Clinical characteristics of synchronous colorectal cancer are different according to tumour location

Oncologic relevance of genetic alterations in sporadic synchronous and solitary colorectal cancer: a retrospective multicenter study

BACKGROUND

Oncologic impact of genetic alteration across synchronous colorectal cancer (CRC) still remains unclear. This study aimed to compare the oncologic relevance according to genetic alteration between synchronous and solitary CRC with performing systematic review.

METHODS

Multicenter retrospective analysis was performed for CRC patients with curative resection. Genetic profiling was consisted of microsatellite instability (MSI) testing, RAS (K-ras, and N-ras), and BRAF (v-Raf murine sarcoma viral oncogene homolog B1) V600E mutation. Multivariate analyses were conducted using logistic regression for synchronicity, and Cox proportional hazard model with stage-adjusting for overall survival (OS) and disease-free survival (DFS).

RESULTS

It was identified synchronous (n = 36) and solitary (n = 579) CRC with similar base line characteristics. RAS mutation was associated to synchronous CRC with no relations of MSI and BRAF. During median follow up of 77.8 month, Kaplan-meier curves showed significant differences according to MSI-high for OS, and in RAS, and BRAF mutation for DFS, respectively. In multivariable analyses, RAS and BRAF mutation were independent factors (RAS, HR = 1.808, 95% CI = 1.18-2.77, p = 0.007; BRAF, HR = 2.417, 95% CI = 1.32-4.41, p = 0.004). Old age was independent factor for OS (HR = 3.626, 95% CI = 1.09-12.00, p = 0.035).

CONCLUSION

This study showed that oncologic outcomes might differ according to mutation burden characterized by RAS, BRAF, and MSI between synchronous CRC and solitary CRC. In addition, our systematic review highlighted a lack of data and much heterogeneity in genetic characteristics and survival outcomes of synchronous CRC relative to that of solitary CRC.

In-Situ-Sprayed Dual-Functional Immunotherapeutic Gel for Colorectal Cancer Postsurgical Treatment

Surgery remains the most preferred treatment options for colorectal cancer (CRC). Paradoxically, local recurrence and distant metastasis are usually accelerated postsurgery as a consequence of local and systemic immunosuppression caused by surgery. Therefore, modulating tumor postoperative immune microenvironment and activating systemic antitumor immunity are necessary supplementaries for CRC therapy. Here, an in-situ-sprayed immunotherapeutic gel loaded with anti-OX40 antibody (iSGels@aOX40) is reported for CRC postsurgical treatment. The iSGel is formed instantly after spraying with strong adhesion ability via crosslinking between tannic acid (TA) and poly(l-glutamic acid)-g-methoxy poly(ethylene glycol)/phenyl boronic acid (PLG-g-mPEG/PBA). TA not only serves as one component of the iSGel but also relieves the postsurgical immunosuppressive microenvironment by inhibiting the activity of cyclo-oxygenase-2 (COX-2). The aOX40 serves as an immune agonistic antibody and is released from the iSGel in a constant manner lasting for over 20 days. In a subcutaneous murine CRC model, the iSGels@aOX40 results in complete inhibition on tumor recurrence. In addition, the cured mice show resistance to tumor re-challenge, suggesting that immune memory effects are established after the iSGels@aOX40 treatment. In an orthotopic CRC peritoneal metastatic model, the iSGels@aOX40 also remarkably inhibits the growth of the abdominal metastatic tumors, suggesting great potential for clinical CRC therapy.

Three colonic cancers, two sites of complete occlusion, one patient: A case report

BACKGROUND

Synchronous colonic cancer incidence is uncommon, and awareness about this rare condition is improved recently. However, in the presence of acute colonic obstruction, investigation and management of synchronous colonic cancer can be difficult and challenging.

CASE SUMMARY

A patient presented with acute colonic obstruction with impending rupture and complete examination of this patient revealed the presence of three colonic cancers, of which two were completely occluding.

CONCLUSION

The presence of multiple colonic cancers must be ruled out in order to plan the best management. We present the case with a review of literature and discuss the management of the case.

Incidence and epidemiological features of synchronous and metachronous colorectal cancer

Introduction patients with sporadic colorectal cancer or cases associated with syndromes are at risk of having synchronous or metachronous cancer. Although it is an important subject, Brazilian data on the subject are scarce.

Objective to evaluate the incidence and epidemiological features in patients with synchronous and metachronous colorectal cancer in a reference service of proctology in the Rio Grande do Sul.

Methods cross-sectional observational study, performed between January and July 2012, analyzing all patients admitted in the service that met the inclusion criteria. A retrospective review of records was performed, noting demographic variables, comorbidities and tumor-related variables.

Results 150 records were analyzed, of which 53.3% were males and mean age was 63 (± 13.01) years old. The most frequently found tumor location was the sigmoid colon and high rectum (50.67%), followed by the lower rectum (36%). Adenocarcinomas were the most prevalent histological subtype (88%), followed by epidermoid tumors (1.33%). Hereditary syndromes were identified in five patients (3.33%), with four being Familial adenomatous polyposis (FAP) and one hereditary nonpolyposis colorectal cancer (HNPCC). Among the analyzed patients, four (2.67%) had synchronous and one (0.67%) had metachronous cancer.

Conclusion the incidence of synchronous and metachronous colorectal cancer was, respectively, 2.67% and 0.67%, results that corroborate those reported in international literature.

Unexplained neoplastic anastomotic recurrence after right hemicolectomy: a case report

Background

Anastomotic recurrences of the colon are postulated to arise due to inadequate margins, tumor implantation by exfoliated cells, altered biological properties of bowel anastomosis, and missed synchronous lesions. In this paper, a case of unexpected early local recurrence after surgery for colon cancer is presented.

Case presentation

A 68-year-old Caucasian man underwent right hemicolectomy for invasive G2 adenocarcinoma. Two months later, endoscopy revealed a wide and well-functioning anastomosis with a hyperemic, hard, and thickened mucosal area of about 2 cm in diameter. Biopsies showed the presence of an adenocarcinoma with the same grading of the previous lesion. Ten days later, the patient underwent a new intervention; the last 10 cm of the ileum and half of the remaining transverse colon were resected, and the patient started adjuvant therapy. Specimen examination confirmed the presence of an adenocarcinoma (G2) penetrating the muscular layer of the wall; also, in this case, resection edges were free from tumoral invasion, and the removed lymph nodes were exempt from neoplastic colonization. The patient was seen in follow-up for about 5 years, and he did not show local or systemic manifestations.

Conclusions

Whenever a neoplastic recurrence on the anastomotic line occurs, in the presence of negative intestinal margins, as usual in right colectomies, the implantation of neoplastic cells could be the possible cause.

Quadruple advanced synchronous colorectal cancers successfully treated by laparoscopic surgery: a case report

Among synchronous colorectal cancers (SCRCs) reported previously, the incidence of quadruple advanced SCRCs is very rare. We present the case who underwent laparoscopic two-segment resection of the colon requiring two anastomoses that was performed for quadruple advanced cancers, and four tumors were curatively removed. There were no signs of recurrence at 64 months after surgery. Laparoscopic surgery provided less invasiveness even for quadruple advanced SCRCs in terms of early recovery with an acceptable long-term outcome.

Synchronous colorectal cancer using CT colonography vs. other means: a systematic review and meta-analysis

OBJECTIVES

The objective of our study was to systematically review the evidence about synchronous colorectal cancer diagnosed with or without computed tomography colonography (CTC).

MATERIALS AND METHODS

Two systematic searches were performed (PubMed and EMBASE) for studies reporting the prevalence of synchronous colorectal cancer (CRC): one considering patients who underwent CTC and the another one considering patients who did not undergo CTC. A three-level analysis was performed to determine the prevalence of patients with synchronous CRC in both groups of studies. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% confidence interval (CI) were calculated. A quality assessment (STROBE) was done for the studies.

RESULTS

For CTC studies, among 2645 articles initially found, 21 including 1673 patients, published from 1997 to 2018, met the inclusion criteria. For non-CTC studies, among 6192 articles initially found, 27 including 111,873 patients published from 1974 to 2015 met the inclusion criteria. The pooled synchronous CRC prevalence was 5.7% (95% CI 4.7%-7.1%) for CTC studies, and 3.9% (95% CI 3.3%-4.4%) for non-CTC studies, with a significant difference (p = 0.004). A low heterogeneity was found for the CTC group (I² = 10.3%), whereas a high heterogeneity was found in the non-CTC group of studies (I² = 93.5%), and no significant explanatory variables were found. Of the 22 STROBE items, a mean of 18 (82%) was fulfilled by CTC studies, and a mean of 16 (73%) by non-CTC studies.

CONCLUSIONS

The prevalence of synchronous CRC was about 4-6%. The introduction of CTC is associated with a significant increase of the prevalence of synchronous CRCs.

Multiplicity of Advanced T Category-Tumors Is a Risk Factor for Survival in Patients with Colorectal Carcinoma

Background

Previous studies on synchronous colorectal carcinoma (SCRC) have reported inconsistent results about its clinicopathologic and molecular features and prognostic significance.

Methods

Forty-six patients with multiple advanced tumors (T2 or higher category) who did not receive neoadjuvant chemotherapy and/or radiotherapy and who are not associated with familial adenomatous polyposis were selected and 99 tumors from them were subjected to clinicopathologic and molecular analysis. Ninety-two cases of solitary colorectal carcinoma (CRC) were selected as a control considering the distributions of types of surgeries performed on patients with SCRC and T categories of individual tumors from SCRC.

Results

SCRC with multiple advanced tumors was significantly associated with more frequent nodal metastasis (p = .003) and distant metastasis (p = .001) than solitary CRC. KRAS mutation, microsatellite instability, and CpG island methylator phenotype statuses were not different between SCRC and solitary CRC groups. In univariate survival analysis, overall and recurrence-free survival were significantly lower in patients with SCRC than in patients with solitary CRC, even after adjusting for the extensiveness of surgical procedure, adjuvant chemotherapy, or staging. Multivariate Cox regression analysis revealed that tumor multiplicity was an independent prognostic factor for overall survival (hazard ratio, 4.618; 95% confidence interval, 2.126 to 10.030; p < .001), but not for recurrence-free survival (p = .151).

Conclusions

Findings suggested that multiplicity of advanced T category–tumors might be associated with an increased risk of nodal metastasis and a risk factor for poor survival, which raises a concern about the guideline of American Joint Committee on Cancer’s tumor-node-metastasis staging that T staging of an index tumor determines T staging of SCRC.

A relationship to survival is seen by combining the factors of mismatch repair status, tumor location and age of onset in colorectal cancer patients

Background

The progression of colorectal cancer (CRC) may differ depending on the location of the tumor and the age of onset of the disease. Previous studies also suggested that the molecular basis of CRC varies with tumor location, which could affect the clinical management of patients. Therefore, we performed survival analysis looking at different age groups and mismatch repair status (MMR) of CRC patients according to primary tumor location in an attempt to identify subgroups of CRC that might help in the prognosis of disease.

Methods

A group of 2233 patients operated on to remove their CRC tumors were analyzed (521 with right colon cancer, 740 with left colon cancer and 972 with rectal cancer). The expression of four MMR genes was assessed by immunohistochemistry (IHC), independent of clinical criteria. From the data collected, a predictive model for overall survival (OS) could be constructed for some associations of tumor location and age of onset using Kaplan-Meier, logistic and Cox regression analysis.

Results

When tumor location was considered as the lone factor, we found no statistical difference in overall survival (OS) between right cancer (68%), left cancer (67%) or rectal cancer tumor locations (71%) (HR: 1.17, 95%CI (confidence interval): 0.97–1.43, P = 0.057). When age of onset was considered, middle age (40–59 years) and older (60–85 years) patients were found to have higher OS than younger onset cancer (20–39 years) patients (69% vs 71% vs 59%, HR: 1.07, 95% confidence interval (CI): 0.91–1.25, P = 0.008). When both age of onset and tumor location were considered in combination as disease factors, we found that the subgroup of patients with left colon cancer from middle age (69%) and older (67%) aged patients had higher OS than younger (54%) patients (HR: 0.89, 95%CI: 0.68–1.16, P = 0.048). However in patients with right colon cancers, we found no statistical difference is OS between younger, middle age or older grouped patients (60% vs 71% vs 67%, HR: 0.84, 95% CI: 0.61–1.16, P = 0.194). With regard to rectal located cancers, we found that younger (62%) and middle age (68) patients had lower OS than older (77%) patients (HR:1.46, 95%CI: 1.13–1.88, P = 0.004). The rates of deficient MMR (dMMR) was 10.4%. We found no statistical difference in OS stratified by tumor locations. However, right colon cancer patients with dMMR (86%) had higher OS than those with proficient MMR (pMMR) (63%) (HR: 3.01, 95% CI: 1.82–4.97, P<0.001). Left colon cancer patients with dMMR (76%) also had higher OS than those with pMMR (66%) (HR: 1.67, 95% CI: 0.95–2.92, P = 0.01). Oppositely, rectal cancer patients with dMMR (60%) had lower OS than those pMMR (68%) (HR: 0.77, 95% CI: 0.51–1.17, P = 0.04).

Conclusions

These data demonstrate that primary tumor location can be an important factor when considered along with age of onset for the prognosis of CRC. Primary tumor location is also an important factor to evaluate the predictive effect of MMR status for the prognosis of CRC.

Clinical characteristics of synchronous colorectal cancers in Japan

BACKGROUND

Incidence and clinical characteristics of synchronous colorectal cancer (sCRC) patients significantly vary among studies, likely due to differences in surveillance methodology. If remain undetected, sCRC can progress to more advanced stages seriously aggravating patient prognosis. We studied the incidence and clinicopathological characteristics of Japanese patients with sCRCs who underwent surgery for primary CRC and received exhaustive perioperative surveillance.

METHODS

We recruited 1005 patients with surgically resected CRCs between January 2007 and December 2011. The associations of clinical and pathological factors with sCRC development were assessed by univariate and multivariate logistic regression.

RESULTS

Eighty-four patients (8.4 %) developed sCRCs, 16 of them (19.0 %) harboring three or more cancers. Companion sCRCs were smaller and earlier stage than the index lesion (P < 0.0001). In multivariate analysis, advanced age (odds ratio (OR) 1.03 per year; P = 0.009) and left colon tumor location (OR 1.78; P = 0.013) are associated with higher risk of sCRCs, particularly in females. Overall survival did not differ between solitary CRC and sCRC (P = 0.62).

CONCLUSIONS

Our results highlight the importance of perioperative colonoscopy examination to ensure the absence of sCRCs that, being small and early staged, are more difficult to detect. The incidence of sCRC, and notably of triple or more sCRCs, was higher than previously recognized. Because they are also significantly higher than expected by merely stochastic accumulation of individual cancerous lesions, we suggest that the occurrence of many sCRC reflects a hitherto uncharacterized predisposition condition.

Synchronous trifocal colorectal cancer

Synchronous colorectal cancers (SCRCs) have been increasingly diagnosed due to emerging diagnostic modalities. The presence of three or more synchronous colorectal cancers has, however, only rarely been reported. A 76-year-old white man presented for management of two concurrent colorectal adenocarcinomas in the left colon evidenced on total colonoscopy. Preoperative abdominal ultrasonography and thoracoabdominal computed tomography were negative for metastatic disease. The patient underwent an elective left hemicolectomy. The pathology report ultimately showed the presence of three moderately differentiated, distinct colorectal cancers. The patient experienced an uneventful recovery.

Laparoscopic subtotal colectomy for synchronous triple colorectal cancer: A case report

Synchronous colorectal cancers refer to the simultaneous occurrence of multiple colorectal tumors in a single patient, excluding any metastases from other organs. At present, radical surgery is considered the standard curative treatment; however, individualized surgical strategies depend on tumor location, the depth of invasion and the general health of the patient. In the present study, the case of a 52-year-old man who presented with a 2-month history of abdominal pain that was accompanied by intermittent hematochezia and weight loss is reported. The patient had no family history of cancer. Computed tomography (CT) of the abdomen revealed intestinal wall thickness in the transverse colon and volvulus in the hepatic flexure of colon. Colonoscopy identified 3 tumors: The first tumor was located in the descending colon with lumen stenosis ~60 cm from the anal verge, the second tumor was located in the hepatic flexure of the colon, and the third tumor was located in the sigmoid colon, 23 cm from the anal verge. Subsequently, laparoscopic subtotal colectomy was performed and all three tumors were removed, and the diagnosis was confirmed by histopathological examination. The patient did not undergo chemotherapy following surgery, due to personal reasons. Subsequent to 19 months of follow-up examinations using CT and colonoscopy every 6 months, the patient exhibited no signs of recurrence. Thus, laparoscopic subtotal colectomy represents an effective surgical approach for the treatment of synchronous colorectal cancer following imaging and endoscopic diagnosis.

The co-localization of carcinomas and adenomas favors a regional field defect in the colon: an observational study

PURPOSE

Finding common genetic alterations in colorectal cancers (CRCs) and peri-tumoral mucosa first led to the notion of colonic field defects. The hypothesis of a genetically determined mosaicism would explain these defects and would make the co-localization of tumors likely. Our purpose was to indirectly test this hypothesis by searching for a possible correlation between the location of colorectal cancers and adenomas

METHODS

This is a retrospective observational study. Patients operated for colorectal cancers at an oncological hospital, who had a full colonoscopy performed in the two peri-operative years, were surveyed. Sex, age, familial risk of cancer, tumor and adenoma locations, and the presence of adenomas larger than 1 cm, with villous component or high-grade dysplasia were recorded.

STATISTICS

T test, chi-square, exact, logistic regression (SPSS18®).

RESULTS

This study included 224 patients (57 % male, mean age 67.6 years), 45 % of which had synchronous adenomas. There was a significant correlation between cancer location and location of all adenomas (p = 0.01) and of adenomas larger than 1 cm (p = 0.01). Adenomas of the right colon were more frequent in patients with right colon cancer (p = 0.008), and the same was true on the left colon (p = 0.002).

CONCLUSIONS

The strong correlation between the locations of CRC and synchronous adenomas, namely risk adenomas, may point to a common early defect. It does also suggest that hemicolectomy may always be the surgery of choice for colon cancer.

Synchronous colorectal cancer: Clinical, pathological and molecular implications

Synchronous colorectal carcinoma refers to more than one primary colorectal carcinoma detected in a single patient at initial presentation. A literature review has shown that the prevalence of the disease is approximately 3.5% of all colorectal carcinomas. This disease has a male to female ratio of 1.8:1. The mean age at presentation of patients with synchronous colorectal cancer is in the early half of the seventh decade. Patients with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease), hereditary non-polyposis colorectal cancer, familial adenomatous polyposis and serrated polyps/hyperplastic polyposis are known to have a higher risk of synchronous colorectal carcinoma. These predisposing factors account for slightly more than 10% of synchronous colorectal carcinomas. Synchronous colorectal carcinoma is more common in the right colon when compared to solitary colorectal cancer. On pathological examination, some synchronous colorectal carcinomas are mucinous adenocarcinomas. They are usually associated with adenomas and metachronous colorectal carcinomas. Most of the patients with synchronous colorectal cancer have two carcinomas but up to six have been reported in one patient. Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. Overall, the prognosis of patients with synchronous colorectal carcinoma is not significantly different from that in patients with solitary colorectal carcinoma, although a marginally better prognosis has been reported in patients with synchronous colorectal carcinoma in some series. A different management approach and long-term clinical follow-up are recommended for some patients with synchronous colorectal cancer.