Frequency of therapy-relevant staging shifts in colorectal cancer through the introduction of pN1c in the 7th TNM edition

Development and validation of a nomogram for preoperative prediction of tumor deposits in colorectal cancer

BACKGROUND

Based on the clinical data of colorectal cancer (CRC) patients who underwent surgery at our institution, a model for predicting the formation of tumor deposits (TDs) in this patient population was established.

AIM

To establish an effective model for predicting TD formation, thus enabling clinicians to identify CRC patients at high risk for TDs and implement personalized treatment strategies.

METHODS

CRC patients (n = 645) who met the inclusion criteria were randomly divided into training (n = 452) and validation (n = 193) cohorts using a 7:3 ratio in this retrospective analysis. Least absolute shrinkage and selection operator regression was employed to screen potential risk factors, and multivariable logistic regression analysis was used to identify independent risk factors. Subsequently, a predictive model for TD formation in CRC patients was constructed based on the independent risk factors. The discrimination ability of the model, its consistency with actual results, and its clinical applicability were evaluated using receiver-operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

Thirty-four (7.5%) patients with TDs were identified in the training cohort based on postoperative pathological specimens. Multivariate logistic regression analysis identified female sex, preoperative intestinal obstruction, left-sided CRC, and lymph node metastasis as independent risk factors for TD formation. The AUCs of the nomogram models constructed using these variables were 0.839 and 0.853 in the training and validation cohorts, respectively. The calibration curve demonstrated good consistency, and the training cohort DCA yielded a threshold probability of 7%-78%.

CONCLUSION

This study developed and validated a nomogram with good predictive performance for identifying TDs in CRC patients. Our predictive model can assist surgeons in making optimal treatment decisions.

Cutoff value of IC50 for drug sensitivity in patient-derived tumor organoids in colorectal cancer

Patient-derived tumor organoids (PDTOs) have the potential to be used to predict the patient response to chemotherapy. However, the cutoff value of the half-maximal inhibition concentration (IC₅₀) for PDTO drug sensitivity has not been validated with clinical cohort data. We established PDTOs and performed a drug test in 277 samples from 242 CRC patients who received FOLFOX or XELOX chemotherapy. After follow-up and comparison of the PDTO drug test and final clinical outcome results, the optimal IC₅₀ cutoff value for PDTO drug sensitivity was 43.26 μmol/L. This PDTO drug test-defined cutoff value could predict patient response with 75.36% sensitivity, 74.68% specificity, and 75% accuracy. Moreover, this value distinguished groups of patients with significant differences in survival benefit. Our study is the first to define the IC₅₀ cutoff value for the PDTO drug test to effectively distinguish CRC patients with chemosensitivity or nonsensitivity and predict survival benefits.

Clinical Significance of Tumor Deposits in Gastric Cancer: a Retrospective and Propensity Score-Matched Study at Two Institutions

BACKGROUND

Gastric cancer (GC) treatment is largely determined by tumor stage. Despite improvements in the mode of treatment of various types of advanced disease, staging is still evolving. The role of tumor deposits (TDs) in staging remains debated. The purpose of this research is to investigate the relationship between TDs and prognosis in GC.

METHODS

A total of 3098 patients were considered eligible for prognostic analysis (2706 patients in the TDs-negative group and 392 patients in the TDs-positive group). A one-to-one propensity score-matching analysis was performed using a logistic regression mode and the following covariates: age, gender, tumor location, size, differentiation, perineural invasion, lymphovascular invasion, pTNM stage, type of gastrectomy, and the number of lymph nodes retrieved between TDs-negative and TDs-positive group, then 323 patients in each group were analyzed. Univariate and multivariate analyses of prognostic factors were conducted accordingly. The predictive ability of different staging system incorporating TDs was evaluated.

RESULTS

TDs were present in 14.5% cases and almost all of the patients (99%) suffered from advanced GC. Multivariate analysis showed that pN stage, chemotherapy, and TDs were the independent prognostic factors. The TDs-positive group showed a lower rate of 5-year disease-free survival compared with the TDs-negative group in all patients, stage II, and stage III patients (p = 0.001, 0.029, and 0.003, respectively). The 5-year disease-free survival for patients with TDs and without TDs was 27.6% and 34.4%, respectively.

CONCLUSIONS

Our research shows that TDs are closely associated with prognosis in GC. TDs should be incorporated into the TNM staging system, which could then accurately improve the staging reliability and prognostic assessment.

The unique prognostic characteristics of tumor deposits in colorectal cancer patients

Background

Both AJCC 7th and 8th TNM systems have included tumor deposits (TDs) in nodal staging when lymph nodes metastases (LNMs) are negative in colorectal cancer (CRC). However, the prognostic role of TDs has not been determined in the presence of positive LNMs.

Methods

Two independent large-scale cohorts of CRC patients from the Surveillance Epidemiology and End Results (SEER) database (n=69,178) [2010-2013] and Fudan University Shanghai Cancer Center (FUSCC) (n=3,137) [2010-2014] were retrospectively analyzed. Kaplan-Meier method was used to estimate survival curves and univariate and multivariate analyses were performed by Cox proportional hazard model.

Results

TDs were observed in 12.3% (n=8,480) and 14.8% (n=463) of patients in the SEER and FUSCC cohorts, respectively. Multivariate analysis suggested TDs were an independent adverse prognostic factors for overall survival (OS) (P<0.001). Remarkably, both cohorts showed the presence of TDs was significantly associated with OS, but not was the number of TDs (P=0.982 and P=0.252 for the SEER and FUSCC cohorts, respectively). In the presence of LNMs, positive TDs were associated with a shorter OS [hazard ratio (HR): 2.69, 95.0% confidence interval (CI): 2.597-2.778; P<0.001]. Further analysis combining TDs with LNMs demonstrated that the prognosis of patients with N1TD (N1 with positive TDs) was same as the N2 patients, and N2TD (N2 with positive TDs) patients had much worse prognosis than N2 (P<0.001).

Conclusions

Our results have shown the unique features of TDs in patients with CRC, different from LNMs. In the presence of LNMs, TDs should also be considered in TMN system.

Short-term outcomes of robotic-assisted laparoscopic rectal surgery: A pilot study during the introductory period at a local municipal hospital

OBJECTIVES

The aim of this pilot study was to confirm the safety and feasibility of the induction of robotic-assisted laparoscopic rectal surgery (RRS) at a local municipal hospital. A municipal hospital does not indicate a small hospital. The most significant difference between a municipal hospital and a center or university hospital is that most surgeons in a municipal hospital are general surgeons.

METHODS

The first 30 patients who underwent RRS at the municipal hospital were enrolled between April 2015 and June 2016. All surgeries were performed by a single trained surgeon using the da Vinci^Ⓡ Si surgical system. The primary endpoint was the incidence of postoperative major complications.

RESULTS

Of the study patients, 29 had adenocarcinoma and 1 had ulcerative colitis. The surgical procedures included anterior resection (n = 22), intersphincteric resection (n = 2), abdominoperineal resection (n = 4), Hartmann's procedure (n = 1), and total coloproctectomy (n = 1). There were no intraoperative complications and conversion cases. The median operative time and blood loss were 283.5 min and 9 ml, respectively. The incidence rate of postoperative major complications was 10%, which included anastomotic leakage in 2 patients and ileus in 1 patient. Postoperative urinary dysfunction did not occur in any patient. Complete resection was achieved for all patients.

CONCLUSIONS

We demonstrated that the induction of RRS was safe and feasible, even at a local municipal hospital, given that the surgeons had the sufficient skills and experience in both laparoscopic and colorectal surgery. *The study protocol was registered at the University Hospital Medical Information Network (UMIN000017022).

Indoleamine 2, 3-dioxygenase and B7-H1 expressions as prognostic and follow-up markers in human pancreatic carcinoma

This study was to test hypotheses that indoleamine 2, 3-dioxygenase and B7-H1 expressions can be used as prognostic markers in human pancreatic carcinoma (PC). Ninety-five patients were recruited who had undergone radical surgical resection for PC. IDO and B7-H1 expressions in PC tissue specimens were evaluated by immunohistochemistry (IHC) techniques. The clinical and pathological features of these specimens were analyzed. IDO positive, B7-H1 positive, and combined IDO/B7-H1 positive tumors exhibited significant correlations with lymphocytic infiltration, perineural invasion, TNM status, and pathologic grade (p < .05), which tended to show strong correlations with malignant progression of PC. Also, IDO correlated with diabetes mellitus (DM) and HAD scale and B7-H1 correlated with smoke (p < .05). In addition, the correlation analysis indicated that IDO had a positive correlation with B7-H1 (p < .05). Moreover, the results showed that a combination of IDO and B7-H1 expressions could serve as independent prognostic marker after adjusting by Cox proportional hazards regression models (p < .05). IDO and B7-H1 expressions were observed in patient with PC tissues and are important markers for PC malignant progression. A combination of IDO and B7-H1 expression can be served as an independent prognostic marker for PC.

Prognostic value and characteristics of N1c colorectal cancer

AIM

The presence of tumour deposits (TDs) in colorectal cancer (CRC) is associated with poor prognosis. The seventh edition of TNM subclassified a new nodal stage, N1c, characterized by the presence of TDs without any concurrent positive lymph node (LN). It is not clear if the N1c category is or is not equal to LN metastasis. We aimed to examine the prevalence, characteristics and prognostic significance of this new subcategory.

METHOD

Consecutive patients who underwent surgery for CRC in two centres (2011-2014) were analysed. N1 cM0 patients were matched against non-N1 cM0 (N0, N1a and N1b) patients for 3-year overall survival (OS) and disease-free survival (DFS).

RESULTS

We identified 1122 patients with 648 (57.8%) colonic cancers. In 57 patients (5.1%), N1c status was associated with rectal cancers [rectum = 33/57 (57.9%) vs colon = 24/57 (42.1%); P = 0.029], a higher pathological tumour stage [pT3-T4 N1c = 55/843 (6.5% vspT3-T4 non-N1c = 2/279 (0.7%); P < 0.0001] and vascular emboli [n = 35 (61.4%) vs n = 552 (51.8%); P = 0.0305]. Synchronous metastasis was observed in 23 cases (40%). After a mean follow-up of 31 months, 3-year OS for M0 patients, was 89.4%, 89.1%, 86.6% and 81.8% for N0, N1a, N1b and N1c tumours, respectively. DFS was significantly worse for N1c than for N0 (P = 0.0169), with N1c status having a significant effect on DFS in colonic cancers (P = 0.014). The presence of more than one TD was associated with a significantly worse DFS (P = 0.021).

CONCLUSION

Our results indicate that N1c CRC patients should be included among high-risk patients for whom it is widely accepted that adjuvant chemotherapy should be considered.

Histopathological Predictors of Recurrence in Stage III Colon Cancer: Reappraisal of Tumor Deposits and Tumor Budding Using AJCC8 Criteria

Patients with stage III colonic adenocarcinoma have a spectrum of risk for recurrent disease, and histopathological variables that predict recurrence can help stratify patients into prognostic groups. To identify histopathological predictors of recurrence, we investigated the effect of implementation of the eighth edition of the American Joint Committee on Cancer (AJCC8) staging system definition of tumor deposits and International Tumor Budding Consensus Conference (ITBCC) criteria for tumor budding compared with other known prognostic variables in 256 resected colonic adenocarcinomas, including 150 stage III and 106 stage II tumors. In stage III colon cancer, tumor deposits and high tumor budding were the only independent histological variables that predicted disease recurrence. In a multivariable analysis in stage III colon cancer, tumor deposits and high tumor budding were associated with a 2.2- and 1.5-fold increased risk of developing disease recurrence, respectively (95% CI = 1.1-4,2, P = .02, and 95% CI = 1.1-2.1, P = .01, respectively). The negative prognostic effect of tumor deposits was most pronounced in patients with stage IIIB disease in which tumor deposits were associated with a 3.2-fold increased risk of disease recurrence (95% CI = 1.4-7.1; P = .005). Within the N1 cohort, patients with tumor deposits without concurrent positive lymph nodes (N1c) had a significantly decreased disease-free survival compared with patients with N0 tumors ( P < .001) and patients with N1a/b tumors ( P = .02). As independent risk factors for recurrence, tumor deposits and high tumor budding are important histopathological variables and should be included as a part of a routine comprehensive pathological risk assessment in stage III colon cancer.

Beyond T, N and M: The impact of tumor deposits on the staging and treatment of colorectal and gastric carcinoma

This review aims to describe the results of the most recent studies on the prognostic value of TDs and highlight the impact of TDs on the staging and treatment of colorectal and gastric carcinoma. For colorectal carcinoma TDs have an adverse prognostic effect that is at least similar to that of positive regional lymph nodes. However, support is growing in favor of including of TDs in the M category, rather than the N or T categories of the TNM classification. Moreover, TDs seem to have an adverse effect on outcomes not only in patients without lymph node involvement but also in patients with nodal involvement. Although the prognostic impact of TDs in gastric cancer appears to be undeniable, the actual prognostic determinants of TDs, particularly in relation to the number, size and histological types, remain to be established. Although the 7th and 8th Edition of the TNM classification of colorectal and gastric carcinoma includes TDs in the N category, no current procedures or methods to assess preoperative or intraoperative N-status allow TD detection. After neoadjuvant treatment for advanced rectal carcinoma, the presence of TDs may indicate incomplete eradication of the main tumor and not discontinuous tumor foci. TDs have an undeniable prognostic impact but no algorithm of staging and strategy of treatment has been conformed to this prognostic factor to overcome the classical T,N, and M prognostic categories. Staging and treatment of colorectal and gastric cancers should be reconsidered in light of the emerging prognostic value of TDs.

Radiotherapy for Patients With Resected Tumor Deposit-Positive Colorectal Cancer: A Surveillance, Epidemiology, and End Results-Based Population Study

CONTEXT

- According to the American Joint Committee on Cancer's Cancer Staging Manual, 7th edition, TNM classification, tumor deposit (TD)-positive colorectal cancers (CRCs) are classified as N1c. The effects of radiotherapy and the effects of the updated American Joint Committee on Cancer 7th edition TNM N1c classification for patients with TD-positive CRC are unclear.

OBJECTIVE

- To investigate outcomes of radiotherapy in patients with resected TD-positive CRC.

DESIGN

- Resected TD-positive CRCs diagnosed from 2010 to 2014 were identified in the Surveillance, Epidemiology, and End Results 18 database. Factors associated with overall survival (OS) and cancer-specific survival (CSS) were investigated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

- We included 2712 qualified CRC patients, who either underwent adjuvant radiotherapy (n = 187; 6.9%) or received no radiotherapy (n = 2525; 93.1%). Univariate Cox proportional models showed improved CSS among all CRC patients who underwent adjuvant radiotherapy (CSS hazard ratio, 0.73; 95% CI, 0.57-0.95) and among rectal cancer patients when separated by location (hazard ratio, 0.57; 95% CI, 0.40-0.83), although these associations were attenuated in multivariable-adjusted models. There was improved OS among rectal cancer patients (hazard ratio, 0.77; 95% CI, 0.59-0.99). In subgroup analyses, radiotherapy was not associated with OS or CSS in either metastatic or nonmetastatic CRC patients. Instead, N1c category (versus N0) was associated with a worse OS (hazard ratio, 1.43; 95% CI, 1.31-1.57) but was not associated with CSS.

CONCLUSIONS

- Radiotherapy did not independently improve OS among TD-positive CRC patients. In this study, classifying TD positivity as N1c was associated with worse OS than classifying TD positivity as N0. The findings seem to challenge the benefits of radiotherapy and the new N1c classification of TD for TD-positive CRC patients.

Vascular Invasion and Stromal S100A4 Expression at the Invasive Front of Colorectal Cancer are Novel Determinants and Tumor Prognostic Markers

Object: The aim of the present study was to investigate the clinicopathological characteristics and prognostic factors associated with sporadic colorectal cancer (CRC). We examined the clinicopathological findings and immunohistochemical expression of tumor prognostic markers at tumor budding sites to determine their predictive value for patient prognosis.

Materials and Methods: Immunohistochemical examination was performed by tissue microarray (TMA) of specimens from 106 patients with CRC. On hematoxylin and eosin (H&E)-stained tumor tissue slides, a representative area of tumor budding at the invasive front was selected for the construction of a TMA. Immunostaining for matrix metalloproteinase-7 (MMP7), the laminin-5 (ln-5) γ2 chain and S100A4 was performed to determine the association between patient survival and these markers.

Results: Clinicopathological variables were also assessed. Tumor location, histological type, degree of lymphatic invasion and vascular invasion, tumor stage, epithelial expression of S100A4, stromal cell expression of S100A4 and expression of the ln-5γ2 chain were associated with an increased risk of mortality. Five factors were retained in the multivariate logistic regression analysis. Specifically, the tumor location, degree of lymphatic invasion and vascular invasion, tumor stage and stromal cell expression of S100A4 remained significant predictors of patient survival after controlling for the other variables.

Conclusion: Vascular invasion and stromal expression of S100A4 in the tumor budding areas correlated with patient survival. Stromal immunostaining of S100A4 may be useful for identifying high-risk patients with advanced CRC.

Tumor Deposits in Colorectal Cancer: Improving the Value of Modern Staging-A Systematic Review and Meta-Analysis

Purpose Colorectal cancer (CRC) treatment is largely determined by tumor stage. Despite improvements made in the treatment of various types of metastatic disease, staging has not been refined. The role of tumor deposits (TDs) in staging remains debated. We have assessed the relation of TDs with metastatic pattern to evaluate whether TDs might add significant new information to staging. Methods We performed a systematic literature search that was focused on the role of TDs in CRC. Studies with neoadjuvant-treated patients were excluded. Data on stage, histologic factors, and outcome were extracted. Data from four large cohorts were analyzed for the relevance of the presence of TDs, lymph node metastases (LNMs), and extramural vascular invasion (EMVI) on the pattern of metastases and outcomes. Results Of 10,106 included patients with CRC, 22% presented with TDs. TDs are invariably associated with poor outcome. Presence of TDs was associated with presence of LNMs and EMVI. In a pairwise comparison, effects of TD were stronger than those of both LNMs and EMVI. In the logistic regression model, TDs in combination with LNMs is the strongest predictor for liver (odds ratio [OR], 5.5), lung (OR, 4.3) and peritoneal metastases (OR, 7.0). Presence of EMVI adds information for liver and lung metastases, but not for peritoneal metastases. Conclusion We have shown that TDs are not equal to LNMs or EMVI with respect to biology and outcome. We lose valuable prognostic information by allocating TDs into nodal category N1c and only considering TDs in the absence of LNMs. Therefore, we propose that the number of TDs should be added to the number of LNMs to derive a final N stage.

miR-10b promotes invasion by targeting HOXD10 in colorectal cancer

Studies have shown that homeobox D10 (HOXD10) is the target gene of microRNA-10b (miR-10b) and is closely associated with the inhibition of cell migration and invasion. Ras homolog family member C (RhoC) has been reported to promote tumor metastasis in various types of cancer. The effect of miR-10b on colorectal cancer (CRC) metastasis and the associated molecular mechanisms remain elusive. The present study aimed to investigate whether miR-10b could promote invasion by targeting HOXD10 in CRC by exploring the association between miR-10b and HOXD10 expression in CRC patients. The findings revealed that miR-10b levels were elevated in the CRC specimens and significantly correlated with advanced clinical stage and lymph node metastasis. In addition, HOXD10 was a direct target of miR-10b, and the increased expression of RhoC and downregulation of HOXD10 correlated with the increased expression level of miR-10b. HOXD10 protein level was also markedly attenuated in lymph node metastasis-positive tumor tissues compared with lymph node metastasis-free tumor tissues. These findings suggest that miR-10b may stimulate the upregulation of RhoC through targeting HOXD10, thus promoting the invasion and migration in CRC tumor.