Effect of duration of adjuvant chemotherapy for patients with stage III colon cancer (IDEA collaboration): final results from a prospective, pooled analysis of six randomised, phase 3 trials

Treatment approaches and survival outcomes in elderly colorectal cancer patients: a single-center comparative study

BACKGROUND

Geriatric patients account for nearly half of new colorectal cancer (CRC) cases. This study compares clinicopathological features, treatments, outcomes, and frailty in elderly (≥ 70) and younger (< 70) CRC patients at our center.

MATERIALS AND METHODS

Patients diagnosed with non-metastatic or de novo metastatic CRC between January 2015 and April 2024 were included. Demographic, pathological, and survival data were retrospectively collected. Analyses were performed using SPSS version 25, with statistical significance set at P < 0.05.

RESULTS

Of the 414 non-metastatic CRC patients, 26.6% were aged ≥ 70. Elderly patients received less perioperative chemotherapy (60% vs. 81.6%, P < 0.001) and had more dose reductions (41.6% vs. 19.2%, P < 0.001). Frailty reduced perioperative chemotherapy in elderly non-metastatic patients (54.5% vs. 92.1%, P < 0.001) but did not affect dose reduction (37.9% vs. 33.3%, P = 0.764) or treatment duration (median 24 weeks for both groups, P = 0.909). In metastatic patients, frailty shortened chemotherapy duration (9.5 vs. 15.5 weeks, P = 0.129). Elderly patients had lower 5- and 8-year overall survival (OS) rates (64.7%, 60.1% vs. 83.0%, 78.8%, P = 0.004). In the de novo metastatic cohort (135 patients), age did not affect OS (19.4 vs. 17.3 months, P = 0.590) or PFS (9.8 vs. 7.5 months, P = 0.209). Rectal cancer (HR: 2.751, P = 0.005) and early chemotherapy termination (HR: 4.138, P < 0.001) worsened OS in non-metastatic CRC, while absence of RAS (HR: 2.043, P = 0.047), BRAF mutations (HR: 8.263, P = 0.010), and metastasectomy (HR: 3.650, P = 0.036) improved OS in metastatic CRC.

CONCLUSION

Age does not independently worsen CRC survival, though early chemotherapy discontinuation impacts outcomes. Reduced-dose chemotherapy or monotherapy can help minimize adverse effects in elderly patients.

Survival among patients treated with total mesorectal excision or selective watch-and-wait after total neoadjuvant therapy: a pooled analysis of the CAO/ARO/AIO-12 and OPRA randomized phase II trials

BACKGROUND

Prospective data comparing watch-and-wait (WW) to mandatory total mesorectal excision (TME) in patients with locally advanced rectal cancer (LARC) remain limited, as randomized control trials assessing these two treatment approaches are considered impractical. This pooled analysis of the CAO/ARO/AIO-12 and OPRA trials analyzes survival outcomes among LARC patients managed with either a selective WW or mandatory TME strategy following total neoadjuvant therapy (TNT).

PATIENTS AND METHODS

The CAO/ARO/AIO-12 and OPRA trials were multicenter, phase II trials that randomized patients with stage II/III rectal cancer to receive either induction or consolidation chemotherapy as part of TNT. All patients in the CAO/ARO/AIO-12 trial underwent TME within 6 weeks of completing TNT. The OPRA trial allowed patients with a complete or near-complete response to enter WW while those with an incomplete response proceeded to TME. The primary endpoint of the present pooled analysis was disease-free survival (DFS). Secondary endpoints included distant recurrence-free survival (DRFS), local recurrence-free survival (LRFS) and overall survival (OS).

RESULTS

This pooled analysis included 628 patients (n = 304 CAO/ARO/AIO-12; n = 324 OPRA). Median follow-up was 3.6 [interquartile range (IQR) 1.13] years and 5.1 (IQR 2.2) years, respectively. Patients in the CAO/ARO/AIO-12 trial were more likely to have cT3/4 and cN-positive disease while patients in the OPRA trial had tumors closer to the anal verge. Compliance to TNT and rates of grade 3+ adverse events were similar between studies. There were no differences in DFS, DRFS, LRFS or OS based on treatment strategy or TNT treatment arm.

CONCLUSIONS

This pooled analysis demonstrated equivalent oncologic outcomes between patients treated with mandatory TME and selective WW strategies following TNT. These results strengthen available evidence indicating that WW is a safe treatment option for patients with an excellent response to neoadjuvant therapy.

Combined Analyses of Circulating Tumor DNA and Immunoscore in Patients With Stage III Colon Cancer: A Post Hoc Analysis of the PRODIGE-GERCOR IDEA-France/HORG-IDEA-Greece Trials

PURPOSE

Immunoscore (IS) and circulating tumor DNA (ctDNA) are two emerging technologies in improving prognostication and tailoring adjuvant treatments in patients resected from a stage III colon cancer (CC). Here, we analyzed the prognostic value of the two biomarkers in patients who participated in the randomized phase III IDEA-France and HORG trials.

METHODS

Plasma samples were collected after surgery and before adjuvant chemotherapy. ctDNA analysis was performed using a clinically validated, personalized, tumor-informed 16-plex protein chain reaction assay. Multivariable analyses for time to recurrence (TTR; patients without recurrence or death due to CC) and overall survival (OS) were performed using ctDNA and IS results, along with other parameters including treatment duration and disease risk group.

RESULTS

Of the 554 patients with available ctDNA results, 445 were ctDNA-negative (80.3%) and 109 were ctDNA-positive (19.7%); baseline characteristics showed more T4/N2 and venous embolism/lymphatic invasion/perineural invasion+ in ctDNA-positive patients. With a median follow-up of 6.7 years, the 2-year TTR rate was 43.5% (95% CI, 34.1 to 52.6) for ctDNA-positive patients and 88.1% (95% CI, 84.7 to 90.8) for ctDNA-negative patients (P < .0001). ctDNA was confirmed as an independent prognostic marker for both TTR (adjusted hazard ratio [adjHR], 5.21 [95% CI, 3.59 to 7.58]; P < .001) and OS (adjHR, 4.84 [95% CI, 3.40 to 6.89]; P < .001). ctDNA remained the most significant prognostic factor irrespective of disease stage, treatment duration, and IS results. IS was not prognostic in ctDNA-positive patients but remained a significant prognostic tool for ctDNA-negative patients.

CONCLUSION

In this combined analysis of two adjuvant trials dedicated to patients with stage III CC after surgery, ctDNA was detectable in 19.7% of the patients and was confirmed as a major independent prognostic biomarker. IS seems to bring additional prognostic information in the 80.3% of patients who are ctDNA-negative.

Determining the optimal use of approved drugs in oncology

Optimising the use of approved drugs requires evidence from post-approval trials that investigate variations of their use. Determining optimal drug use goes beyond the dominant, academic effort to conduct trials to identify effective lower doses of new drugs. Other important therapeutic approaches that use either less, similar, or more drug than the standard dose need testing in clinical trials, to get the most out of these drugs. Trial objectives on survival outcomes vary greatly; some aim for superiority, others for equivalent exposure or non-inferiority. This Personal View aims to inform academic trialists in how to conceive and prioritise questions aimed at determining the optimal use of drugs, taking into account the perspectives of patients, clinicians, and trial funders, to maximise the chances of successful delivery and impact for patients globally.

Neoadjuvant therapy for colorectal cancer from 2015 to 2024: a visual analysis and bibliometric analysis

Background

Colorectal cancer (CRC) imposes a substantial burden on global health., but research trends and hotspots in this field are still not clear. The purpose of this research is to create a visual knowledge map based on bibliometric analysis, identify research hotspots and predict future research trends.

Method

Utilizing the Web of Science Core Collection (WoSCC) as data source and integrating the visualization capabilities of the Bibliometrix R software package, CiteSpace, and VOSviewer, analyze the authors, research institutions, countries, cited documents, publishing journals, abstracts, and keyword information of literature pertaining to neoadjuvant therapy for colorectal cancer spanning from January 2015 to December 2024.

Result

The analysis included 1,587 articles from 1,464 institutions, 385 journals, and 61 countries or regions. China has the largest number of publications (449) and the largest number of citations (5,035). The United States occupies the leading position with an average of 21.6. "Annals of Surgical Oncology" is the most published journal with 51 articles, and "Journal of Clinical Oncology" is the journal with the most references (4,465 references). Highly cited references focus on clinical trials and guidelines for neoadjuvant therapy for colorectal cancer. In recent years, the most important keywords in the research on colorectal cancer and neoadjuvant therapy have been "artificial intelligence", "total neoadjuvant therapy" and "immunotherapy".

Conclusion

This article provided a review of the research on neoadjuvant therapy for colorectal cancer, can provide reference for subsequent research on neoadjuvant therapy for colorectal cancer. The results offered valuable insights and data that informed the direction of future advancements.

The prognostic outcome of tumor deposit in colorectal cancer beyond stage N staging

BACKGROUND

Tumor deposits (TD) have been shown to have prognostic implications in patients diagnosed with colorectal cancer (CRC), although their impact appears to be modest compared to regional lymph node metastases.

PATIENTS AND METHODS

A retrospective analysis was conducted involving patients with colorectal cancer in stages I-III who underwent curative resections between January 2015 and December 2019 in the tertiary care center in Thailand. These patients were divided into two cohorts: TD positive and TD negative. Additionally, the patients were subsequently classified into N0, N1, and N2 groups. Disease-free survival and overall survival were compared.

RESULTS

Among the 1015 eligible patients, 176 (17.3 %) had tumor deposits (TD), while 374 patients (36.8 %) had positive lymph nodes (LN). The TD positive group demonstrated a significantly lower 5-year overall survival rate (OS) and 5-year disease-free survival rate (DFS) compared to the TD negative group (73.5 % vs 85.9 %, p < 0.001 and 72.5 % vs 87.9 %, p < 0.001 respectively). Upon stratification by various N stages, the presence of TD was notably associated with DFS in the N1 group (5-year DFS: 84.3 % vs. 89.2 %, p = 0.006). Multivariate logistic analyses shown TD as an independent predictor of disease recurrence [p = 0.02; hazard ratio (HR):1.71 (1.11-2.64)].

CONCLUSION

The presence of TD was significantly correlated with reduced overall survival (OS) and disease-free survival (DFS) in colorectal cancer, especially in patients with nodal metastases.

Efficacy and safety of postoperative adjuvant chemotherapy with oxaliplatin for elderly patients: results from the CCOG-1302 study

BACKGROUND

Postoperative adjuvant chemotherapy using oxaliplatin in addition to 5-FU-based anticancer agents has become the standard treatment for colorectal cancer, however, there is insufficient evidence regarding the efficacy and safety of oxaliplatin combination therapy in the elderly patients. In this study, retrospective analysis of the results from the CCOG-1302 study was performed to confirm them.

METHODS

The patients in the CAPOX continuous (8 courses of CAPOX) and intermittent (2 courses of CAPOX + 4 courses of capecitabine + 2 courses of CAPOX) treatment arms in the CCOG-1302 study were divided into two groups, namely, the elderly (≥ 70) and non-elderly (< 70 years) groups. The adverse events, residual peripheral sensory neuropathy (PSN) and prognosis were analyzed.

RESULTS

The incidence of grade 3 or higher hematologic and non-hematologic toxicities in the continuous and intermittent treatment arm were not significantly different between the elderly and non-elderly groups. During the follow-up period, the percentages of grade I or higher PSN residuals were significantly higher among the elderly individuals in the continuous treatment arm at years 2, 3, 4, and 5. On the other hand, PSN decreased over time in the intermittent treatment arm as well as in the elderly and non-elderly patients. The 3-year DFS was not significantly different between the elderly and non-elderly groups in the continuous and intermittent treatment arms.

CONCLUSION

Oxaliplatin combination chemotherapy can be safely administered to elderly patients. In addition, intermittent administration may be more useful in elderly individuals for the prevention of PSN.

COVID-19 lockdown-related treatment modifications did not impact the outcome of digestive cancers: the Clin-COVIDICA prospective study

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic modified the organization of cancer care pathways worldwide. Few prospective long-term data assessing these therapeutic modifications are available.

METHODS

Clin-COVIDICA was a prospective cohort aiming at determining the clinical impact of COVID-19-related therapeutic modifications in patients with digestive cancer in our center. All consecutive patients undergoing an oncologic treatment for a digestive cancer from March 1 to April 30, 2020, were enrolled in the cohort and followed-up for 24 months. The primary endpoint was progression-free survival (PFS). Secondary endpoints included COVID-19 rate, adverse events (AE) and overall survival (OS). Survival curves were estimated using the Kaplan-Meier method and compared by the log-rank test.

RESULTS

Of the 401 patients included, 39.6% were female, mean age was 68 years old and most frequent tumor were colorectal (50.0%) and pancreatic (17.9%) cancers. All in all, 55 patients (13.7%) have undergone therapeutic modifications. The most frequent were a switch to an oral drug (capecitabine, 30.9%), treatment holidays (29.1%) and treatment cancellation (18.2%). Considering patients with palliative treatment (n = 339), there was a non-significant trend for longer OS (52.0 months versus 36.4 months, p = 0.07) and a significant longer PFS (15.4 months versus 6.2 months, p = 0.009) in patients with therapeutic modifications. There were more all grades AEs in patients without therapeutic modifications (84.4% vs. 65.5%, p = < 0.001), but more severe AEs (grade 3-5) among patients with therapeutic modifications (18.2% versus 8.7%, p = 0.048), especially for patients with a switch to an oral drug, which resulted in 8 severe adverse events and one death. Six patients (1.5%) had a COVID-19, with one COVID-19-related death and one definitive cancellation of a curative surgery due to the consequences of COVID-19.

DISCUSSION

We observed no negative survival impact of therapeutic modifications due to the COVID-19 pandemic in digestive cancer management. This may be due to the selection of patients with less aggressive disease. More severe AEs were observed upon therapeutic modifications, especially switching to oral capecitabine.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04389684; date of registration (15/05/2020).

Real-World Tolerability of Capecitabine and Oxaliplatin in Patients in the United States With Localized Colorectal Cancer Undergoing Curative-Intent Treatment

PURPOSE

The combination of capecitabine and oxaliplatin (CAPOX) is commonly used in patients with localized colorectal cancer (CRC) receiving curative-intent treatment. Our study aimed to assess the real-world tolerability of CAPOX in a single-institution cohort of patients with localized CRC.

METHODS

This is a single-institution retrospective study that included patients with localized CRC receiving neoadjuvant or adjuvant CAPOX. The primary end point was completion rate of intended number (obtained by chart review) of CAPOX cycles irrespective of dose levels. Secondary outcome measures included the rate of grade ≥3 adverse events, hospital admission rate, and dose reductions.

RESULTS

The study included 153 patients with a median age of 61 years; 49% were female and 78.4% had stage III CRC. The proportion of patients (95% CI) who completed all planned CAPOX cycles was 44.4% (36 to 52) in the entire cohort and 34.6% (23 to 45) among female patients. Independent variables associated with treatment completion in multivariable analysis were race, sex, and intended number of cycles. Notably, the therapy completion rates (95% CI) were 55% (43 to 66) and 33% (20 to 45) in patients intended to receive four and eight cycles of CAPOX, respectively. The rate of grade ≥3 adverse events and hospitalization because of CAPOX-related toxicity were 30.7% (95% CI, 23 to 38) and 17.6% (95% CI, 11 to 23), respectively.

CONCLUSION

This study highlights that a substantial number of patients with localized CRC undergoing curative-intent treatment with CAPOX do not complete the planned cycles of chemotherapy because of toxicity. These findings underscore the need for careful patient selection and appropriate supportive care to optimize the therapeutic benefit of CAPOX in this setting.

Prognostic significance of tumor deposit counts in stage III colorectal cancer based on T/N staging and chemotherapy status: A retrospective cohort study

Background

We aimed to evaluate the impact of tumor deposit (TD) count on cancer-specific survival (CSS) and disease-free survival (DFS) in stage III colorectal cancer (CRC) patients stratified by T and N staging, and further explore its impact on chemotherapy effect.

Method

We determined the optimal TD cut-off value for stage III CRC patients from the SEER database utilizing X-tile analysis, and retrospectively analyzed the clinicopathological data of 443 patients from the First Affiliated Hospital of Wenzhou Medical University from 2019 to 2020. Chi-square (χ2) tests compared categorical variables. Kaplan-Meier assessed CSS and DFS. Cox regression model evaluated prognostic factors on CSS and DFS.

Results

2TD is the optimal cutoff value for prognosis in Stage III CRC, in the low-risk group (T1-T3 and N1), ≥3TD patients faced higher cancer-specific mortality (HR = 3.445, 95%CI = 1.254-9.465, P = 0.017) and recurrence risks (HR = 1.934, 95%CI = 1.095-3.416, P = 0.024) vs. 1-2TD, while 1-2TD and no-TD patients showed no difference in survival. In the high-risk group (T4 or N2), both ≥3TD and 1-2TD patients had poor prognosis. Chemotherapy reduced cancer-specific mortality in both groups (1-2TD: HR = 0.347, 95%CI = 0.138-0.870, P = 0.024; ≥3TD: HR = 0.272, 95%CI = 0.077-0.960, P = 0.043) but did not significantly improve recurrence risk (1-2TD: P = 0.177; ≥3TD: P = 0.058).

Conclusion

TD indicates poor prognosis in stage III CRC, with ≥3 TD significantly worsening survival, yet the prognosis remains poor in TD-positive patients with high-risk (T4 or N2) regardless of TD count. Moreover, TD count does not influence chemotherapy's mortality benefit.

Treatment Adherence to Adjuvant Chemotherapy According to the New Standard 3-month CAPOX Regimen in High-risk Stage II and Stage III Colon Cancer: A Population-based Evaluation in The Netherlands

BACKGROUND

A 3-month adjuvant treatment regimen with capecitabine and oxaliplatin (CAPOX) for high-risk stage II (T4N0) and stage III (node-positive) colon cancer was implemented in the Netherlands in 2017. The IDEA trial showed a clinically irrelevant difference in long-term outcomes in combination with a substantial decrease in toxicity in comparison with a 6-month regimen. A significantly increased dose intensity was observed in the 3-month arm, which might be essential to achieve optimal long-term outcomes. Hence, the aim of the present study was to evaluate if a similar dose intensity could be achieved in patients treated with adjuvant CAPOX for 3 months in daily practice.

MATERIALS AND METHODS

Patients scheduled for 3 months of adjuvant CAPOX for high-risk stage II or stage III colon cancer were selected from the Netherlands Cancer Registry. The number of administered cycles and the daily cumulative dose of capecitabine and oxaliplatin were extracted from the medical files. Relative dose intensity (RDI) was determined by comparing the administered dose intensity with the standard dose intensity.

RESULTS

In total, 802 (80.0%) of the 1002 patients completed 4 cycles of CAPOX. The overall mean RDI of adjuvant treatment was 82.9% for capecitabine, and 83.8% for oxaliplatin, based on the combination of dose reductions and omitting cycles.

CONCLUSION

One out of 5 patients did not complete 4 cycles of CAPOX. The administered dose of capecitabine and oxaliplatin in the first year after the update of the guideline was lower than the advised dose for the 3-month CAPOX regimen, and the administered dose in the IDEA study. The impact on long-term oncological outcomes should be awaited.

Impact of tumor and node stages on the efficacy of adjuvant oxaliplatin-based chemotherapy in stage III colon cancer patients: an ACCENT pooled analysis

BACKGROUND

Standard adjuvant treatment of stage III colon cancer (CC) is fluoropyrimidine with oxaliplatin. Recently, stage III was subdivided into low-risk (T1-3, N1) and high-risk (T4 and/or N2), with the benefit of adding oxaliplatin varying across these substages. In this study, we aimed to assess the impact of oxaliplatin on survival outcomes in subdividing stage III CC patients based on T and N staging.

PATIENTS AND METHODS

A total of 4942 stage III CC patients were pooled from the three randomized pivotal trials of oxaliplatin. Kaplan-Meier curves, Cox models stratified by study, and interaction tests were used to assess the oxaliplatin effect across subgroups based on T and N stages. The primary endpoint was overall survival (OS).

RESULTS

The prevalence of tumor stages was T1-2 12.4%, T3 74.4%, and T4 13.1%; nodal stages were N1 64.7% and N2 35.3%. A significant OS benefit from oxaliplatin was seen only in T3 (5-year OS = 77.2% versus 73.0%, P < 0.001): T3N1 (hazard ratio 0.72, 95% confidence interval 0.62-0.85, P < 0.001) and T3N2 (hazard ratio 0.81, 95% confidence interval 0.69-0.95, P = 0.010). No benefit was observed for T1-2 (5-year OS = 87.8% versus 88.7%, P = 0.644) or T4 patients (5-year OS = 62.6% versus 60.2%, P = 0.648). Subgroup analysis revealed a significant interaction between T stage and the effect of oxaliplatin treatment on OS, whereas no such interaction was observed for N stage.

CONCLUSIONS

Our analysis revealed that oxaliplatin-based chemotherapy offers a significant survival benefit in stage III CC patients with T3 tumors. In contrast, no survival benefit was observed for T1-2 or T4 patients. These results suggested that T stage plays a more crucial role than N stage in predicting treatment benefit, highlighting the need for tailored treatment strategies based on tumor characteristics.

Three Versus Six Months of Adjuvant Oxaliplatin-Containing Chemotherapy for Patients With Stage III Colorectal Cancer: A Contemporary Real-World Analysis

PURPOSE

Based on the International Duration Evaluation of Adjuvant Chemotherapy analysis, 3 months of adjuvant chemotherapy with capecitabine and oxaliplatin (CAPOX) is an option for stage III colorectal cancer (colorectal cancer [CRC]), with cost and toxicity benefits. We examined the patterns of uptake of CAPOX versus fluorouracil, leucovorin, and oxaliplatin (FOLFOX) and chemotherapy duration in a contemporary real-world cohort of patients in Canada.

METHODS

The provincial pharmacy database was used to identify patients with resected stage III CRC receiving adjuvant chemotherapy between January 2021 and December 2022. Demographic, tumor, and treatment information was collected and compared.

RESULTS

Of 452 patients, 234 (52%) and 218 (48%) were planned to receive 3 and 6 months of chemotherapy, respectively. Within the 3-month group, 226 (97%) received CAPOX. Within the 6-month group, there was a 51%-49% split between CAPOX and FOLFOX. Age >70 years (P = .039), well/moderately differentiated (P = .005), and low-risk disease (P < .0001) were significantly associated with 3 months. Performance status, ileostomy, or preexisting neuropathy did not affect treatment choice. Of patients planned for 6 months, 29% had low-risk disease, with 52% of these receiving CAPOX. Patients receiving 6 months were more likely to report neuropathy (68 v 36%, P < .0001) and to stop oxaliplatin early (54 v 31%, P < .0001). The most likely reason for early adjuvant discontinuation was neuropathy in the 6-month group and gastrointestinal toxicity in the 3-month group (P < .0001). Irrespective of duration, mean time from consult to starting chemotherapy was longer for FOLFOX versus CAPOX (24 v 19 days, P = .007).

CONCLUSION

In this contemporary cohort, 6 months chemotherapy is still being offered to patients with low-risk disease and is associated with more neuropathy. Exploration of patient preferences and resource costs may improve adoption of reduced duration adjuvant CAPOX in stage III CRC.

Assessing the Efficacy and Safety of Shorter versus Extended Adjuvant Treatment Duration for Stage III Low-Risk Colon Cancer: A Comparative Analysis

BACKGROUND

In recent years, reducing adjuvant treatment period from 6 months to 3 months in low-risk stage 3 colon cancer has shown no decline in efficiency and fewer adverse effects, particularly neuropathy.

AIM

We examined the efficacy and side effects of 3- and 6-month adjuvant chemotherapy regimens in low-risk stage 3 colon cancer patients.

METHODS

Twelve oncology centers retrospectively scanned operated, low-risk, stage 3 (T1-3, N1) colon cancer patients. Capecitabine and oxaliplatin (CAPOX) were given to all 3-month adjuvant chemotherapy patients, while 6-month patients received FOLFOX orCAPOX. Two adjuvant treatment groups compared DFS (disease-free survival) and side effects.

RESULTS

In total, 204 patients were included in our study and the patients' median age was 56 years. Regarding treatment duration, 40.6% of patients (n:83) were treated for 3 months and 59.4% (n:121) were treated for 6 months. The 24-month DFS was numerically high in the 6-month treatment arm, but the difference was not statistically significant (91% vs 84%, respectively; HR: 0.7 95 CI% 0.3-1.58, p: 0.38). During the treatment time, both in all grades (30% vs 54.5%) and in grade 3 (6% vs 15%), neuropathy was significantly higher in the 6-month treatment arm. After the end of the treatment, the average persistent neuropathy frequency after 12 months of follow-up was significantly higher in the 6-month treatment arm, and all of them were at grade 1-2 (12% vs 31%, respectively).

CONCLUSION

In adjuvant treatment of low-risk stage 3 colon cancer, 3-month CAPOX and 6-month FOLFOX/CAPOX had similar 2-year DFS. The neuropathy was significantly lower in the 3-month treatment arm.

Tumor aggression-defense index-a novel indicator to predicts recurrence and survival in stage II-III colorectal cancer

BACKGROUND

Although the TNM staging system plays a critical role in guiding adjuvant chemotherapy for colorectal cancer (CRC), its precision for risk stratification in stage II and III CRC patients with proficient DNA mismatch repair (pMMR) remains limited. Therefore, precise predictive models and research on postoperative treatments are crucial for enhancing patient survival and improving quality of life.

METHODS

This retrospective study analyzed 1051 pMMR CRC patients who underwent radical resection and were randomly assigned to training (n = 736) and validation (n = 315) groups. Immunohistochemistry and hematoxylin and eosin staining were utilized to evaluate regulatory-Immunoscore (RIS), tertiary lymphoid structures (TLS), and tumor budding (TB). The Tumor Aggression-Defense Index (TADI) was derived through a multi-factor COX regression model. Subgroup analysis demonstrated potential of TADI in guiding personalized adjuvant therapy for stage II and III CRC.

RESULTS

Univariate and multivariate Cox analysis indicated that TADI was an independent prognostic indicator. Among stage II CRC, chemotherapy was significantly correlated with improved recurrence times in individuals with intermediate (95% CI 0.19-0.59, P < 0.001) and high (95% CI 0.36-0.95, P = 0.031) TADI. In stage III CRC receiving adjuvant chemotherapy, a duration of 3 months or longer was notably associated with a prolonged time to recurrence in those with high TADI (95% CI 0.40-0.98, P = 0.041) compared to durations of less than 3 months.

CONCLUSION

The TADI serves as an effective parameter for predicting the survival outcomes of stage I-III pMMR CRC patients and guiding precision treatment strategies.

Complete blood counts as potential risk factors of early dissemination to liver and lungs in resected colorectal cancer: a retrospective cohort study

PURPOSE

Liver and lung metastases demonstrate distinct biological, particularly immunological, characteristics. We investigated whether preoperative complete blood count (CBC) parameters, which may reflect the immune system condition, predict early dissemination to the liver and lungs in colorectal cancer (CRC).

METHODS

In this retrospective single-centre study, we included 268 resected CRC cases with complete 2-year follow-up and analysed preoperative CBC for association with early liver or lung metastasis development. Next, selected CBC and clinicopathological parameters were analysed with uni- and multivariable Cox regression. Independent factors affecting liver or lung metastasis-free survival were incorporated into composite scores, which were further evaluated with receiver operating characteristic (ROC) curves and dichotomised using a modified, specificity-focused, Youden approach to identify particularly high-risk patients.

RESULTS

Compared to metastasis-free patients, early liver metastases were related to decreases in red blood cells, haematocrit, lymphocytes and elevated monocyte-to-lymphocyte ratio, while lung metastases to lower eosinophil counts. A composite score of independent factors (erythrocytopenia, lower lymphocyte count and pN) yielded HR of 8.01 (95% CI 3.45-18.57, p < 0.001) for liver-specific metastasis-free survival (MFS). For lung-specific MFS, the combination of eosinopenia, pN and primary tumour location showed HR of 13.69 (95% CI 4.34-43.20, p < 0.001).

CONCLUSION

Early CRC metastases to the liver and lungs are associated with partially divergent clinicopathological and peripheral blood features. We propose simple, clinically implementable scores, based on routinely assessed parameters, to identify patients with an increased risk of early dissemination to the liver or lungs. After validation in independent cohorts, these scores may provide easily available prognostic information.

Surgical Deescalation Within Gynecologic Oncology

Importance

The goal of surgical deescalation is to minimize tissue damage, enhance patient outcomes, and reduce the adverse effects often associated with extensive or traditional surgical procedures. This shift toward less invasive techniques has the potential to revolutionize surgical practices, profoundly impacting the methods and training of future surgeons.

Objective

To evaluate adoption of surgical deescalation within the field of gynecologic oncology using The National Cancer Database.

Design, Setting, and Participants

This cohort study used prospectively collected data from the National Cancer Database from January 2004 to December 2020. Eligible participants included women in the US who received a diagnosis of clinical stage I to IV endometrial, ovarian, cervical, or vulvar cancer within this time frame. Data were analyzed between January and June 2024.

Exposure

Diagnosis of stage I to IV endometrial, ovarian, cervical, or vulvar cancer.

Main Outcomes and Measures

The primary outcome was surgical deescalation, which included evaluation of receipt of surgical intervention, the surgical approach, the type of lymph node assessment, and salvage interventions for disease-affected organs. A Poisson model was applied to estimate the average annual percentage change (AAPC) in the receipt of surgical treatment.

Results

A total of 1 218 490 patients (mean [SD] age at diagnosis, 61.2 [13.7] years) were included. Over the study period, the percentage of patients undergoing surgery decreased from 47.4% to 39.9% for those with cervical cancer (AAPC, -1.3%; 95% CI, -1.6% to -1.1%), from 72.0% to 67.9% for those with ovarian cancer (AAPC, -0.5%; 95% CI, -0.6% to -0.4%), from 83.7% to 79.1% for those with endometrial cancer (AAPC, -0.5%; 95% CI, -0.7% to 11 -0.4%), and from 81.1% to 72.6% for those with vulvar cancer (AAPC, -1.3%; 95% CI, -1.6% to -0.9%). The use of minimally invasive surgery increased from 45.8% to 82.2% for those with endometrial cancer (AAPC, 4.6%; 95% CI, 4.5% to 4.8%) and from 13.3% to 37.0% for those with ovarian cancer (AAPC, 9.4%; 95% CI, 9.0% to 9.7%). Sentinel lymph node dissection increased from 0.7% to 39.6% for patients with endometrial cancer (AAPC, 51.8%; 95% CI, 50.5% to 53.2%), from 0.2% to 10.6% for patients with cervical cancer (AAPC, 44.0%; 95% CI, 39.3% to 48.9%), and from 12.3% to 36.9% for patients with vulvar cancer (AAPC, 10.7%; 95% CI, 8.0% to 13.5%) cancers, whereas the rate of complete lymphadenectomies decreased in all 3 groups. The rate of fertility-sparing surgery for patients with cervical cancer younger than 40 years rose from 17.8% to 28.1% (AAPC, 3.1%; 95% CI, 2.3%-3.9%).

Conclusions and Relevance

These findings suggest that over the past 15 years, the field of gynecologic oncology has moved toward surgical deescalation through an overall reduction in the number of patients who undergo surgery, increased use of minimally invasive surgical techniques, and increased use of sentinel lymph node techniques. Future research should focus not only on understanding the impact of surgical escalation on patients (including disease outcomes, quality of life, and equitable access to these services), but also on surgical training.

Patients with T4N0 and T1‑3N1 colon cancer and a high preoperative carcinoembryonic antigen level benefit from adjuvant chemotherapy with oxaliplatin for 6 months

A shorter duration of oxaliplatin adjuvant chemotherapy has recently emerged as a potential option for patients with high-risk stage II and low-risk stage III (T1-3N1) colon cancer (CC). The present study aimed to elucidate the risk factors for recurrence in these patient populations and to identify the appropriate indications for shortened treatment durations. The present study retrospectively analyzed 396 patients who underwent curative surgery for pathological T4N0 or stage III CC, followed by adjuvant chemotherapy, at two institutes. Overall, 234 patients with T4N0 and low-risk stage III CC were categorized into the low-risk group and 162 patients with high-risk stage III CC into the high-risk group. The 3-year relapse-free survival rate was significantly higher in the low-risk group than in the high-risk group. Multivariate Cox model analysis of the low-risk group revealed that high preoperative serum levels of carcinoembryonic antigen (CEA) and incomplete 6-month adjuvant chemotherapy with oxaliplatin were independent poor prognostic factors. The prognosis of patients in the low-risk group who had abnormal CEA levels and did not complete the 6-month adjuvant treatment with oxaliplatin was similar to that of patients in the high-risk group. However, the prognosis of patients in the low-risk group with high CEA levels improved with a 6-month adjuvant treatment with oxaliplatin to a similar level to that of all patients with low CEA levels in the low-risk group. In conclusion, the present study suggested that the duration of adjuvant chemotherapy with oxaliplatin should not be shortened in patients with high preoperative CEA levels, even in the low-risk group.

Assessing the clinical utility of tumor invasion proportion of lymph nodes for enhanced risk stratification in N1 colorectal cancer

N staging systems are paramount clinical features for colorectal cancer (CRC). In N1 stage (N1) CRC, patients present with a limited number of metastatic lymph nodes, yet their prognoses vary widely. The tumor invasion proportion of lymph nodes (TIPLN) has gained attention, but its prognostic value in N1 CRC remains unclear. We retrospectively analyzed 416 N1 CRC patients who underwent radical surgery from January 2014 to December 2018, reviewing 713 hematoxylin and eosin (H&E)-stained slides to assess TIPLN. Overall survival was the primary outcome in our study. Using restricted cubic splines, we explored the relationship between TIPLN and prognosis, with Cox regression and subgroup analyses adjusting for potential confounders. We found that increased TIPLN was associated with an unfavorable prognosis. At a cut-off value of 50%, patients with high-TIPLN exhibiting poorer outcomes than their low-TIPLN counterparts (hazard ratio: 3.77, P < 0.001). Furthermore, high-TIPLN was confirmed as an independent risk factor for overall survival (hazard ratio: 3.12, P < 0.001) after adjusting for clinical confounders. Notably, TIPLN could also enhance risk stratification within the T and N stages, where patients with low-risk (T1-3 stage) and high-TIPLN demonstrated poorer overall survival compared to those with high-risk (T4 stage) and low-TIPLN (hazard ratio: 2.54, P = 0.021). In conclusion, TIPLN is a promising prognostic indicator for N1 CRC patients that complements traditional N staging system for a more comprehensive evaluation. Integrating TIPLN into the TNM staging system could enhance risk stratification and guide treatment decisions.

Assessment of the Addition of Oxaliplatin to Fluoropyrimidine-Based Adjuvant Chemotherapy in Patients With High-Risk Stage II Colon Cancer: An ACCENT Pooled Analysis

PURPOSE

The adjuvant treatment for stage III colon cancer (CC) is chemotherapy combining fluoropyrimidine (FP) and oxaliplatin (OX). FP regimen plus OX (FPOX) may benefit in high-risk stage II CC. We performed a pooled analysis of pivotal MOSAIC and C-07 studies evaluating FPOX for the treatment of high-risk stage II CC according to prognostic factors, number of high-risk factors, and current clinicopathologic risk classification on the basis of T stage, tumor perforation, and number of lymph nodes examined.

PATIENTS AND METHODS

One thousand five hundred and ninety-five patients with stage II CC receiving FP or FPOX were pooled. The overall survival (OS) benefit of OX was analyzed using Kaplan-Meier curves and unadjusted Cox models stratified by study. Three thousand and fifty-nine patients with stage III CC were used only for interaction tests between the allocated chemotherapy and stage.

RESULTS

In the pooled analysis of stage II patients, independent prognostic factors in multivariable analysis were sex, age, perforation/obstruction, and tumor sidedness. There was a significant interaction in OS between stage and allocated chemotherapy with hazard ratios (HRs) of 1.03 for stage II (95% CI, 0.82 to 1.29; P = .813) and 0.82 for stage III (95% CI, 0.73 to 0.92; P = .001; Pint = .073). There was no benefit from the addition of OX to FP for any of the prognostic factors. The number of high-risk factors tested was not predictive of OX benefit. According to the currently agreed clinicopathologic risk classification, no OS benefit of OX was observed, as HR was 0.86 (95% CI, 0.63 to 1.18; P = .349).

CONCLUSION

No OS benefit of adjuvant OX was found in high-risk stage II CC, regardless of the definition used to characterize tumors as having a high risk for recurrence. Hence, our analysis suggests that OX should not be the standard of care for adjuvant chemotherapy for stage II CC, even in high-risk patients.

Survival analysis in pT1-3 and paracolic lymph-node invasion colorectal cancer: the prognostic role of positive paracolic lymph-node ratio for adjuvant chemotherapy

PURPOSE

Several studies have observed that some stage III colorectal cancer (CRC) patients cannot benefit from standard adjuvant chemotherapy. However, there is no unified screening standard to date.

METHODS

Consecutive patients with pathologically confirmed colon adenocarcinoma treated in 3 centers between January 2016 and December 2018 were included. Patients were divided into four groups according to different stages and positive paracolic lymph-node ratio (P-LNR) [Cohort 1: pT1-3N0M0, Cohort 2: pT1-3N + (P-LNR ≤ 0.15)M0, Cohort 3: pT4N0M0, Cohort 4: stage III patients except for pT1-3N + (P-LNR ≤ 0.15)M0], and further overall survival was compared by Kaplan-Meier method. The univariate and multivariate analyses were employed for cox proportional hazards model.

RESULTS

We retrospectively reviewed 5581 consecutive CRC patients with, and 2861 eligible patients were enrolled for further analysis. The optimal cut-off value of P-LNR in our study was 0.15. There was no significant difference in OS (91.36 vs. 93.74%) and DFS (87.65 vs. 90.96%) between stage III patients with pT1-3N + (P-LNR ≤ 0.15)M0 and those with pT1-3N0M0. Further analysis demonstrated that CRC patients with pT1-3N + (P-LNR ≤ 0.15)M0 were less likely to benefit from 8 cycles of CAPOX or FOLFOX chemotherapy and suffered fewer adverse events from declining chemotherapy. Comparing with 0-4 cycles versus 8 cycles, the overall survival rates were 91.35 versus 90.19% (P = 0.79), and with a DFS of 87.50 versus 88.24% (P = 0.49), the duration of adjuvant chemotherapy was not an independent risk factor for patients with pT1-3N + (P-LNR ≤ 0.15)M0 (HR: 0.70, 95% CI 0.90-1.30, P = 0.42).

CONCLUSION

The concept of P-LNR we proposed might have a high clinical application value and accurately enable clinicians to screen out specific CRC patients who decline or prefer limited chemotherapy.

TRIAL REGISTRY

The clinical trial registration number: ChiCTR2300076883.

Estimate the relationship between CXCR4-SDF-1 axis and inhibitory molecules (CTLA4 and PD-1) in patients with colon cancer

Colon neoplasia is one of the major malignancies in industrialized countries due to their Western-style food habits. It accounts for more than 50% of the population developing adenomatous polyps by the age of 70 years, but 10% of cancers in developed countries. The aim of this study was to evaluate the pathological role of the C-X-C chemokine receptor type 4/stromal-derived factor 1 axis (CXCR4-SDF-1 axis), and the inhibitory molecules PD-1 and cytotoxic T-lymphocyte associated protein 4 (CTLA-4) in postoperative colon cancer patients undergoing treatment with chemotherapy (oxaliplatin and capecitabine) and estimate the correlation between these studied factors to deeply understand the basic mechanisms and potential diagnostic or therapeutic effects. The study involved 90 patients, including 50 colon cancer patients (male and female, aged 35-65) diagnosed by oncologists at Al-Ramadi Hospital, Ramadi, Iraq. All patients underwent surgical resection and received four cycles of chemotherapy with oxaliplatin (85 mg every 21 days) and capecitabine (6 grams daily for 21 days). Additionally, 40 age- and sex-matched individuals served as the control group. For each participant, CXCR4 and SDF-1 levels were measured using ELISA and the gene expression of CTLA-4 and PD-1 were measured using RT-PCR. The colon cancer patient group showed significantly lower levels of CXCR4 and SDF-1 compared to control groups (0.163±0.012 vs 0.376±0.025 pg/mL and 0.376±0.025 vs 0.699±0.110 pg/mL, respectively, both had p=0.001). Moreover, the colon cancer patient group had significantly lower expression of PD-1 and CTLA4 compared to control group (0.102±0.029-fold vs 1.199±0.391-fold, p=0.02; and 0.302±0.140-fold vs 1.441±0.334-fold, p=0.008, respectively). In conclusion, the results suggest that CXCR4 and SDF-1 appear promising as diagnostic markers for distinguishing colon cancer patients from healthy conditions.

Stool and blood biomarkers for colorectal cancer management: an update on screening and disease monitoring

BACKGROUND

Biomarkers have revolutionized the management of colorectal cancer (CRC), facilitating early detection, prevention, personalized treatment, and minimal residual disease (MRD) monitoring. This review explores current CRC screening strategies and emerging biomarker applications.

MAIN BODY

We summarize the landscape of non-invasive CRC screening and MRD detection strategies, discuss the limitations of the current approaches, and highlight the promising potential of novel biomarker solutions. The fecal immunochemical test remained the cornerstone of CRC screening, but its sensitivity has been improved by assays that combined its performance with other stool analytes. However, their sensitivity for advanced adenomas and the patient compliance both remain suboptimal. Blood-based tests promise to increase compliance but require further refinement to compete with stool-based biomarker tests. The ideal scenario involves leveraging blood tests to increase screening participation, and simultaneously promote stool- and endoscopy-based screening among those who are compliant. Once solely reliant on upfront surgery followed by stage and pathology-driven adjuvant chemotherapy, the treatment of stage II and III colon cancer has undergone a revolutionary transformation with the advent of MRD testing after surgery. A decade ago, the concept of using a post-surgical test instead of stage and pathology to determine the need for adjuvant chemotherapy was disruptive. Today, a blood test may be more informative of the need for chemotherapy than the stage at diagnosis.

CONCLUSION

Biomarker research is not just improving, but bringing a transformative change to CRC clinical management. Early detection is not just getting better, but improving thanks to a multi-modality approach, and personalized treatment plans are not just becoming a reality, but a promising future with MRD testing.

Exploring the molecular profile of localized colon cancer: insights from the AIO Colopredict Plus registry

Introduction

Understanding the mutational landscape of colon cancer (CC) is crucial for targeted therapy development. Microsatellite instability (MSI-H), rat sarcoma (RAS), and B-Raf proto-oncogene, serine/threonine kinase (BRAF) mutations (MT) are pivotal markers. Further investigation into clinicopathological features of RAS and BRAF MT in microsatellite stable (MSS) and MSI-H tumors is warranted.

Methods

A retrospective analysis of 4883 localized CC patients (pts.) was conducted. Molecular profiling assessed MSI, KRAS, NRAS, and BRAF MT. Correlation with clinicopathological data employed ANOVA and Chi-square tests. Disease-free survival (DFS) and overall survival (OS) were analyzed adjusting for age, gender, sidedness, UICC stage, Charlson Comorbidity Index (CCI). A Cox model incorporated all variables as covariates.

Results

This analysis included 4883 pts. (2302 female/2572 male, 3865 (79.2%) MSS, 1018 (20.8%) MSI-H). MSS pts. had more All-Wild Type (WT), KRAS MT, and NRAS MT tumors vs. MSI-H pts. (42.1% vs. 21.1%; 39.8% vs. 15.4%; 3.6% vs. 0.7%; p<0.001 for each). BRAF MT tumors (95.5% BRAF V600E MT) were more prevalent in MSI-H individuals (62.8% vs. 8.1%, p<0.001). KRAS and BRAF MT tumors were more frequently right-sided, while BRAF MT tumors were associated with female gender, advanced disease stage, lymph node positivity, and poorer differentiation in the MSS subset (p<0.001). Common KRAS mutations included p.G12D (30.44%) and p.G12V (21.3%) in MSS and p.G13D (28.9%) and p.G12D (22.37%) in MSI-H. NRAS MT tumors were dominated by codon 61 mutations (51.7%). Survival analysis revealed worst prognosis in BRAF MT MSS tumors (DFS: HR 1.74 (95% CI 1.15-2.62, p=0.009; OS: HR 1.61 (95% CI 0.99-2.6), p=0.055). The 3-years DFS and 5-years OS rates were lowest in this subset (61.6% and 57.7% respectively).

Discussion

These findings highlight the complex interplay between molecular subtypes, clinicopathological features, and survival outcomes in early CC. Further research is needed to elucidate underlying mechanisms and develop personalized treatment strategies.

A novel risk classification model integrating CEA, ctDNA, and pTN stage for stage 3 colon cancer: a post hoc analysis of the IDEA-France trial

BACKGROUND

We assessed the added value of incorporating carcinoembryonic antigen (CEA) to circulating tumor DNA (ctDNA) and pathological TN (pTN) stage for risk classification in stage 3 colon cancer (CC).

PATIENTS AND METHODS

We retrospectively analyzed postoperative CEA values in patients with CC from the IDEA-France phase 3 trial. The relation between disease-free survival (DFS) and CEA was modeled through restricted cubic splines. Prognostic value of CEA, ctDNA, and pTN was assessed with the Kaplan-Meier method. Multivariate analysis was used to identify prognostic and predictive factors for DFS.

RESULTS

Among 696 patients (35%), CEA values were retrievable, and for 405 (20%) both CEA and ctDNA were available. An optimized CEA threshold of 2 ng/mL was identified, the 3-year DFS was 66.4% for patients above the threshold and 80.9% for those below (HR, 1.74; 95% CI, 1.33-2.28, P < .001). In multivariate analysis, CEA ≥ 2 ng/mL contributed significantly to model variability, becoming an independent prognostic factor for DFS (HR, 1.82; 95% CI,1.27-2.59), alongside ctDNA (HR, 1.88; 95% CI, 1.16-3.03) and pTN (HR, 1.78; 95% CI, 1.24-2.54). A novel integrated risk classification combining CEA, ctDNA, and pTN stage reclassified 19.8% of pT4/N2 patients as low risk and 2.5% of pT3/N1 patients as high risk. This new classification demonstrated the 3-year DFS of 80.8% for low-risk patients and 55.4% for high-risk patients (HR, 2.66, 95% CI, 1.84-3.86, P < .001).

CONCLUSIONS

Postoperative CEA value is a prognostic factor for DFS in stage 3 CC, independently of ctDNA and pTN. It advocates for systematic reporting in future adjuvant trials. Integrating both biomarkers with pTN could refine risk classification in stage 3 CC.

Essential updates 2022-2023: Surgical and adjuvant therapies for locally advanced colorectal cancer

Pivotal articles that had been published between 2022 and 2023 on surgical and perioperative adjuvant treatments for locally advanced colorectal cancer (CRC) were reviewed. This review focuses on new evidence in the following areas: optimization of surgical procedures for colon cancer, including the optimal length of bowel resection and use of the no-touch isolation technique; minimally invasive surgery for rectal cancer, such as laparoscopic transanal total mesorectal excision and robotic surgery; neoadjuvant treatments for rectal cancer, including total neoadjuvant therapy; neoadjuvant chemotherapy for colon cancer; and postoperative adjuvant chemotherapy for Stage II and III colon cancer. Although the current understanding may not enable perfect decision-making for patients and medical professionals, ongoing advancements are expected to result in more effective personalized treatment plans, ultimately improving the prognosis and quality of life of patients.

SEOM-GEMCAD-TTD clinical guidelines for the adjuvant treatment of colon cancer (2023)

Colorectal cancer (CRC) has a 5-year overall survival rate of over 60%. The decrease in the rate of metastatic disease is due to screening programs and the population's awareness of healthy lifestyle. Similarly, advancements in surgical methods and the use of adjuvant chemotherapy have contributed to a decrease in the recurrence of resected disease. Before evaluating a patient's treatment, it is recommended to be discussed in a multidisciplinary tumor board. In stage II tumors, the pathologic characteristics of poor prognosis must be known (T4, number of lymph nodes analyzed less than 12, lymphovascular or perineural invasion, obstruction or perforation, poor histologic grade, presence of tumor budding) and it is mandatory to determine the MSI/MMR status for avoiding administering fluoropyridimidines in monotherapy to patients with MSI-H/dMMR tumors. In stage III tumors, the standard treatment consists of a combination of fluoropyrimidine (oral or intravenous) with oxaliplatin for 6 months although the administration of CAPOX can be considered for 3 months in low-risk tumors. Neoadjuvant treatment is not consolidated yet although immunotherapy is achieving very good preliminary results in MSI-H patients. The use of ctDNA to define the treatment and monitoring of resected tumors is only recommended within studies. These guidelines are intended to help decision-making to offer the best management of patients with non-metastatic colon cancer.

Exploring prognostic biomarkers in pathological images of colorectal cancer patients via deep learning

Hematoxylin and eosin (H&E) whole slide images provide valuable information for predicting prognostic outcomes in colorectal cancer (CRC) patients. However, extracting prognostic indicators from pathological images is challenging due to the subtle complexities of phenotypic information. We trained a weakly supervised deep learning model on data from 640 CRC patients in the prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial dataset and validated it using data from 522 CRC patients in the cancer genome atlas (TCGA) dataset. We created the colorectal cancer risk score (CRCRS) to assess patient prognosis, visualized the pathological phenotype of the risk score using Grad-CAM, and employed multiomics data from the TCGA CRC cohort to investigate the potential biological mechanisms underlying the risk score. The overall survival analysis revealed that the CRCRS served as an independent prognostic indicator for both the PLCO cohort (p < 0.001) and the TCGA cohort (p < 0.001), with its predictive efficacy remaining unaffected by the clinical staging system. Additionally, satisfactory chemotherapeutic benefits were observed in stage II/III CRC patients with high CRCRS but not in those with low CRCRS. A pathomics nomogram constructed by integrating the CRCRS with the tumor-node-metastasis (TNM) staging system enhanced prognostic prediction accuracy compared with using the TNM staging system alone. Noteworthy features of the risk score were identified, such as immature tumor mesenchyme, disorganized gland structures, small clusters of cancer cells associated with unfavorable prognosis, and infiltrating inflammatory cells associated with favorable prognosis. The TCGA multiomics data revealed potential correlations between the CRCRS and the activation of energy production and metabolic pathways, the tumor immune microenvironment, and genetic mutations in APC, SMAD2, EEF1AKMT4, EPG5, and TANC1. In summary, our deep learning algorithm identified the CRCRS as a prognostic indicator in CRC, providing a significant approach for prognostic risk stratification and tailoring precise treatment strategies for individual patients.

Adjuvant Chemotherapy Duration and Disease-Free Survival in Low-Risk Stage III Colon Cancer with N1a-b and N1c Disease: Insights from a Single-Center Retrospective Analysis

BACKGROUND

Tumor deposits (TDs) are known to have a poor prognosis independent of lymph node (LN) involvement and are considered equivalent to LN metastases in the latest staging system. In stage III colon cancer (CC), high-risk patients (pT4 or pN2) receive 6 months of adjuvant chemotherapy, while low-risk patients (pT1-3 and N1) are recommended either 3 or 6 months of CAPOX or 6 months of FOLFOX therapy. However, the optimal chemotherapy duration for low-risk patients classified as pN1c remains unknown. The aim of this study is to investigate the impact of adjuvant chemotherapy duration (3 months vs. 6 months) on survival in patients with low-risk stage III CC either in pN1a-b and pN1c patient groups.

METHODS

We retrospectively analyzed patients with stage III CC who underwent surgery at a tertiary center between January 2014 and May 2024. Demographic and pathological data of patients were retrospectively collected. The primary outcome was disease-free survival (DFS).

RESULTS

A total of 142 patients were included. Among the patients, 116 were pT1-3N1a-b and 26 were pT1-3N1c. Local (23.1% vs. 1.7%, P < 0.001) and overall (38.5% vs 14.6%, P = 0.011) recurrences were significantly higher in the pN1c group. Univariate and multivariate analyses revealed no significant impact of adjuvant chemotherapy duration on DFS in the pN1a-b group (P = 0.359), whereas in the pN1c group, 3-month chemotherapy resulted in significantly shorter DFS (P = 0.044) in univariate analysis.

CONCLUSION

Our study indicates that shorter duration of adjuvant chemotherapy is associated with worse survival and 6-month chemotherapy is recommended for patients with pT1-3 and N1c disease.

Sex differences in recovery from postoperative sarcopenia during adjuvant CAPOX therapy for colorectal cancer

BACKGROUND

Women are predisposed to develop intolerance to cancer chemotherapy. Sarcopenia and chemotherapy are mutually related. Women are generally intolerable to chemotherapeutics such as 5-fluorouracil. Although adjuvant oxaliplatin-based chemotherapy, e.g. CAPOX is commonly used to treat colorectal cancer, its effects on patients in terms of sarcopenia and sex remain unknown. We investigated sex disparities in the impacts of CAPOX on body composition in this study.

METHODS

We conducted a prospective study on diagnostic metrics used for sarcopenia in colorectal cancer patients receiving adjuvant CAPOX. Evaluations of the nutritional status by the Mini-Nutritional Assessment (MNA), gait speed, grip strength, skeletal muscle mass, fat mass, and bone mineral content using a body composition analyzer were performed in the first, fourth, and eighth cycles of CAPOX (first, second, and third measurements, respectively).

RESULTS

Among 80 eligible patients, 61 completed four CAPOX cycles. The median differences in MNA, gait, grip strength, muscle mass, fat mass, and bone mineral content between the first and second measurements for men (n = 35) and women (n = 26) were + 10.5% and + 2.9% (p = 0.067), + 4.5% and - 2.6% (p = 0.16), + 1.8% and + 2.8% (p = 0.66), + 2.7% and + 1.3% (p = 0.021), + 4.5% and + 3.5% (p = 0.59), and + 3.3% and + 0.0% (p = 0.006), There were no sex differences in comparisons of the above metrics between the first and third measurements in 34 patients who completed eight CAPOX cycles (19 wen and 15 women).

CONCLUSIONS

Early cycles of adjuvant CAPOX may have a negative impact on the postoperative recovery of several metrics for diagnosing sarcopenia in women.

Long-term outcomes of intraoperative chemotherapy with 5-FU for colorectal cancer patients receiving curative resection (IOCCRC): a randomized, multicenter, prospective, phase III trial

BACKGROUND

The authors aimed to compare combined intraoperative chemotherapy and surgical resection with curative surgical resection alone in colorectal cancer patients.

METHODS

The authors performed a multicenter, open-label, randomized, phase III trial. All eligible patients were randomized and assigned to intraoperative chemotherapy and curative surgical resection or curative surgical resection alone (1:1). Survival after long-term follow-up was performed in patients analyzed on an intention-to-treat basis.

RESULTS

From January 2011 to January 2016, 696 colorectal cancer patients were enrolled and randomly assigned to intraoperative chemotherapy and radical surgical resection ( n =341) or curative surgical resection alone ( n =344). Intraoperative chemotherapy with surgical resection showed no significant survival benefit over surgical resection alone in colorectal cancer patients [3-year disease-free survival (DFS): 91.1 vs. 90.0%, P =0.328; 3-year OS: 94.4 vs. 95.9%, P =0.756). However, colon cancer patients benefitted from intraoperative chemotherapy, with a relative 4% reduction in liver and peritoneal metastasis (HR=0.336, 95% CI: 0.148-0.759, P =0.015) and a 6.5% improvement in 3-year DFS (HR=0.579, 95% CI: 0.353-0.949, P =0.032). Meanwhile, patients with colon cancer and abnormal pretreatment carcinoembryonic antigen (CEA) levels achieved significant survival benefits from intraoperative chemotherapy (DFS: HR=0.464, 95% CI: 0.233-0.921, P =0.029 and OS: HR=0.476, 95% CI: 0.223-1.017, P =0.049).

CONCLUSIONS

Intraoperative chemotherapy showed no significant extra prognostic benefit in total colorectal cancer patients who underwent radical surgical resection; however, in colon cancer patients with abnormal pretreatment serum CEA levels (> 5 ng/ml), intraoperative chemotherapy could improve long-term survival.

Identification of circulating tumor DNA as a biomarker for diagnosis and response to therapies in cancer patients

The sampling of circulating biomarkers provides an opportunity for non-invasive evaluation and monitoring of cancer activity. In modern day practice, this has typically been in the form of circulating tumor DNA (ctDNA) detected in plasma. The field of ctDNA has been a burgeoning technology, with prominent applications for blood-based cancer screening and in disease status assessment, especially after curative-intent surgery to evaluate for minimal residual disease (MRD). Clinical applications for the latter show an incredibly high sensitivity in certain cancer types with a need for additional studies to determine how much clinical decision-making should be adapted based on ctDNA results and which cancer types, stages, and treatments are best informed by ctDNA results. This chapter provides an overview of ctDNA detection as tool for cancer screening, detecting MRD, and/or molecularly characterizing a cancer, highlighting the rapidly amassing research as a prognostic biomarker and emerging data on ctDNA as a predictive biomarker.

Oncological risks associated with the planned watch-and-wait strategy using total neoadjuvant treatment for rectal cancer: A narrative review

Overall survival benefit of total neoadjuvant treatment (TNT) remains unconfirmed. Thus, in our opinion, the main rationale for using TNT is a planned watch-and-wait (w&w) strategy to improve patients' long-term quality of life through organ preservation. The OPRA randomized trial, which examined a planned w&w strategy using TNT, showed a higher organ preservation rate but also a higher regrowth rate compared to studies on the opportunistic w&w strategy. Higher rates of complete clinical response with TNT did not improve disease-free survival compared to historical controls. Therefore, the gain in organ-sparing capability might not be balanced by the increased oncological risk. The ultimate local failure rate in the intention-to-treat analysis of the OPRA trial was 13% for induction chemotherapy and 16% for consolidation chemotherapy, which seems higher than expected compared to 8% in a meta-analysis of w&w studies or 12% after TNT and surgery in the PRODIGE-23 and RAPIDO trials, which enrolled patients with more advanced cancers than the OPRA trial. Other studies also suggest worse local control when surgery is delayed for radio-chemoresistant cancers. Our review questions the safety of the planned w&w strategy using TNT in unselected patients. To reduce the oncological risk while maintaining high organ preservation rates, we suggest that the planned w&w strategy using TNT requires a two-tier patient selection process: before treatment and after tumor response assessment at the midpoint of consolidation chemotherapy. These robust selections should identify patients who are unlikely to achieve organ preservation with TNT and would be better managed by preoperative chemoradiotherapy (without consolidation chemotherapy) and surgery, or by discontinuing consolidation chemotherapy and proceeding directly to surgery.

Survival and patient-reported outcomes of real-world high-risk stage II and stage III colon cancer patients after reduction of adjuvant CAPOX duration from 6 to 3 months

AIM

Adjuvant chemotherapy has been advised for high-risk stage II and III colon cancer since 2004. After the IDEA study showed no clinically relevant difference in outcome, reduction of adjuvant CAPOX duration from 6 to 3 months was rapidly adopted in the Dutch treatment guideline in 2017. This study investigates the real-world impact of the guideline change on overall survival (OS) and patient-reported outcomes (PROs).

METHODS

Patients with high-risk stage II (pT4 +) and III (pN+) colon cancer were selected from the Netherlands Cancer Registry, based on surgical resection and adjuvant CAPOX before (2015-2016) versus after (2018-2019) the guideline change. Both groups were compared on OS, using multivariable Cox regression, and on PROs.

RESULTS

Patients treated before (n = 2330) and after (n = 2108) the guideline change showed similar OS (HR 1.02; 95 %CI [0.89-1.16]), also in high-risk stage III (pT4/N2, HR 1.06 [0.89-1.26]). After the guideline change, 90 % of patients were treated for 3 months with no inferior OS to those still receiving 6 months (HR 0.89 [0.66-1.20]). PROs 2 years after CAPOX completion, available for a subset of patients, suggest a lower neuropathy (n = 366; 26.2 [21.3-31.1] to 16.5 [14.4-18.6]) and better quality of life (n = 396; 80.9 [78.6-83.2] to 83.9 [82.8-84.9]), but no significant difference in workability (n = 120; 31.5 [27.9-35.1]) to 35.3 [33.8-36.7]), with reduction from 6 to 3 months of CAPOX.

CONCLUSION

This real-world study confirmed that shorter adjuvant CAPOX did not compromise OS and may improve PROs, complementing the IDEA study and supporting 3 months of adjuvant CAPOX in daily clinical practice.

PRM1201 effectively inhibits colorectal cancer metastasis via shaping gut microbiota and short- chain fatty acids

BACKGROUND

PRM1201 is a traditional medicine with beneficial effects against colorectal cancer (CRC) metastasis. However, the underlying mechanism of this action remains to be determined.

HYPOTHESIS

Remodeling microbiota and short-chain fatty acids (SCFAs) metabolism might be a potential mechanism to explain the anti-metastatic action of PRM1201, as this gut-microbiota dependent effect involves downregulation of histone deacetylation and EMT.

METHODS

To investigate this possibility, clinical specimens were sequenced and the correlation between the anti-metastatic efficacy of PRM1201 and the restoration of SCFA-producing bacteria was studied. To obtain solid causal evidence, a mouse metastasis model was established to detect the influence of PRM1201 on cancer metastasis. Specifically, 16S amplicon sequencing, ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis, and bacterial manipulation were used to examine the gut microbiota-driven anti-metastatic action of PRM1201.

RESULTS

Clinical data showed that PRM1201 increased both the number of SCFA-producing bacteria and generation of SCFAs in the feces of CRC patients. A positive correlation between the anti-metastatic efficacy of PRM1201 and the restoration of SCFAs observed. The animal experiments demonstrated that PRM1201 effectively blocked CRC metastasis in a dose-dependent manner. PRM1201 treatment modulated the composition of gut microbiota, and promoted the proliferation of beneficial SCFAs producers such as Akkermansia, Lachnospiraceae_NK4A136_group and Blautia, while simultaneously reducing the abundance of pathogenic bacteria like Escherichia-Shigella. In addition, PRM1201 led to augmentation of SCFAs content. Further results indicated that the anti-cancer metastatic mechanism of PRM1201 was linked to inhibition of histone deacetylation and suppression of epithelial-to-mesenchymal transition (EMT) in metastatic lesions. Microbiota depletion treatment and fecal microbiota transplantation (FMT) underscored the microbiota-dependent nature of this phenomenon. Moreover, this anti-colorectal cancer metastatic effect and mechanism of total SCFAs and single SCFA were also confirmed.

CONCLUSION

In summary, PRM1201 exerts its anti-metastatic effects by modulating SCFA-producing bacteria and enhancing the production of SCFAs. Furthermore, the prebiotic-like actions of PRM1201, along with the PRM1201-treated bacteria, function as inhibitors of histone deacetylases (DHACs) thereby effectively suppressing EMT events.

Vasorin (VASN) overexpression promotes pulmonary metastasis and resistance to adjuvant chemotherapy in patients with locally advanced rectal cancer

BACKGROUND

LARC patients commonly receive adjuvant therapy, however, hidden micrometastases still limit the improvement of OS. This study aims to investigate the impact of VASN in rectal cancer with pulmonary metastasis and understand the underlying molecular mechanisms to guide adjuvant chemotherapy selection.

METHODS

Sequencing data from rectal cancer patients with pulmonary metastasis from Sun Yat-sen University Cancer Center (SYSUCC) and publicly available data were meticulously analyzed. The functional role of VASN in pulmonary metastasis was validated in vivo and in vitro. Coimmunoprecipitation (co-IP), immunofluorescence, and rescue experiments were conducted to unravel potential molecular mechanisms of VASN. Moreover, VASN expression levels in tumor samples were examined and analyzed for their correlations with pulmonary metastasis status, tumor stage, adjuvant chemotherapy benefit, and survival outcome.

RESULTS

Our study revealed a significant association between high VASN expression and pulmonary metastasis in LARC patients. Experiments in vitro and in vivo demonstrated that VASN could promote the cell proliferation, metastasis, and drug resistance of colorectal cancer. Mechanistically, VASN interacts with the NOTCH1 protein, leading to concurrent activation of the NOTCH and MAPK pathways. Clinically, pulmonary metastasis and advanced tumor stage were observed in 90% of VASN-positive patients and 53.5% of VASN-high patients, respectively, and VASN-high patients had a lower five-year survival rate than VASN-low patients (26.7% vs. 83.7%). Moreover, the Cox analysis and OS analysis indicated that VASN was an independent prognostic factor for OS (HR = 7.4, P value < 0.001) and a predictor of adjuvant therapy efficacy in rectal cancer.

CONCLUSIONS

Our study highlights the role of VASN in decreasing drug sensitivity and activating the NOTCH and MAPK pathways, which leads to tumorigenesis and pulmonary metastasis. Both experimental and clinical data support that rectal cancer patients with VASN overexpression detected in biopsies have a higher risk of pulmonary metastasis and adjuvant chemotherapy resistance.

Use of Circulating Tumor DNA to Guide Decision-making in Adjuvant Colon Cancer

PURPOSE OF REVIEW

The use of circulating tumor DNA (ctDNA) assays to guide clinical decision-making in early-stage colon cancer is an area of rapidly advancing active research. With assays clinically available, clinicians must be informed how to best use this novel tool to treat patients.

RECENT FINDINGS

Recent observational and prospective studies have suggested that ctDNA has potential to guide clinical decision-making in early-stage colon cancer by detecting minimal residual disease (MRD) and predicting recurrence risks. MRD-negative patients may be able to de-escalate or forgo adjuvant chemotherapy (ACT) without compromising disease-free survival or overall survival, while MRD-positive patients may benefit significantly from ACT. Recent and ongoing studies have given reason for optimism about the future of ctDNA as a useful biomarker for clinicians treating early-stage colon cancer. Data thus far are mostly limited to observational studies; inconsistent results highlight the need for caution. As more evidence emerges, ctDNA may become standard of care for colon cancer patients.

Association of oxaliplatin-containing adjuvant duration with post-treatment fall-related injury and fracture in patients with stage III colon cancer: a population-based retrospective cohort study

PURPOSE

Oxaliplatin-containing adjuvant chemotherapy yields a significant survival benefit in stage III colon cancer and is the standard of care. Simultaneously, it causes dose-dependent peripheral neuropathy that may increase the risk of fall-related injury (FRI) such as fracture and laceration. Because these events carry significant morbidity and the global burden of colon cancer is on the rise, we examined the association between treatment with a full versus shortened course of adjuvant chemotherapy and post-treatment FRI and fracture.

METHODS

In this overlap propensity score weighted, retrospective cohort study, we included patients aged ≥ 18 years with resected stage III colon cancer diagnosed 2007-2019 and treated with oxaliplatin-containing adjuvant chemotherapy (oxaliplatin plus a fluoropyrimidine; capecitabine [CAPOX] or 5-fluorouracil and leucovorin [FOLFOX]). Propensity score methods facilitate the separation of design from analysis and comparison of baseline characteristics across the weighted groups. Treatment groups were defined as 50% (4 cycles CAPOX/6 cycles FOLFOX) and > 85% (7-8 cycles CAPOX/11-12 cycles FOLFOX) of a maximal course of adjuvant chemotherapy to approximate the treatment durations received in the IDEA collaboration. The main outcomes were time to any FRI and time to fracture. We determined the subdistribution hazard ratios (sHR) estimating the association between FRI/fracture and treatment group, accounting for the competing risk of death.

RESULTS

We included 3,461 patients; 473 (13.7%) received 50% and 2,988 (86.3%) received > 85% of a maximal course of adjuvant therapy. For post-treatment FRI, median follow-up was 4.6 years and total follow-up was 17,968 person-years. There were 508 FRI, 301 fractures, and 692 deaths. Treatment with > 85% of a maximal course of therapy conferred a sHR of 0.84 (95% CI 0.62-1.13) for post-treatment FRI and a sHR of 0.72 (95% CI 0.49-1.06) for post-treatment fracture.

CONCLUSION

For patients with stage III colon cancer undergoing treatment with oxaliplatin-containing adjuvant chemotherapy, any potential neuropathy associated with longer durations of treatment was not found to result in greater rates of FRI and fracture. Within the limits of this retrospective study, our findings suggest concern about FRI, while mechanistically plausible, ought not to determine treatment duration.

Factors Affecting Recurrence and Survival in Stage IIA Colon Cancer Patients

INTRODUCTION

Our study delves into the intricate interplay of risk factors and the strategic selection of adjuvant therapy, scrutinizing their influence on recurrence and survival outcomes in stage IIA (T3N0M0) colon cancer patients.

MATERIALS AND METHODS

The study examined the medical records of patients who underwent surgery for stage IIA colon cancer. Identification of stage IIA (pT3N0M0) colon cancer involved a comprehensive review of postoperative clinical records and histological reports. Parameters such as demographic data, tumor characteristics, microsatellite instability status, tumor locations, recurrence risk factors, preoperative carcinoembryonic antigen levels, and adjuvant treatments were systematically evaluated.

RESULTS

In our study involving 220 patients, 138 were male (62.7%), with a median age of 62 years and a median body mass index of 25.1 kg/m2. In the patient group without risk factors, no statistically significant difference was detected in disease-free survival (DFS) rates between those who received treatment and those who did not (p = 0.546). DFS rates of patients with >1 risk factor were statistically significantly lower than those with a single risk factor (p = 0.017). In patients with >1 risk factor, the DFS of those who did not receive adjuvant treatment was significantly lower than those who received adjuvant treatment (p < 0.001). In the patient group with recurrence, when adjuvant treatments were considered, recurrence was significantly higher in the group receiving capecitabine (p = 0.01).

CONCLUSION

The decision for adjuvant chemotherapy in stage IIA colon cancer patients involves careful consideration of various parameters and risk factors. The evolving landscape of research may refine recommendations, ensuring optimal treatment outcomes while minimizing unnecessary toxicity.

Colorectal cancer

Despite decreased incidence rates in average-age onset patients in high-income economies, colorectal cancer is the third most diagnosed cancer in the world, with increasing rates in emerging economies. Furthermore, early onset colorectal cancer (age ≤50 years) is of increasing concern globally. Over the past decade, research advances have increased biological knowledge, treatment options, and overall survival rates. The increase in life expectancy is attributed to an increase in effective systemic therapy, improved treatment selection, and expanded locoregional surgical options. Ongoing developments are focused on the role of sphincter preservation, precision oncology for molecular alterations, use of circulating tumour DNA, analysis of the gut microbiome, as well as the role of locoregional strategies for colorectal cancer liver metastases. This overview is to provide a general multidisciplinary perspective of clinical advances in colorectal cancer.

Dermatology-related quality-of-life outcomes in patients with RAS wild-type metastatic colorectal cancer treated with fluorouracil and folinic acid with or without panitumumab (Pmab) maintenance after FOLFOX + Pmab induction: a prespecified secondary analysis of the phase II randomized PanaMa (AIO KRK 0212) trial

BACKGROUND

The key endpoints for the assessment of the effect of maintenance therapy for metastatic colorectal cancer (mCRC) are survival and quality-of-life outcomes. We aimed to compare dermatology-related quality of life (DRQOL) in patients with RAS wild-type (wt) mCRC treated with fluorouracil and folinic acid (FU/FA) + panitumumab (Pmab) versus FU/FA alone as maintenance therapy after folinic acid, fluorouracil and oxaliplatin + Pmab induction.

PATIENTS AND METHODS

The phase II randomized PanaMa (AIO KRK 0212; NCT01991873) trial included 387 patients at 70 community/academic sites in Germany. For this prespecified secondary analysis, DRQOL outcomes were assessed using the Functional Assessment of Cancer Therapy-epidermal growth factor receptor inhibitor (FACT-EGFRI), Dermatology Life Quality Index (DLQI), and Skindex-16 questionnaires at every second cycle of therapy until disease progression/death.

RESULTS

At least one DRQOL questionnaire was completed by a total of 310/377 (82%) patients who received induction therapy, and by 216/248 (87%) patients who were randomized and received maintenance therapy. Patients who experienced skin toxicity according to the National Cancer Institute (NCI)-Common Terminology Criteria for Adverse Events (CTCAE) during induction therapy had significantly worse DRQOL according to all three measures, compared to those who did not [i.e. Skindex-16, mean difference at cycle 2 -12.87; 95% confidence interval (CI) -20.01 to -5.73; P < 0.001]. During maintenance therapy, significantly improved recovery was observed in all DRQOL measures for patients receiving FU/FA, compared to those receiving additional Pmab (i.e. Skindex-16, mean difference at cycle 6 -16.53; 95% CI -22.68 to -10.38; P < 0.001).

CONCLUSIONS

In this secondary analysis of a phase II randomized clinical trial, patient-reported DRQOL outcomes correlated with skin toxicity according to NCI-CTCAE during induction therapy. Maintenance therapy with FU/FA + Pmab was associated with deteriorated DRQOL versus FU/FA alone in patients with RAS wt mCRC.

Circulating Tumor DNA Predicts Early Recurrence Following Locoregional Therapy for Oligometastatic Colorectal Cancer

(1) Background: Local therapies offer a potentially curative approach for patients with oligometastatic colorectal cancer (CRC). An evidence-based consensus recommendation for systemic therapy following definitive locoregional therapy is lacking. Tumor-informed circulating tumor DNA (ctDNA) might provide information to help guide management in this setting. (2) Methods: A multi-institutional retrospective study was conducted, including patients with CRC that underwent curative-intent locoregional therapy to an isolated site of metastatic disease, followed by tumor-informed ctDNA assessment. The Kaplan-Meier method and log-rank tests were used to compare disease-free survival based on ctDNA results. ctDNA test performance was compared to carcinoembryonic antigen (CEA) test results using McNemar's test. (3) Results: Our study cohort consisted of 87 patients treated with locoregional interventions who underwent ctDNA testing. The initial ctDNA test post-intervention was positive in 28 patients and negative in 59 patients. The median follow-up time was 14.0 months. Detectable ctDNA post-intervention was significantly associated with early disease recurrence, with a median disease-free survival (DFS) of 6.63 months compared to 21.30 months in ctDNA-negative patients (p < 0.001). ctDNA detected a numerically higher proportion of recurrences than CEA (p < 0.097). Post-intervention systemic therapy was not associated with improved DFS (p = 0.745). (4) Conclusions: ctDNA results are prognostically important in oligometastatic CRC, and further prospective studies are urgently needed to define its role in guiding clinical decisions.

Prognostic and Predictive Value of Immunoscore in Stage III Colorectal Cancer: Pooled Analysis of Cases From the SCOT and IDEA-HORG Studies

PURPOSE

Immunoscore (IS) is prognostic in stage III colorectal cancer (CRC) and may predict benefit of duration (6 v 3 months) of adjuvant infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX) chemotherapy. We sought to determine IS prognostic and predictive value in stage-III CRC treated with adjuvant FOLFOX or oral capecitabine and infusional oxaliplatin (CAPOX) in the SCOT and IDEA-HORG trials.

METHODS

Three thousand sixty-one cases had tumor samples, of which 2,643 (1,792 CAPOX) were eligible for IS testing. Predefined cutoffs (IS-Low and IS-High) were used to classify cases into two groups for analysis of disease-free survival (3-year DFS) and multivariable-adjusted hazard ratios (mvHRs) by Cox regression.

RESULTS

IS was determined in 2,608 (99.5%) eligible cases, with 877 (33.7%) samples classified as IS-Low. IS-Low tumors were more commonly high-risk (T4 and/or N2; 52.9% IS-Low v 42.2% IS-High; P < .001) and in younger patients (P = .024). Patients with IS-Low tumors had significantly shorter DFS in the CAPOX, FOLFOX, and combined cohorts (mvHR, 1.52 [95% CI, 1.28 to 1.82]; mvHR, 1.58 [95% CI, 1.22 to 2.04]; and mvHR, 1.55 [95% CI, 1.34 to 1.79], respectively; P < .001 all comparisons), regardless of sex, BMI, clinical risk group, tumor location, treatment duration, or chemotherapy regimen. IS prognostic value was greater in younger (≤65 years) than older (>65 years) patients in the CAPOX cohort (mvHR, 1.92 [95% CI, 1.50 to 2.46] v 1.28 [95% CI, 1.01 to 1.63], PINTERACTION = .026), and in DNA mismatch repair proficient than deficient mismatch repair disease (mvHR, 1.68 [95% CI, 1.41 to 2.00] v 0.67 [95% CI, 0.30 to 1.49], PINTERACTION = .03), although these exploratory analyses were uncorrected for multiple testing. Adding IS to a model containing all clinical variables significantly improved prediction of DFS (likelihood ratio test, P < .001) regardless of MMR status.

CONCLUSION

IS is prognostic in stage III CRC treated with FOLFOX or CAPOX, including within clinically relevant tumor subgroups. Possible variation in IS prognostic value by age and MMR status, and prediction of benefit from extended adjuvant therapy merit validation.

Multicenter randomized phase II study on S-1 and oxaliplatin therapy as an adjuvant after hepatectomy for colorectal liver metastases (YCOG1001)

PURPOSE

The high recurrence rate of colorectal cancer liver metastasis (CRCLM) after surgery remains a crucial problem. However, adjuvant chemotherapy after hepatectomy for CRCLM has not yet been established. This study evaluated the efficacy of adjuvant therapy with S-1 and oxaliplatin (SOX).

METHODS

In a multicenter, randomized, phase II study, patients undergoing curative resection of CRCLM were randomly enrolled in a 1:1 ratio to either the low- or high-dose group. S-1 and oxaliplatin were administered from days 1 to 14 of a 3-week cycle as a 2-h infusion every 3 weeks. The dose of S-1 was fixed at 80 mg/m2. The doses in the low- and high-dose oxaliplatin groups were 100 mg/m2 (low-dose group) and 130 mg/m2 (high-dose group), respectively. This treatment was repeated eight times. The primary endpoint was the rate of discontinuation owing to toxicity. The secondary endpoints were the relapse-free survival (RFS) and frequency of adverse events (AEs).

RESULTS

Between August 2010 and March 2015, 44 patients (low-dose group: 31 patients and high-dose group: 13 patients) were enrolled in the study. Of these, one patient was excluded from the efficacy analysis. In the high-dose group, five of nine patients were unable to continue the study due to toxicity in February 2013. At that time, recruitment to the high-dose group was stopped from the protocol. The relative dose intensity (RDI) for S-1 in the low- and high-dose groups were 49.8 and 48.7% (p = 0.712), and that for oxaliplatin was 75.9 and 73.0% (p = 0.528), respectively. The rates of discontinuation due to toxicity were 60 and 53.8% in the low- and high-dose groups, respectively, with no marked difference noted between the groups (p = 0.747). The frequency of grade ≥ 3 common adverse events was neutropenia (23.3%/23.1%), diarrhea (13.3%/15.4%), and peripheral sensory neuropathy (6.7%/7.7%). The disease-free survival (DFS) at 3 years was 52.9% in the low-dose group, which was not significantly different from that in the high-dose group (46.2%; p = 0.705).

CONCLUSIONS

SOX regimens as adjuvant therapy after hepatectomy for CRCLM had high rates of discontinuation due to toxicity in both groups. In particular, the RDI of S-1 was < 50%. Therefore, the SOX regimen is not recommended as adjuvant chemotherapy after hepatectomy for CRCLM.

Colorectal cancer: a comprehensive review of carcinogenesis, diagnosis, and novel strategies for classified treatments

Colorectal cancer is the third most common and the second deadliest cancer worldwide. To date, colorectal cancer becomes one of the most important challenges of the health system in many countries. Since the clinical symptoms of this cancer appear in the final stages of the disease and there is a significant golden time between the formation of polyps and the onset of cancer, early diagnosis can play a significant role in reducing mortality. Today, in addition to colonoscopy, minimally invasive methods such as liquid biopsy have received much attention. The treatment of this complex disease has been mostly based on traditional treatments including surgery, radiotherapy, and chemotherapy; the high mortality rate indicates a lack of success for current treatment methods. Moreover, disease recurrence is another problem of traditional treatments. Recently, new approaches such as targeted therapy, immunotherapy, and nanomedicine have opened new doors for cancer treatment, some of which have already entered the market, and many methods have shown promising results in clinical trials. The success of immunotherapy in the treatment of refractory disease, the introduction of these methods into neoadjuvant therapy, and the successful results in tumor shrinkage without surgery have made immunotherapy a tough competitor for conventional treatments. It seems that the combination of those methods with such targeted therapies will go through promising changes in the future of colorectal cancer treatment.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

Improved Risk-Stratification Scheme for Mismatch-Repair Proficient Stage II Colorectal Cancers Using the Digital Pathology Biomarker QuantCRC

PURPOSE

There is a need to improve current risk stratification of stage II colorectal cancer to better inform risk of recurrence and guide adjuvant chemotherapy. We sought to examine whether integration of QuantCRC, a digital pathology biomarker utilizing hematoxylin and eosin-stained slides, provides improved risk stratification over current American Society of Clinical Oncology (ASCO) guidelines.

EXPERIMENTAL DESIGN

ASCO and QuantCRC-integrated schemes were applied to a cohort of 398 mismatch-repair proficient (MMRP) stage II colorectal cancers from three large academic medical centers. The ASCO stage II scheme was taken from recent guidelines. The QuantCRC-integrated scheme utilized pT3 versus pT4 and a QuantCRC-derived risk classification. Evaluation of recurrence-free survival (RFS) according to these risk schemes was compared using the log-rank test and HR.

RESULTS

Integration of QuantCRC provides improved risk stratification compared with the ASCO scheme for stage II MMRP colorectal cancers. The QuantCRC-integrated scheme placed more stage II tumors in the low-risk group compared with the ASCO scheme (62.5% vs. 42.2%) without compromising excellent 3-year RFS. The QuantCRC-integrated scheme provided larger HR for both intermediate-risk (2.27; 95% CI, 1.32-3.91; P = 0.003) and high-risk (3.27; 95% CI, 1.42-7.55; P = 0.006) groups compared with ASCO intermediate-risk (1.58; 95% CI, 0.87-2.87; P = 0.1) and high-risk (2.24; 95% CI, 1.09-4.62; P = 0.03) groups. The QuantCRC-integrated risk groups remained prognostic in the subgroup of patients that did not receive any adjuvant chemotherapy.

CONCLUSIONS

Incorporation of QuantCRC into risk stratification provides a powerful predictor of RFS that has potential to guide subsequent treatment and surveillance for stage II MMRP colorectal cancers.

Non-metastatic colon cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatments, and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, AFEF, and SFR)

INTRODUCTION

This article is a summary of the French intergroup guidelines regarding the management of non-metastatic colon cancer (CC), revised in November 2022.

METHODS

These guidelines represent collaborative work of all French medical and surgical societies involved in the management of CC. Recommendations were graded in three categories (A, B, and C) according to the level of evidence found in the literature published up to November 2022.

RESULTS

Initial evaluation of CC is based on clinical examination, colonoscopy, chest-abdomen-pelvis computed tomography (CT) scan, and carcinoembryonic antigen (CEA) assay. CC is usually managed by surgery and adjuvant treatment depending on the pathological findings. The use of adjuvant therapy remains a challenging question in stage II disease. For high-risk stage II CC, adjuvant chemotherapy must be discussed and fluoropyrimidine monotherapy or oxaliplatin-based chemotherapy proposed according to the type and number of poor prognostic features. Oxaliplatin-based chemotherapy (FOLFOX or CAPOX) is the current standard for adjuvant therapy of patients with stage III CC. However, these regimens are associated with significant oxaliplatin-induced neurotoxicity. The results of the recent IDEA study provide evidence that 3 months of treatment with CAPOX is as effective as 6 months of oxaliplatin-based therapy in patients with low-risk stage III CC (T1-3 and N1). A 6-month oxaliplatin-based therapy remains the standard of care for high-risk stage III CC (T4 and/or N2). For patients unfit for oxaliplatin, fluoropyrimidine monotherapy is recommended.

CONCLUSION

French guidelines for non-metastatic CC management help to offer the best personalized therapeutic strategy in daily clinical practice. Each individual case must be discussed within a multidisciplinary tumor board and then the treatment option decided with the patient.