be a standard assessment modality for colorectal cancer.

BRMS1: a multifunctional signaling molecule in metastasis

Despite high mortality rates, molecular understanding of metastasis remains limited. It can be regulated by both pro- and anti-metastasis genes. The metastasis suppressor, breast cancer metastasis suppressor 1 (BRMS1), has been positively correlated with patient outcomes, but molecular functions are still being characterized. BRMS1 has been implicated in focal adhesion kinase (FAK), epidermal growth factor receptor (EGFR), and NF-κB signaling pathways. We review evidence that BRMS1 regulates these vast signaling pathways through chromatin remodeling as a member of mSin3 histone deacetylase complexes.

Conventional peritoneal cytology lacks the prognostic significance of detecting local or peritoneal recurrence in colorectal cancer: An Egyptian experience

Background and Aim

Colorectal cancer (CRC) accounts for over 8% of all deaths each year, with 1.2 million new cases diagnosed annually worldwide. It represents the seventh most common cancer in Egypt. Early detection of peritoneal metastasis is a major challenge in such cases. It helps with the decision of the immediate application of intraperitoneal chemotherapy after resection. Meta-analysis studies reported contrast evidence for a possible prognostic role of intraperitoneal free cancer cells (IPCCs) in peritoneal recurrence and survival after curative resection. In this work, we aim to evaluate the prevalence and impact of detecting free malignant cells in peritoneal fluid on survival and local recurrence and to estimate the incidence of peritoneal carcinomatosis (PC) during follow up.

Methods

Design: This was a prospective cohort study. Settings: From June 2016 to December 2018, samples were collected from 104 patients who underwent abdominal surgery for colorectal cancer in the Egyptian National Cancer Institute. A total of 96 Egyptian CRC patients who underwent curative resection were enrolled. Intraoperative peritoneal lavage was performed to detect IPCC by conventional cytology. Patients with no residual tumor after surgery and no evidence of PC were followed up for a median 14 months. The cumulative 12-month overall survival rate for patients with IPCC was 100% versus 86% for patients with negative cytology.

Results

Our results demonstrated that the prevalence of IPCC in the peritoneal lavage was 11.5%. Peritoneal and local recurrence occurred at a higher rate in patients with cytology positive lavage (9.1% vs 6.3% and 9.1% vs 3.8%, respectively), although this was statistically insignificant. Distant metastasis occurred significantly in patients with positive cytology (45.5% vs 8.9%) with P-value <0.001.The conventional cytology technique has a high specificity but less sensitivity.

Conclusions

The presence of IPCC using conventional cytology was not an independent prognostic factor for the development of PC or survival.

Assessment of circulating tumor cells in peripheral blood using flow cytometry in patients with surgery for colorectal cancer – review

Introduction: Colorectal cancer (CRC) is the third most common neoplasia in the world. Circulating tumor cells (CTC) have a prognostic value and can be useful in monitoring solid neoplasia. Only one method for CTC identification has received the approval and this is the CellSearch® system based on the immunomagnetic separation. Multiple markers are used in CTC identification, as epithelial markers and cytokeratines. CTC identification in peripheral blood is associated with a worse prognostic and reduced free survival in CRC.

Material and methods: We performed a systematic search in PubMed database for articles that reports the circulating tumor cells in CRC until July 2019. We selected studies in English and French and the main words used for search were ‘circulating tumor cells’, ‘colorectal cancer’, ‘colon cancer’, ‘rectal cancer’, ‘flow cytometry’, ‘peripheral blood’. We included studies with more than 10 patients, where samples were collected from the blood in relation with surgery and flow cytometry was used as analyzing technique.

Results: We included 7 studies in final analysis, that showed in flow cytometry analysis a cut-off value of CTC that can vary from 2-4 CTC/ 7.5 ml peripheral blood with a sensitivity of 50.8% and specificity of 95%. Patients with positive CTC were associated with higher T stage and positive lymph nodes, with a worse overall survival (OS) and disease free survival (DFS) comparing with negative patients.

Conclusion: CTC are considered to be a prognostic factor who needs more validation studies in order to be included in the clinical practice.

Preventive intraperitoneal hyperthermic perfusion chemotherapy for patients with T4 stage colon adenocarcinoma

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be an effective treatment for peritoneal tumors; whether preventive HIPEC after radical resection for T4 stage colon adenocarcinoma could decrease peritoneal recurrence remains unknown. The aim of the present study was to compare peritoneal recurrence and short-term survival in patients with T4 stage colon adenocarcinoma undergoing HIPEC plus adjuvant chemotherapy or adjuvant chemotherapy alone following surgery.

METHODS

We retrospectively reviewed T4 stage colon adenocarcinoma patients who had radical tumor resection at our institution between January 2014 and January 2019. Clinical data were extracted from the database at our institution, and patient survival and long-term complications were assessed through repeated outpatient examinations and telephone interviews.

RESULTS

A total of 352 patients were included in this study; 157 patients received postoperative HIPEC plus adjuvant chemotherapy (HIPEC group), 195 patients received adjuvant chemotherapy alone (conventional chemotherapy group). Forty-one (26.1%) patients in the HIPEC group had a peritoneal recurrence and the peritoneum was the first site of tumor recurrence in 6 (14.6%) of them. However, 73 (37.4%) patients experienced peritoneal recurrence in the conventional group, and the peritoneum was the first site of tumor recurrence in 25 (34.2%) (p = 0.019). Disease-free survival in the HIPEC group at 1 and 3 years was 93.3% and 61.1%, respectively, versus 89.3% and 51.7% in the conventional chemotherapy group (p = 0.038). Overall survival in the HIPEC group at 1 and 3 years was 100.0% and 82.7%, respectively, versus 100.0% and 76.9% in the conventional chemotherapy group (p = 0.420). The two groups did not differ with respect to severe complications.

CONCLUSIONS

Preventive HIPEC after radical surgery may decrease peritoneal recurrence and promote disease-free survival for T4 stage colon adenocarcinoma. Large-scale randomized controlled studies are needed to confirm the results of our study.

Laparoscopic Surgery of Gastric Cancer with D2 Lymphadenectomy and Omentum Preservation: Our 10 Years Experience

Introduction: The debate is still open about laparoscopic treatment of gastric cancer. The aim of this retrospective study is to analyze our short-, medium-, and long-term surgical and oncological results in laparoscopic treatment of gastric cancer with D2 lymphadenectomy and omentum preservation. Materials and Methods: From January 2010 to June 2018, after >150 surgical procedures for gastric cancer performed by minimally invasive approach, we performed 100 laparoscopic subtotal gastrectomies and 38 total gastrectomies, both for early gastric cancer (EGC) and advanced gastric cancer (AGC). We always made a D2 lymphadenectomy or higher. As often as possible, we performed omentum-preserving technique. Primary outcomes analyzed included incidence of medical and surgical complications. Secondary outcomes analyzed were survival probability and incidence of relapse. Every patient read and signed informed consent before surgery. Results: Mean operative time: 2.4 ± 0.7 hours (range 1.2-4.7 hours). Rate of conversions: 14.5% (20/138); intraoperative complications: 1.4% (2/138) and positive resection margins: 6.5% (9/138). Overall incidence of duodenal fistula: 3.6% (5/138). Rate of reoperation was 7.3% (10/138). Postoperative complications according to Clavien-Dindo classification: I 3.6% (5/138); II 13.0% (18/138); III 5.8% (8/138); III B 0.7% (1/138); V 1.4% (2/138). Overall survival with 60 months follow-up was 58%. Overall 60 months incidence of relapse was 44%. Patients with omentum preservation had a lower incidence of relapse than patients with omentectomy (40% versus 57% P = .002). Conclusions: Laparoscopic treatment of gastric cancer with D2 lymphadenectomy and omentum preservation is safe and feasible, both for EGC and for AGC. Although this study has limitations, omentum-preserving technique was associated with a statistically lower recurrence rate.

Intraoperative detection of circulating tumor cells in pulmonary venous blood during metastasectomy for colorectal lung metastases

Circulating tumor cells (CTC) have been studied extensively in various tumor types and are a well-established prognosticator in colorectal cancer (CRC). This is the first study to isolate CTC directly from the tumor outflow in secondary lung tumors. For this purpose in 24 patients with CRC who underwent pulmonary metastasectomy in curative intent blood was drawn intraoperatively from the pulmonary vein (tumor outflow). In 22 samples CTC-enumeration was performed using CellSieve-microfilters and immunohistochemical- and Giemsa-staining. Additionally 10 blood samples were analyzed using the CellSearch-System. We could isolate more CTC in pulmonary venous blood (total 41, range 0-15) than in samples taken from the periphery at the same time (total 6, range 0-5, p = 0.09). Tumor positive lymph nodes correlated with presence of CTC in pulmonary venous blood as in all cases CTC were present (p = 0.006). Our findings suggest a tumor cell release from pulmonary metastases in CRC and a correlation of CTC isolated from the tumor outflow with established negative prognostic markers in metastasized CRC. The presented data warrant further investigations regarding the significance of local tumor compartments when analyzing circulating markers and the possibility of tumor cell shedding from secondary lung tumors.

Applications of hyperthermic intraperitoneal chemotherapy for metastatic colorectal cancer

INTRODUCTION

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) plays a pivotal role in the current treatment of peritoneal carcinomatosis (PC) from colorectal cancer (CRC). Since the first demonstration, benefits for patients and especially an increase in survival have been described. In recent years, feasibility, efficacy and safety of HIPEC have been improved and progress has been made in understanding its oncological mechanism. Areas covered: In this article, leading publications have been reviewed including clinical trials to describe the clinical presentation of PC due to CRC and present recent evidence of the CRS/HIPEC procedure. The surgical approach including evaluation of the extent of PC is described and, in addition, the article reports about different HIPEC techniques as well as several protocols. Furthermore, the development and prognostic benefit of the combination of intraperitoneal and intravenous chemotherapy are outlined. Consideration has been given in particular to patient selection and the use of HIPEC if complete cytoreduction is not feasible. Expert commentary: The CRS/HIPEC procedure represents a curative approach to treat patients with PC from CRC. However, surgical skills and the HIPEC technique still require specialized oncological centers.

Detection of circulating tumor cells with CK20 RT-PCR is an independent negative prognostic marker in colon cancer patients - a prospective study

Background

Detection of circulating (CTC) or disseminated tumor cells (DTC) has been associated with negative prognosis and outcome in patients with colorectal cancer, though testing for these cells is not yet part of clinical routine. There are several different methodological approaches to detect tumor cells but standardized detection assays are not implemented so far.

Methods

In this prospective monocentric study 299 patients with colon cancer were included. CTC and DTC were detected using CK20 RT-PCR as well as immunocytochemistry staining with anti-pan-keratin and anti-EpCAM antibodies. The primary endpoints were: Evaluation of CTC and DTC at the time of surgery and correlation with main tumor characteristics and overall (OS) and disease free survival (DFS).

Results

Patients with detectable CTC had a 5-year OS rate of 68% compared to a 5-year OS rate of 85% in patients without detectable CTC in the blood (p = 0.002). Detection of DTC in the bone marrow with CK20 RT-PCR was not associated with a worse OS or DFS. Detection of pan-cytokeratin positive DTC in the bone marrow correlated with a significantly reduced 5-year OS rate (p = 0.048), but detection of DTC in the bone marrow with the anti-EpCAM antibody did not significantly influence the 5-year OS rate (p = 0.958). By multivariate analyses only detection of CTC with CK20 RT-PCR in the blood was revealed to be an independent predictor of worse OS (HR1.94; 95% CI 1.0–3.7; p = 0.04) and DFS (HR 1.94; 95% CI 1.1–3.7; p = 0.044).

Conclusions

Detection of CTC with CK20 RT-PCR is a highly specific and independent prognostic marker in colon cancer patients. Detection of DTC in the bone marrow with CK20 RT-PCR or immunohistochemistry with anti-EpCAM antibody is not associated with a negative prognostic influence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-3035-1) contains supplementary material, which is available to authorized users.

[No-touch pancreatectomy and radical antegrade modular pancreatosplenectomy: a systematic review]

AIM

To summarize the data of 'no-touch isolation technique' (NIT) for pancreatoduodenectomy and radical antegrade modular pancreato-splenectomy (RAMPS) for pancreatic malignancies.

MATERIAL AND METHODS

We looked through Pubmed and Cochrane databases for scientific papers published from January 2000 until September 2014.

RESULTS

Eight studies were included. There were 7 retrospective cohort studies and one randomized controlled trial (RCT). Mean operation time and blood loss were 267 min (198-386 min) and 132 ml (331-744 ml) respectively. Mean morbidity rate was 35% (17-58%). There was no 30-day mortality. Mean incidence of R0-resection varied from 50% to 97% with average value 84%. Median survival was reported in 3 studies (17, 18 and 26 months). Five-year actuarial overall survival was reported in 4 studies (31, 36, 40 and 53%).

CONCLUSION

Positive results of NIT and RAMPS might justify further evaluation of the method in pancreatic cancer. Prospective randomized controlled trials needs to be done to demonstrate the oncological value of this novel surgical technique.

Role of peritoneal lavage cytology and prediction of prognosis and peritoneal recurrence after curative surgery for colorectal cancer

Purpose

In colorectal cancer, the role of detecting free malignant cells from peritoneal lavage is currently unclear. In this study, we investigated the positive rate of free malignant cells in peritoneal lavage fluid and their predictive value for prognosis and peritoneal recurrence after a curative resection.

Methods

From October 2009 to December 2011, in a prospective manner, we performed cytologic examinations of peritoneal lavage fluid obtained just after the abdominal incision from 145 patients who underwent curative surgery for colorectal cancer. We used proportional hazard regression models to analyze the predictive role of positive cytology for peritoneal recurrence and survival.

Results

Among total 145 patients, six patients (4.1%) showed positive cytology. During the median follow-up of 32 months (range, 8-49 months), 27 patients (18.6%) developed recurrence. Among them, 5 patients (3.4%) showed peritoneal carcinomatosis. In the multivariate analysis, positive cytology was an independent predictive factor for peritoneal recurrence (hazard ratio [HR], 136.5; 95% confidence interval [CI], 12.2-1,531.9; P < 0.0001) and an independent poor prognostic factor for overall survival (HR, 11.4; 95% CI, 1.8-72.0; P = 0.009) and for disease-free survival (HR, 11.1; 95% CI, 3.4-35.8; P < 0.0001).

Conclusion

Positive cytology of peritoneal fluid was significantly associated with peritoneal recurrence and worse survival in patients undergoing curative surgery for colorectal cancer. Peritoneal cytology might be a useful tool for selecting patients who need intraperitoneal or systemic chemotherapy.

Molecular biomarkers for the detection of metastatic colorectal cancer cells

Approximately half of all patients with colorectal cancer develop local recurrence or distant metastasis during the course of their illness. Recently, the molecular detection of metastatic cancer cells in various types of clinical samples, such as lymph nodes, bone marrow, peripheral blood, and peritoneal lavage fluid, has been investigated as a potential prognostic marker. The prognostic value of molecular tumor cell detection was independent of the type of detection method used. As assays become more sensitive and quantitative, a more thorough assessment of the cancer status of patients will be based on molecular markers alone. At present, it is difficult to conclude that one specific molecular marker is superior to others. Comparative analyses are recommended to assess the prognostic impact of molecular analyses in the same patient and determine the biomarkers that provide the most accurate prognostic information.

Intra-operative peritoneal lavage for colorectal cancer

Free cancer cells can be detected in peritoneal fluid at the time of colorectal surgery. Peritoneal lavage in colorectal surgery for cancer is not used in routine, and the prognostic significance of intraperitoneal free cancer cells (IPCC) remains unclear. Data concerning the technique of peritoneal lavage to detect IPCC and its timing regarding colorectal resection are scarce. However, positive IPCC might be the first step of peritoneal spread in colorectal cancers, which could lead to early specific treatments. Because of the important heterogeneity of IPCC determination in reported studies, no treatment have been proposed to patients with positive IPCC. Herein, we provide an overview of IPCC detection and its impact on recurrence and survival, and we suggest further multi-institutional studies to evaluate new treatment strategies.

Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions

Debate on appropriate triggers for transfusion of allogeneic blood products and their effects on short- and long-term survival in surgical and critically ill patients continue with no definitive evidence or decisive resolution. Although transfusion-related immune modulation (TRIM) is well established, its influence on immune competence in the recipient and its effects on cancer recurrence after a curative resection remains controversial. An association between perioperative transfusion of allogeneic blood products and risk for recurrence has been shown in colorectal cancer in randomized trials; whether the same is true for other types of cancer remains to be determined. This article focuses on the laboratory, animal, and clinical evidence to date on the mechanistic understanding of inflammatory and immune-modulatory effects of blood products and their significance for recurrence in the cancer surgical patient.

Prognostic significance of isolated tumor cells in patients with colorectal cancer in recent 10-year studies

Circulating tumor cells (CTCs) that detach from the primary tumor and move into the circulation are detected in patients with metastatic cancer. The discovery of such cancer cells has been used as a predictor of recurrence and prognosis, although a consensus regarding such applications has not been reached. Peritoneal cytology may be used for identifying high risk of recurrence or mortality, whereas the intraoperative presence of tumor cells in drainage veins, bone marrow, or the liver is not always useful for evaluating the prognosis. The reported positive rate for tumor cells in the peripheral blood of patients with colorectal cancer, including metastasis, has varied from 10 to 80%; however, numerous studies have demonstrated significant differences in the recurrence and mortality rates between patients with and without isolated tumor cells (ITCs) in the peripheral blood. However, the clinical significance of CTCs as an absolute prognostic factor has not been elucidated, since the measurement methodologies and/or the number of cases differed between the studies. Future prospective studies including larger patient populations may elucidate the utility of routine detection of ITCs in daily practice.

Systematic review and meta-analysis of intraoperative peritoneal lavage for colorectal cancer staging

BACKGROUND

Intraperitoneal cancer cells are detectable at the time of colorectal cancer resection in some patients. The significance of this, particularly in patients with no other adverse prognostic features, is poorly defined. Consequently peritoneal lavage is not part of routine practice during colorectal cancer resection, in contrast with other abdominal malignancies. The aim of this systematic review was to determine the effect of positive intraoperative peritoneal cytology on cancer-specific outcomes in colorectal cancer.

METHODS

A systematic review of key electronic journal databases was undertaken using the search terms 'peritoneal cytology' and 'colorectal' from 1980 to 2012. Studies including patients with frank peritoneal metastasis were excluded. Meta-analysis for overall survival, local/peritoneal recurrence and overall recurrence was performed.

RESULTS

Twelve cohort studies (2580 patients) met the inclusion criteria. The weighted mean yield was 11·6 (range 2·2-41) per cent. Yield rates were dependent on timing of sampling (before resection, 11·8 per cent; after resection, 13·2 per cent) and detection methods used (cytopathology, 8·4 per cent; immunocytochemistry, 28·3 per cent; polymerase chain reaction, 14·5 per cent). Meta-analysis showed that positive peritoneal lavage predicted worse overall survival (odds ratio (OR) 4·26, 95 per cent confidence interval 2·86 to 6·36; P < 0·001), local/peritoneal recurrence (OR 6·57, 2·30 to 18·79; P < 0·001) and overall recurrence (OR 4·02, 2·24 to 7·22; P < 0·001).

CONCLUSION

Evidence of intraoperative peritoneal tumour cells at colorectal cancer resection is predictive of adverse cancer outcomes.

Prognostic significance of detection of microscopic peritoneal disease in colorectal cancer: a systematic review

BACKGROUND

Free intraperitoneal tumour cells are an independent indicator of poor prognosis, and are encorporated in current staging systems in upper gastrointestinal cancers, but not colorectal cancer. This systematic review aimed to evaluate the role and prognostic significance of positive peritoneal lavage in colorectal cancer.

METHODS

A search was undertaken of PUBMED/Medline and Cochrane databases for English language articles from 1990 to 2012 using a predefined search strategy. Both detection of free tumour cells and/or detection of tumour-associated antigens in peritoneal lavage fluid were considered a positive lavage. Primary endpoints were rates of positive lavage, recurrence and survival.

RESULTS

Of 3805 articles identified by title, 18 met inclusion criteria (n = 3197 patients, 59.5% colon, 40.5% rectal cancer). There was heterogeneity across studies in method of detection of peritoneal disease with 7 studies using more than one method (conventional cytology (14 studies), immunological techniques (6 studies), molecular techniques (4 studies)). The rate of positive lavage varied from 2.1% to 52% across studies, with a weighted mean rate of positive lavage of 13.17% overall (95% CI 12.74-13.59). In 10 studies (n = 2017) positive peritoneal lavage was associated with worse survival, and with increased recurrence in 12 (n = 2371). Clinicopathological factors frequently associated with positive lavage included macroscopic peritoneal disease, increasing tumour stage and nodal disease.

CONCLUSION

Positive peritoneal lavage is a negative prognostic factor in colorectal cancer. However, its utility in staging colorectal cancer is currently limited by wide variation in rates of positive lavage between studies due to differences in methods of peritoneal lavage fluid analysis.

HIPEC in T4a colon cancer: a defendable treatment to improve oncologic outcome?

BACKGROUND

Adequate estimation of the potential benefits of 'adjuvant' hyperthermia and intraperitoneal chemotherapy (HIPEC) in T4 patients through assessment of the burden of peritoneal carcinomatosis (PC) in T4 tumors and the risk of PC as the only metastatic site.

PATIENTS AND METHODS

Analysis of prospectively collected data on patients who underwent surgery for colon cancer (Jan 2004-Jan 2007).

RESULTS

About 379 patients (M/F = 204/175) were included, with a median age of 71.8 years (range 35.4-95.0): 39 stage I, 126 stage II, 89 stage III, 116 stage IV disease (+9 with unknown stage). The median follow-up was 34.8months [range 0.0-79.4]. The 3- and 5-year overall survival rates (OS) were 68.4% (95% confidence interval (CI) 63.9%-72.4%) and 60.3% (95%CI 55.6%-64.7%). Relapse analysis was restricted to stages II-III T3 (N = 154) and T4 tumors (N = 19) with complete relapse data, of which 13.2% developed PC. PC has a detrimental effect on OS [HR 6.3 (95%CI: 3.1-13.0, P < 0.0001)]. 50% of T4a and 20% of T4b developed PC. The 1- and 3-year PC percentage was significantly lower for T3 (4.5% and 9.3%) than T4 tumors (15.6% and 36.7%) (P = 0.008). PC was the only metastatic site in 3/15 T3 [proportion 0.20, 95%CI (0.043-0.481)] and 5/8 T4 tumors with PC [proportion 0.625, 95%CI (0.245-0.915)] (P = 0.071).

CONCLUSIONS

T4a colon tumors have a significantly higher risk of developing PC. Twenty-five percent (5/19) of stages II-III T4 tumors develop PC as the only metastatic site. This could define the possible window of opportunity for adjuvant HIPEC to prevent PC.

[Perioperative tumour dissemination. 1. Influence of perioperative factors]

There has been growing concern in the last few years on the effect of anaesthetic drugs used during oncological surgery could have on tumour progression in the long-term, as well as the influence of other perioperative factors. Although much of the available data has weak evidence, the role of the surgery itself, pain, transfusion of blood derivatives, etc., have been assessed in several studies. How some substances used during the anaesthetic process can influence tumour immune surveillance, cell proliferation or tumour angiogenesis processes have been observed in laboratory studies. The possible relevance of the anaesthetic technique used as regards the long-term tumour progression and survival is still to be determined. However, based on retrospective studies, it seems that those anaesthetic techniques combined with the use of regional anaesthesia and analgesia could be beneficial compared to those that are maintained on opioid use. Further research should help to elucidate the long-term clinical relevance of the perioperative procedures, including the anaesthetic, during oncological surgery.

Biology and significance of circulating and disseminated tumour cells in colorectal cancer

PURPOSE

More than 130 years ago, circulating tumour cells (CTCs) and disseminated tumour cells (DTCs) have been linked to metastasis. Since then, a myriad of studies attempted to characterise and elucidate the clinical impact of CTCs/DTCs, amongst others in colorectal cancer (CRC). Due to a flood of heterogeneous findings regarding CTCs/DTCs in CRC, this review aims to describe the known facts about CTC/DTC biology and clinical impact.

METHODS

To identify the basic scientific literature regarding the biology and clinical impact of CTCs/DTCs in CRC, we reviewed the literature in the PubMed database. We focused on publications written in English and published until January 2012. As search terms, we used "colorectal cancer (CRC)", "colon cancer (CC)", "CTC", "DTC", "bone marrow (BM)", "lymph node (LN)", "peripheral blood (PB)", "significance" and "prognosis".

RESULTS

CTC detection and quantification under standardised conditions is feasible. Several studies in large patient settings have revealed prognostic impact of CTCs in CRC. CRC-derived DTC detection and analysis in BM exhibits a more heterogeneous picture but also shows clinical value. Furthermore, the presence of DTCs in LN has a strong prognostic impact in CRC.

CONCLUSIONS

Clinical relevance and prognostic significance of CTCs/DTCs in CRC have been clearly demonstrated in many experimental studies. The major challenge in CTC/DTC research is now to harmonise the various identification and detection approaches and consequently to conduct large prospective multi-institutional trials to verify the use of CTCs/DTCs as a valid prognostic and predictive biomarker for clinical routine.

Comparative study of complete and partial omentectomy in radical subtotal gastrectomy for early gastric cancer

PURPOSE

Curative surgery for patients with advanced or even early gastric cancer can be defined as resection of the stomach and dissection of the first and second level lymph nodes, including the greater omentum. The aim of this study was to evaluate the short- and long- term outcomes of partial omentectomy (PO) as compared with complete omentectomy (CO).

MATERIALS AND METHODS

Seventeen consecutive open distal gastrectomies with POs were initially performed between February and July in 2006. The patients' clinicopathologic data and post-operative outcomes were retrospectively compared with 20 patients who underwent open distal gastrectomies with COs for early gastric cancer in 2005.

RESULTS

The operation time in PO group was significantly shorter than that in CO group (142.4 minutes vs. 165.0 minutes, p=0.018). The serum albumin concentration on the first post-operative day in PO group was significantly higher than CO group (3.8 g/dL vs. 3.5 g/dL, p=0.018). Three postoperative minor complications were successfully managed with conservative treatment. Median follow-up period between PO and CO was 38.1 and 37.7 months. All patients were alive without recurrence until December 30, 2009.

CONCLUSION

PO during open radical distal gastrectomy can be considered a more useful procedure than CO for treating early gastric cancer. To document the long-term technical and oncologic safety of this procedure, a large-scale prospective randomized trial will be needed.

Expression of chemokine receptor CCR5 correlates with the presence of hepatic molecular metastases in K-ras positive human colorectal cancer

BACKGROUND

Molecular metastases are precursors of postoperative recurrence, detected by molecular-biological tools. Chemokines and their receptors contribute to dissemination and local immune recognition. A strong expression of the chemokine receptor CCR5 is associated with non-metastatic colorectal cancer and increased CD8+ T-cell infiltration. The aim of this study was to analyze whether CCR5 expression correlates with the presence of hepatic molecular metastases (MM).

METHODS

Ninety-three patients undergoing elective surgery for colorectal cancer were assessed. The K-ras mutation status was defined by PCR-RFLP, and the CCR5 expression status was analyzed by CCR5-specific reverse transcription (RT-PCR) analysis. Liver biopsy samples had been intra-operatively taken to screen for MM. MM were detected by K-ras-specific PCR-RFLP and nested CK20/GCC RT-PCR. Prevalence of MM was correlated with CCR5 expression status.

RESULTS

Human colorectal cancer harboured K-ras mutations in 53% (codon 12: 47%; codon 13: 6%) of cases. Among K-ras mutants, MM were detected in 27-53% of patients, dependent on the technique applied (K-ras-specific PCR-RFLP assay vs. nested CK20/GCC RT-PCR approach (P = 0.004)). CCR5 expression of K-ras mutants ranged from absent (23/49: 47%), weak (17/49: 35%), intermediate (4/49: 8%) to strong (5/49: 10%). MM were found in 30% of CCR5 negative and in 23% of CCR5 positive cancer patients by the K-ras-specific PCR-RFLP assay. The nested CK20/GCC RT-PCR assay detected MM in 87% of CCR5 negative and in 27% of CCR5 positive colorectal cancer patients (P = 0.00002).

CONCLUSION

Thus, CCR5 expression of the primary cancer might be a valuable biomarker indicating the absence of hepatic molecular metastases.

Effects of intraperitoneal chemotherapy with mitomycin C on the prevention of peritoneal recurrence in colorectal cancer patients with positive peritoneal lavage cytology findings

BACKGROUND

The detection of intraperitoneal free cancer cells in colorectal cancer (CRC) patients is associated with a poorer prognosis. The aim of this study was to investigate the effects of intraperitoneal chemotherapy (IPC) with mitomycin C (MMC) on preventing peritoneal recurrence in CRC patients with positive peritoneal lavage cytology findings.

METHODS

A total of 52 CRC patients who had no clinically confirmed peritoneal dissemination and whose status of peritoneal lavage cytology was positive were investigated. Conventional peritoneal lavage cytology was performed. Overall, 31 of the 52 patients (59.6%) were administered IPC with MMC. Before closure of the abdomen, 4 silicon catheters were inserted into peritoneal cavity. After closure, the perfusate (diluting 20 mg MMC with 500 ml saline) was instilled from the catheter, and all catheters were clumped. All catheters were opened 1 h later.

RESULTS

The mean follow-up period was 83.1 months. According to univariate analyses of all 52 patients and the subgroup of 36 patients with stage II or III tumors, patients with IPC had a significantly better peritoneal recurrence-free survival and cancer-specific survival than patients who did not receive IPC (P < 0.005). In multivariate analysis, IPC remained an independent prognostic factor for peritoneal recurrence-free survival in all patients.

CONCLUSIONS

It appears that IPC with MMC is an effective treatment to prevent peritoneal recurrence and prolong the cancer-specific survival in CRC patients without peritoneal dissemination, but who have positive peritoneal lavage cytology. It is necessary to verify the effectiveness of IPC with MMC in a prospective trial.

Prognostic significance of circulating tumour cells following surgical resection of colorectal cancers: a systematic review

Background:

The role of adjuvant chemotherapy after resection of colorectal cancers (CRCs) is well understood for patients with stage-I or stage-III disease. Its efficacy for those with stage-II disease remains much less clear. Many investigators have sought to identify prognostic markers that might clarify which patients have the highest risk of recurrence and would, therefore, be most likely to benefit from chemotherapy. This systematic review examines evidence for the use of peripherally sampled, circulating tumour cells (CTCs) as such a prognostic marker.

Methods:

A comprehensive literature search was used to identify studies reporting on the significance of CTCs in the postoperative blood of CRC patients.

Results:

Fourteen studies satisfied the inclusion criteria. Six of the nine studies that took blood samples 24 h or more postoperatively found detection of postoperative CTCs to be an independent predictor of cancer recurrence.

Conclusion:

The presence of CTCs in peripheral blood at least 24 h after resection of CRCs is an independent prognostic marker of recurrence. Further studies are needed to clarify the optimal time point for blood sampling and determine the benefit of chemotherapy in CTC-positive patients with stage-II disease.

Noncolonic cancer stem cells in bone marrow of colorectal cancer patients

OBJECTIVE

To investigate whether preoperative noncolonic cancer stem cells in bone marrow (BM) of R0 colorectal cancer (CRC) patients are cancer cells and impact on liver metastases (LM) rates.

METHOD

Prospective data on continuous CRC patients were collected from five centres. Bone marrow aspirates, taken at laparotomy, were sent to a single lab. Noncolonic cancer stem cells were defined according to UICC. A quantity of 3 x 10(6) BM cells per patient was processed with monoclonal antibodies against cytokeratin 20. APC or p53 gene mutation and microsatellite instability (MSI) were assessed in primary tumours (PT) by single-strand conformation polymorphism. Noncolonic cancer stem cells in BM of PT mutation or MSI-positive patients were isolated with immunobeads coated with magnetically labelled anti-human epithelial antigen antibody and DNA-screened for mutations.

RESULTS

Although 199 patients were enrolled, 162 patients were available for analysis. No patients were lost to follow-up. Twenty-five (2-170) noncolonic cancer stem cells were found in BM of 40 patients. Twenty-two patients developed LM at 36-month follow-up. Adenomatous polyposis coli (APC) or p53 gene mutation or MSI were identified in the PT of 78 patients. The same gene mutations or MSI were not found in noncolonic cancer stem cells of the BM of these patients. After adjustment, there was no significant effect of confounding factors. Noncolonic cancer stem cells in BM had no impact on LM rates, cancer-specific death rates, or all death rates.

CONCLUSIONS

Preoperative noncolonic cancer stem cells in BM of R0 CRC patients were not cancer cells and had no impact on LM rates.

Circulating tumor cells: evolving evidence and future challenges

Circulating tumor cells (CTCs) are rare malignant cells found in the peripheral blood that originate from the primary tumor or metastatic sites. New techniques have been developed to isolate and characterize these cells. CTC enumeration has been incorporated into different fields of oncology as a prognostic marker, a tool to monitor therapy response, and a method to understand basic tumor characteristics. This review covers the different techniques available for isolation of CTCs, the clinical utility of CTCs in breast, prostate, and colon cancer, and future directions in this field.

Evaluation of intraperitoneal lavage cytology before colorectal cancer resection

PURPOSE

The aim of this study was to assess the usefulness of intraperitoneal lavage cytology (lavage Cy) status before the resection of colorectal cancer as a predictive factor of peritoneal recurrence.

MATERIALS AND METHODS

The lavage Cy-positive [lavage Cy (+)] rate, peritoneal recurrence rate, and 5-year survival rate were examined in 298 cases of colorectal cancer in relation to various clinicopathological factors.

RESULTS

The overall lavage Cy (+) rate was 6.0%. The lavage Cy (+) rate within the group with peritoneal and hepatic metastases was significantly higher than that in the group without metastases (46.7% vs. 3.9% and 26.9% vs. 4.0%, respectively). The lavage Cy (+) rate was not significantly associated with any of the clinicopathological factors examined. The peritoneal recurrence rate was higher in the lavage Cy (+) group than in the lavage Cy-negative [lavage Cy (-)] group, although the difference was not statistically significant. There was no significant difference in survival, regardless of the lavage Cy status, among the 263 patients who underwent curative resection.

CONCLUSION

The lavage Cy status before resection was not a useful predictive factor of peritoneal recurrence in cases of colorectal cancer.

Long-term prognostic value of conventional peritoneal lavage cytology in patients undergoing curative colorectal cancer resection

PURPOSE

Free malignant cells in the peritoneal cavity might play a role in the metastasis process. However, this phenomenon needs further elucidation. The aims of this study were to investigate the frequency of free cancer cells detected on cytologic examination of lavage fluid after peritoneal washing in patients undergoing curative surgery for colorectal cancer, to explore risk factors for exfoliation of cancer cells into the peritoneal cavity, and to evaluate the influence peritoneal lavage cytology as a prognostic tool.

METHODS

Peritoneal lavage was performed in 697 patients undergoing curative resection of colorectal cancer. Before the manipulation of the tumor, 100 mL of physiologic saline solution was administered into the abdominal cavity and the fluid was collected for cytologic examination. Specimens were classified as positive if at least one cancer cell was detected.

RESULTS

The mean follow-up period was 90.5 months. Overall, 15 (2.2%) of the 697 patients had positive results. Four characteristics were identified as risk factors for exfoliation of cancer cells into the peritoneal cavity: 1) depth of invasion, 2) regional lymph nodes, 3) lymphatic invasion, and 4) venous invasion. In univariate analyses of all 697 patients and the subgroup of 374 patients with pT3 or T4 tumors, patients with positive cytology findings had significantly worse disease-free and cancer-specific survival than patients with negative cytology findings (P < 0.001). On multivariate analysis, peritoneal cytology remained an independent predictor of cancer-specific survival in all patients and in patients with pT3 or pT4 tumors. Only peritoneal cytology was a significant prognostic factor for peritoneal recurrence (P < 0.0001).

CONCLUSION

Conventional peritoneal cytology is a useful prognostic tool in patients undergoing curative surgery for colorectal cancer and may be helpful in making decisions whether to select intraperitoneal or systemic chemotherapy.

Circulating tumour cells during laparoscopic and open surgery for primary colonic cancer in portal and peripheral blood

BACKGROUND

The objective of this study was to detect and quantify circulating tumour cells (CTC) in peripheral and portal blood of patients who had open or laparoscopic surgery for primary colonic cancer.

METHODS

Patients in the laparoscopic-group were operated on in a medial to lateral approach ("vessels first"), in the open-group a lateral to medial approach was applied. The enumeration of CTC was performed with the CellSearch System. Intra-operative samples were taken paired-wise (from peripheral and portal circulation) directly after entering the abdominal cavity (T1), after mobilisation of the tumour baring segment (T2), and after tumour resection (T3). Ploidy of both the CTC and tissue of the primary tumour was determined for chromosome 1, 7, 8 and 17.

RESULTS

Thirty-one patients were included; 18 patients had open surgery, 13 patients were operated on laparoscopically. The percentage of samples with CTC at T1 was 7% in peripheral blood and 54% in portal blood (p=0.002). At T2, 4% and 31% respectively (p=0.031). And at T3, 4% and 26% respectively (p=0.125). The cumulative percentage of samples with CTC was significantly higher during open surgery as compared to the laparoscopic approach. Both the CTC and tissue of the primary tumour were diploid for chromosome 1, 7, 8 and 17.

CONCLUSION

The detection rate and quantity of CTC is significantly increased intra-operatively and is significantly higher in portal blood compared to peripheral blood. Significantly less CTC were detected during laparoscopic surgery probably as result of the medial to lateral approach.

DETECTION OF DISSEMINATED TUMOR CELLS IN PERIPHERAL BLOOD

Metastases are the major cause of cancer-related deaths in patients with solid epithelial malignancies, such as breast, colorectal and prostate carcinomas. Hematogenous spreading of tumor cells from a primary tumor can be considered as a crucial step in the metastasis cascade leading eventually to the formation of clinically manifest metastases. Consequently, as shown in recent studies, the detection of disseminated tumor cells in peripheral blood might be of clinical relevance with respect to individual patient prognosis and staging or monitoring of therapy. However, the rarity of disseminated tumor cells in peripheral blood renders the application of sensitive techniques mandatory for their detection. The emergence of highly sophisticated reverse transciptase-polymerase chain reaction (RT-PCR) assays, combining a preanalytical enrichment step with the assessment of multiple molecular tumor markers expressed in disseminated tumor cells, provides a powerful tool in detecting disseminated tumor cells with high sensitivity and specificity. This review will discuss currently used tumor markers as well as experimental means to enhance the sensitivity and specificity of RT-PCR assays to detect disseminated tumor cells in the peripheral blood of patients with breast, colorectal, and prostate cancers, and their clinical relevance assessed in recent studies.

Persistent presence of postoperative circulating tumor cells is a poor prognostic factor for patients with stage I-III colorectal cancer after curative resection

AIM

To detect pre- and postoperative circulating tumor cells (CTCs) in stage I-III colorectal cancer (CRC) patients undergoing curative resection and so identify a subgroup of patients who are at high risk for relapse.

METHODS

Four mRNA molecular markers including human telomerase reverse transcriptase, cytokeratin-19, cytokeratin-20, and carcinoembryonic antigen mRNA were used to detect CTCs in 438 CRC patients underwent curative resection.

RESULTS

Out of 438 patients, 80 CRC patients were classified to preoperative (-)/postoperative (-), 221 patients were preoperative (+)/postoperative (-), while 137 patients were preoperative (+)/postoperative (+). Univariately, postoperative relapse was significantly correlated with depth of invasion (P = 0.032), lymph node metastasis (P < 0.001), vascular invasion (P = 0.001), perineural invasion (P = 0.013), and persistent presence of CTCs (P < 0.001). Using a multivariate proportional hazards regression analysis, the presence of lymph node metastasis (P = 0.012; HR, 7.652; 95% CI: 4.162-14.827), vascular invasion (P = 0.033; HR, 4.360; 95% CI: 2.793-10.847), and the persistent presence of CTCs (P < 0.001; HR, 29.486; 95% CI: 10.281-87.792) were demonstrated to be independent predictors for postoperative relapse. Combination of these three independent predictors showed that patients with any one positive predictor had a hazard ratio of sevenfold to develop postoperative relapse (P < 0.001; HR, 7.064; 95% CI: 4.354-11.464). Furthermore, the persistent presence of CTCs was strongly correlated with poorer relapse-free survival rates (all P < 0.001).

CONCLUSION

The promising results of this study suggest that persistent presence of postoperative CTCs may be a crucial prognostic factor adjuvant to conventional tumor markers in CRC patients who have undergone curative resection. Identification of these high-risk patients of persistent CTCs positivity is important and thus could help to define patients for adjuvant therapy with this tumor entity.

Prognostic significance of multiple molecular markers for patients with stage II colorectal cancer undergoing curative resection

OBJECTIVE

The aim of this study was to determine whether our constructed high-sensitivity colorimetric membrane-array method could detect circulating tumor cells (CTCs) in the peripheral blood of stage II colorectal cancer (CRC) patients and so identify a subgroup of patients who are at high risk for relapse.

SUMMARY BACKGROUND DATA

Adjuvant chemotherapy is not routinely recommended in patients diagnosed with UICC stage II CRC. However, up to 30% of patients with stage II disease relapse within 5 years of surgery from recurrent or metastatic disease. The identification of reliable prognostic factors for high-risk stage II CRC patients is imperative.

METHODS

Membrane-arrays consisting of a panel of mRNA markers that included human telomerase reverse transcription (hTERT), cytokeratin-19 (CK-19), cytokeratin-20 (CK-20), and carcinoembryonic antigen (CEA) mRNA were used to detect CTCs in the peripheral blood of 194 stage II CRC patients who underwent potentially curative (R0) resection between January 2002 and December 2005. Digoxigenin (DIG)-labeled cDNA were amplified by RT-PCR from the peripheral blood samples, which were then hybridized to the membrane-array. All patients were followed up regularly, and their outcomes were investigated completely.

RESULTS

Overall, 53 of 194 (27.3%) stage II patients were detected with the expression of all 4 mRNA markers using the membrane-array method. After a median follow up of 40 months, 56 of 194 (28.9%) developed recurrence/metastases postoperatively. Univariately, postoperative relapse was significantly correlated with the depth of invasion (P < 0.001), the presence of vascular invasion (P < 0.001), the presence of perineural invasion (P = 0.048), the expression of all 4 mRNA markers (P < 0.001), and the number of examined lymph nodes (P = 0.031). Meanwhile, using a multivariate logistic regression analysis, T4 depth of tumor invasion (P = 0.013), the presence of vascular invasion (P = 0.032), and the expression of all 4 mRNA markers (P < 0.001) were demonstrated to be independent predictors for postoperative relapse. Combination of the depth of tumor invasion, vascular invasion, and all 4 mRNA markers as predictors of postoperative relapse showed that patients with any 1 positive predictor had a hazard ratio of about 27-fold to develop postoperative relapse (P < 0.001; 95% CI = 11.42-64.40). The interval between the detection of all 4 positive molecular markers and subsequently developed postoperative relapse ranged from 4 to 10 months (median: 7 months). Furthermore, the expression of all 4 mRNA markers in all stage II CRC patients, or either stage II colon or rectal cancer patients were strongly correlated with poorer relapse-free survival rates by survival analyses (all P < 0.001).

CONCLUSIONS

The pilot study suggests that the constructed membrane-array method for the detection of CTCs is a potential auxiliary tool to conventional clinicopathological variables for the prediction of postoperative relapse in stage II CRC patients who have undergone curative resection.

Can intra-operative intraperitoneal free cancer cell detection techniques identify patients at higher recurrence risk following curative colorectal cancer resection: a meta-analysis

BACKGROUND

Accurate staging of colorectal cancer is important for predicting prognosis and guiding treatment. This study uses meta-analysis to investigate if the pre- or post-resection detection of intraperitoneal free cancer cells can predict recurrence in patients undergoing curative colorectal cancer surgery.

METHODS

A literature search was performed on all studies between January 1990 and July 2007 comparing the detection of intraperitoneal free cancer cells either pre- or post-resection with prognosis in colorectal cancer. The following prognostic outcomes were meta-analyzed: overall recurrence rate and local recurrence rate. A random-effect model was used and heterogeneity was assessed.

RESULTS

Nine studies reporting on a total of 1182 subjects matched the selection criteria. Free cancer cells were detected prior to tumor resection in 125/822 (15.2%) of patients and following resection in 64/533 (12%) of patients. Preresection, the absence of tumor cells was associated with a lower overall recurrence (25.2%) compared to the presence of tumor cells [46.4%, odds ratio (OR) = 0.41, confidence interval (CI) 0.19-0.88]; as well as a significantly lower local recurrence (12.2% versus 21.1%, OR = 0.42, CI 0.21-0.82). Postresection, the absence of tumor cells also resulted in significantly lower overall recurrence (17.3%) when compared to the presence of tumor cells (52.6%, OR = 0.07, CI 0.03-0.18).

CONCLUSIONS

The detection of intraperitoneal free cancer cells is associated with higher recurrence and poorer prognosis. Use of these techniques can identify patients at higher recurrence risk. This could be particularly valuable in stage II disease to identify patients who may benefit from adjuvant chemotherapy.

Comparative analysis of intraperitoneal minimal free cancer cells between colorectal and gastric cancer patients using quantitative RT-PCR: possible reason for rare peritoneal recurrence in colorectal cancer

Peritoneal recurrence has a much lower incidence in colorectal cancer (CRC) patients than gastric cancer (GC) patients. The aim of this study is to clarify the reason for the rare peritoneal recurrence in CRC as compared with GC. The incidence and the abundance of free tumor cells in the peritoneal lavages from 102 CRC and 126 GC patients who underwent curative surgery were assessed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) with carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) as genetic markers. Prognostic significance of CEA and CK20 mRNA was also compared between CRC and GC after 2 years of follow-up by Kaplan-Meyer method with overall and peritoneal recurrence-free survival as endpoints. Positivity rate and average values of CEA and CK20 mRNA in peritoneal lavages of CRC patients, which are correlated to the depth of tumor invasion (pT category), were essentially the same as those of GC cases. Overall survival was significantly (marginally) worse in CEA mRNA (CK20 mRNA)-positive CRC patients than negatives like GC. However, peritoneal recurrence-free survival was not different between CEA (CK20) mRNA-positive and -negative CRC patients, in quite contrast to GC cases. Multivariate analysis showed that CEA mRNA was an independent prognostic factor for overall survival in GC patients, but not in CRC patients. These results suggest that the rare peritoneal recurrence in CRC patients is not due to the low incidence or the small number of intraperitoneal free cancer cells, but more likely reflects due to the low-peritoneal metastatic potential of CRC cells.

Increased detection rate and potential prognostic impact of disseminated tumor cells in patients undergoing endorectal ultrasound for rectal cancer

BACKGROUND

Hematogenous tumor-cell dissemination during diagnostic and therapeutic procedures in patients with colorectal cancer has been demonstrated.

OBJECTIVE

The aim of this study was to investigate the extent of disseminated tumor cells in blood samples of rectal cancer patients after endorectal ultrasound and to determine its prognostic relevance.

MATERIALS AND METHODS

Peripheral venous blood samples from 45 patients with rectal cancer were taken before and after endorectal ultrasound. Blood samples were examined using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay to amplify cytokeratin 20 transcripts. Overall survival of the patients was calculated by the Kaplan-Meier method.

RESULTS

Disseminated tumor cells were detected in peripheral blood samples of 17 of 45 (38%) patients before and after endorectal ultrasound. Circulating tumor cells were found in 11 of 45 (24%) patients only after endorectal ultrasound (p=0.006). There was a clear trend toward a worse prognosis in patients with tumor cells in blood samples after endorectal ultrasound, but this difference was not statistically significant.

CONCLUSION

This study demonstrates significantly increased hematogenous tumor-cell dissemination after endorectal ultrasound in rectal cancer patients. Patients with tumor cells in blood samples after endorectal ultrasound tend to have a worse prognosis. The potential prognostic impact of this finding is presently unclear and has to be further validated in larger clinical trials.

Disseminated tumor cells in peripheral blood: a novel marker for therapy response in locally advanced rectal cancer patients undergoing preoperative chemoradiation

PURPOSE

This study was designed to examine whether disseminated tumor cells in peripheral blood of locally advanced rectal cancer patients undergoing preoperative chemoradiation have the potential to serve as a marker for therapy response. Studies suggest that patients with advanced rectal cancer who respond to preoperative chemoradiation most likely benefit from this treatment.

METHODS

From advanced rectal cancer patients undergoing preoperative chemoradiation, peripheral blood was obtained at defined times: before, during, and after chemoradiation and during surgery. Patients were divided into histopathologic responders (ypT0-T2) and nonresponders (ypT3-T4). Cytokeratin 20 and carcinoembryonic antigen reverse transcriptase-polymerase chain reaction were performed to detect disseminated tumor cells. A blood sample was deemed positive for disseminated tumor cells if both carcinoembryonic antigen and cytokeratin 20 were detected.

RESULTS

The overall population (n = 26) showed a positivity rate of 32 percent for disseminated tumor cells before initiation of chemoradiation. Of the responders (n = 8), 63 percent were positive for disseminated tumor cells before chemoradiation, whereas only 18 percent of nonresponders (n = 18) were positive (P = 0.026). From initiation of chemoradiation to the end of surgery, a significant decrease was seen in tumor cell positivity in the blood of responders (P = 0.042). Moreover, the responders represented a trend toward a decrease in tumor cell positivity during chemoradiation (P = 0.079). In contrast, there were no noticeable alterations within the treatment course in nonresponders.

CONCLUSIONS

This prospective proof of principle study demonstrates that locally advanced rectal cancer with preoperative chemoradiation shows different biologic behavior in terms of tumor cell dissemination in peripheral blood when therapy responders compared with nonresponders.

Insufficient ability of omental milky spots to prevent peritoneal tumor outgrowth supports omentectomy in minimal residual disease

BACKGROUND

The greater omentum is frequently involved in the course of gastrointestinal and ovarian tumors. Therefore, common practice in surgical treatment for especially gastric and ovarian cancer includes removal of the greater omentum. Paradoxically, many immune cells, such as macrophages that accumulate in so-called milky spots, reside within the omentum and are cytotoxic against tumor cells ex vivo. Consequently, omental macrophages might play an important role in killing tumor cells, and may hereby prevent development into local peritoneal recurrences. In the present study, we therefore evaluated the role of the omentum and the clinical relevance of omentectomy in minimal residual disease (MRD).

METHODS

Tumor cell dissemination patterns on the omentum in a rat model were examined using DiI-labelled CC531s tumor cells. Additionally, intra peritoneal (i.p.) tumor load was investigated in rats that underwent omentectomy or sham laparotomy followed by i.p. injection of CC531s cells on day 21, which represented MRD.

RESULTS

At 4 h post injection, tumor cells predominantly adhered on milky spots. Number of cells thereafter declined rapidly suggesting initial tumor killing functions in these specific immune aggregates. Despite initial reduction observed in milky spots, numbers of tumor cells however increased at fatty tissue stripes that border the omentum. This indicated proliferation at these locations, which corresponded to macroscopic observations of the omenta on day 21 after tumor cell injection. Omentectomy resulted in reduced intra-abdominal tumor load, which was completely attributable to the absence of the omentum, as tumor development did not differ on other sites. Even in the MRD group microscopic clusters of tumor cells located in the omentum eventually developed into macroscopic nodules.

CONCLUSION

Since the ability of omental milky spots is, even in MRD, insufficient to prevent intra abdominal tumor outgrowth, omentectomy, which reduces tumor load, is recommended in surgical treatment of intra abdominal tumors that are prone to disseminate intraperitoneally.

Prognostic impact of hematogenous tumor cell dissemination in patients with stage II colorectal cancer

Adjuvant chemotherapy is not routinely recommended in patients with colorectal cancer stage UICC II. Some of these patients, however, develop recurrent disease. Therefore, valid prognostic criteria are needed to identify high-risk patients who might benefit from adjuvant therapy. Disseminated tumor cells, detected in blood and bone marrow, may prove to be a valid marker, however, the prognostic relevance of these cells remains debated. In our study, we examined the prognostic significance of disseminated tumor cells in blood and bone marrow of patients with stage II colorectal cancer. Ninety patients with potentially curative (R0) resection of colorectal cancer stage II were prospectively enrolled into the study. Bone marrow and blood samples were examined for disseminated tumor cells by CK 20 RT-PCR. Patient, tumor and treatment factors were analyzed as prognostic factors. Multivariate analysis confirmed tumor cell detection in blood (hazard ratio 2.1, p = 0.03) and T-category (hazard ratio 2.2, p = 0.02) to be independent prognostic factors for relapse-free survival. Tumor cell detection in postoperative blood samples (hazard ratio 7.7, p < 0.001) and number of removed lymph nodes (hazard ratio 6.4, p < 0.001) were independent prognostic factors for disease-specific survival. Detection of circulating tumor cells in blood samples of patients with stage II colorectal cancer identifies patients with poor outcome. This finding should be confirmed by further studies and could then be used as a basis for conducting a randomized trial evaluating the effect of adjuvant chemotherapy in stage II patients.