Survival improvement for patients with metastatic colorectal cancer over twenty years

Comparative survival outcome of synchronous and metachronous brain metastasis from colorectal cancer: A meta‑analysis

Synchronous and metachronous brain metastases (BM) are increasingly recognized in patients with colorectal cancer (CRC). This study aimed to assess whether the timing of BM development affects survival outcomes by conducting a systematic review and meta-analysis. A comprehensive search of the Cochrane Library, Embase and MEDLINE databases was performed, covering studies from January 1900 to December 2023. To compare survival outcomes between synchronous and metachronous BM, hazard ratios (HRs) for overall survival (OS) were extracted from the included studies and pooled using a random-effects model. The systematic review included nine retrospective cohort studies comprising 910 patients with BM from CRC. Meta-analysis results showed no significant difference in OS between patients with synchronous and metachronous BM (HR, 0.90; 95% confidence interval, 0.59-1.38; P=0.63). In conclusion, this meta-analysis suggests that the timing of BM development does not impact OS in patients with BM from CRC.

Phase angle as a prognostic biomarker in metastatic colorectal cancer: A prospective trial

BACKGROUND

Colorectal cancer (CRC) represents a major global public health issue, ranking as the third most common cancer worldwide. Given the substantial prevalence of CRC, there is a critical need to identify precise prognostic and predictive biomarker tools for better treatment outcomes. Phase angle (PA) has been proposed as a prognostic marker in various non-malignant and malignant clinical conditions.

AIM

To investigate the relationship between PA and survival outcomes in the first-line treatment of metastatic CRC (mCRC).

METHODS

In this prospective observational study, we obtained data on patients who started first-line systemic chemotherapy from the beginning of 2020 until the end of 2022. The PA, assessed by the bioelectrical impedance analysis scale, was evaluated as a possible prognostic factor for treatment outcomes, which were measured as progression-free survival (PFS) and objective response rate (ORR).

RESULTS

Using the cut-point value for PA set at 4.60°, 144 patients were divided into two cohorts. The high PA group of patients exhibited a significantly longer median PFS than the low PA group, 14.8 vs 10.5 months, respectively. No difference in ORR was observed. However, patients with PA ≥ 4.60° had a higher disease control rate.

CONCLUSION

PA represents a novel and objective pre-chemotherapy prognostic factor to identify mCRC patients who are at increased risk of a worse survival outcome.

Glucocorticoid promotes metastasis of colorectal cancer via co-regulation of glucocorticoid receptor and TET2

Glucocorticoids (GCs), commonly used for anti-inflammatory and cancer treatments, have been linked to the promotion of cancer metastasis. Yet, the molecular mechanisms behind this potential remain poorly understood. Clarifying these mechanisms is crucial for a nuanced understanding and potential refinement of GC therapies in the context of cancer treatment. In HEK293T cells, co-immunoprecipitation (Co-IP) and chromatin immunoprecipitation sequencing (ChIP-seq) were used with antibodies of glucocorticoid receptor (GR) and ten-eleven translocation enzymes (TET) family proteins (TET1, TET2, TET3). Drug repositioning was performed through the Connectivity Map database, using common target genes of GR and TET2 in HEK293 and HCT116 cell lines and differentially expressed genes (DEGs) of colorectal cancer (CRC). Cell migration and invasion were tested in CRC cell lines with varying GR expression, that is, HCT116 and HT29 cell lines. Dexamethasone (Dex) treatment resulted in a significant difference in cell migration rates in two CRC cell lines with disparate GR expression levels. Co-IP and ChIP-seq analyses substantiated the interaction between GR and TET family proteins in HEK293T cells. Belinostat, the selected compound, was successfully validated for its potential to counteract the effects of GC-induced invasion in CRC cells in vitro. Transcriptomic analyses of Belinostat-treated HCT116 cells revealed down-regulation of target genes associated with cancer metastasis. This study provides valuable insights into the molecular mechanisms underlying GC-induced metastasis, introducing newly repositioned compounds that could serve as potential adjuvant therapy to GC treatment. Furthermore, it opens avenues for exploring novel drug candidates for CRC treatment.

Stereotactic body radiation therapy for spinal metastases from gastrointestinal primary cancers

PURPOSE

Metastases from gastrointestinal (GI) primary cancers are considered relatively radioresistant. This study is one of the largest to evaluate outcomes following stereotactic body radiation therapy (SBRT) for GI cancer spinal metastases and supplements its findings with a review of the literature.

METHODS

A prospectively maintained single-institution database of spinal metastases treated with SBRT was analyzed. Seventy-five patients with 106 GI primary cancer spinal metastases were identified. The median single-fraction dose was 16 Gy (interquartile range (IQR): 14-16). Multi-fraction regimens ranged from 18 to 35 Gy over 2-5 fractions.

RESULTS

Median follow-up was 5 months (IQR: 1-13). Cumulative incidence rates of 3-, 6-, and 12-month local failure (LF) were 5%, 9%, and 10%, respectively. Rates of 12-month LF were 6% for gastroesophageal, 10% for hepatobiliary, and 13% for colorectal cancers. Multilevel tumors ≥ 2 vertebrae were associated with LF (p = 0.006, HR: 5.61, 95% CI: 1.61-19.5). Rates of 3-, 6-, and 12-month overall survival (OS) were 68%, 50%, and 41%, respectively. Multivariable analysis showed epidural disease associated with inferior OS (p = 0.037, HR: 1.75, 95% CI: 1.04-2.96). Complete or partial pain responses for 93 tumors (88%) presenting with pain were 60%, 51%, 32%, and 32% after 1, 3, 6, and 12 months, respectively. Ten vertebral compression fractures (9%) developed following treatment. Twelve radiation toxicities (11%) were observed, with no cases of neuropathy or myelopathy.

CONCLUSIONS

SBRT offers effective local tumor control and pain palliation with minimal toxicity for GI cancer spinal metastases, whose incidence is expected to rise with advances in screening and systemic therapies.

Quantitative liver function imaging and whole genome sequencing - Effective modalities for a new era in personalised decision-making for operable colorectal liver metastases?

BACKGROUND

The optimal strategy for patients with colorectal liver metastases (CRLM) is unclear. The Precision1 prospective, observational trial assessed whether pre-operative functional imaging and whole genome sequencing (WGS), could enhance individualized decision-making.

METHODS

Patients with CRLM considered for hepatectomy were recruited. In addition to standard staging, patients underwent a quantitative multiparametric MRI (mpMRI) scan, to assess liver function. Use of mpMRI to aid surgical decision-making, was prospectively recorded, as were short-term clinical outcomes in patients who underwent hepatectomy. In the first 45 patients, WGS was performed on blood and liver tumour samples collected per-operatively.

RESULTS

95 mpMRI scans were performed in 84 patients, who underwent 87 resections. The mpMRI scan affected surgical decision-making in 41 % (39/95) of scans, with 11 undergoing dual-vein embolization, 16 undergoing more conservative parenchymal-sparing surgery, 11 having more extensive surgery, and one patient following a low calorie diet pre-operatively. There were significant (Clavien-Dindo grades 3/4) complications in 5 % of patients, no Grade C post-hepatectomy liver failure, and zero 90-day mortality. WGS suggested additional therapeutic options and prognostic factors for 22 of 35 (63 %) evaluable patients.

CONCLUSION

Precision1 shows mpMRI can aid surgical decision-making, and optimise clinical outcomes. WGS provides additional information, to further enhance personalised decision-making.

Molecular features and clinical actionability of gene fusions in colorectal cancer

Colorectal cancer (CRC) is the third leading cause of cancer death and accounts for 10 % of cancer diagnoses worldwide. Despite the advancements achieved over the latest decades, CRC treatments are still based on conventional chemotherapy whose efficacy is limited by acquired resistance and unfavorable toxicity profile, making the search for novel actionable targets a priority. In this context, gene fusions are emerging as promising -albeit very rare - new markers because of their recurrence across different tumor types and their potential actionability. The aim of this review is to investigate the role of gene fusions in CRC by focusing on pathogenesis, screening strategies as well as their clinical implications.

Overall survival with frontline vs subsequent anti-epidermal growth factor receptor therapies in unresectable, RAS/BRAF wild-type, left-sided metastatic colorectal cancer

BACKGROUND

The combination of anti-epidermal growth factor receptor (EGFR) therapy and chemotherapy is currently a preferred first-line treatment for patients with unresectable, RAS and BRAF wild-type, left-sided metastatic colorectal cancer (mCRC). Several studies have also demonstrated the benefit of anti-EGFR therapy in subsequent line settings for this patient population. However, direct evidence comparing the effectiveness of frontline vs subsequent anti-EGFR therapy remains limited, leaving a crucial gap in guiding optimal treatment strategies.

AIM

To compare overall survival (OS) between frontline and subsequent anti-EGFR treatment in patients with unresectable, RAS and BRAF wild-type, left-sided mCRC.

METHODS

We retrospectively reviewed the medical records of mCRC patients treated at The King Chulalongkorn Memorial Hospital and Songklanagarind Hospital, Thailand, between January 2013 and April 2023. Patients were classified into two groups based on the sequence of their anti-EGFR treatment. The primary endpoint was OS.

RESULTS

Among 222 patients with a median follow-up of 29 months, no significant difference in OS was observed between the frontline and subsequent-line groups (HR 1.03, 95%CI: 0.73-1.46, P = 0.878). The median OS was 35.53 months (95%CI: 26.59-44.47) for the frontline group and 31.60 months (95%CI: 27.83-35.37) for the subsequent-line group. In the subsequent-line group, 71 patients (32.4%) who ultimately never received anti-EGFR therapy had a significantly worse median OS of 19.70 months (95%CI: 12.87-26.53).

CONCLUSION

Frontline and subsequent-line anti-EGFR treatments provide comparable OS in unresectable, RAS/BRAF wild-type, left-sided mCRC patients, but early exposure is vital for those unlikely to receive subsequent therapy.

mRNA extracted from frozen buffy coat samples stored long term in tubes with no RNA preservative shows promise for downstream sequencing analyses

Transcriptomics is an important OMICs method that is often unavailable in biobank research. Frozen blood samples are routinely collected and stored in medical biobanks, but transcriptional studies have been limited due to technical difficulties of extracting high-quality RNA from blood frozen in standard tubes (without RNA preservatives). We aimed to determine whether biobanked buffy coat samples stored at -80°C for up to 23 years could be successfully used for mRNA sequencing. We used a CryoXtract CXT 350 to remove frozen sample cores, which were immersed in RNA preservative during thawing prior to RNA extraction. RNA sequencing was then performed on extractions from pooled samples as well as from 23 buffy coat samples from prospective colorectal cancer cases and 23 matched controls included in the population-based, prospective Northern Sweden Health and Disease Study (NSHDS). For all samples, two library preparation methods were used (Illumina TruSeq Stranded mRNA poly-A selection and Illumina Stranded Total RNA with Ribo-Zero Globin). RNA yields of over 1 µg were obtained from the majority of NSHDS samples (mean = 2.57 µg), and over 92% of samples had RIN values of ≥ 6, indicating suitability for downstream analyses. In conclusion, we developed a method for successfully extracting and sequencing high-quality mRNA from frozen buffy coat samples stored long term in tubes with no RNA preservative.

Sequential Treatment with Regorafenib and Trifluridine/Tipiracil ± Bevacizumab in Refractory Metastatic Colorectal Cancer in Community Clinical Practice in the USA

Background: Regorafenib (R) and Trifluridine/Tipiracil ± bevacizumab (T) are approved for treating refractory metastatic colorectal cancer (mCRC) but their optimal sequence is unclear. This study describes the characteristics/clinical outcomes of patients with mCRC in U.S. clinical practice treated sequentially with R-T or T-R. Methods: A retrospective cohort study of 818 patients treated with R-T or T-R between January 2015 and November 2022 was conducted using an electronic health record-derived database. The primary objective was to describe the demographic/clinical characteristics and biomarker status of patients treated with R-T or T-R, stratified by treatment line/age. Secondary objectives were to evaluate/estimate the frequency of neutropenia and myelosuppression-related treatments, the number/type of subsequent therapies, time to treatment discontinuation (TTD), and overall survival (OS). Results: Baseline characteristics were similar among patients who received R-T (n = 393) or T-R (n = 425). Lower rates of moderate/severe neutropenia (26%/12% vs. 32%/16%) and granulocyte colony-stimulating factor/erythropoietin use (22% vs. 24%) were observed with R-T versus T-R. The median TTD was 8.7 months and 8.5 months with R-T versus 8.1 months and 7.9 months with T-R as third- and fourth-line treatment, respectively. The median OS was 13.1 months and 11.6 months with R-T versus 11.5 months and 10.3 months with T-R as third- and fourth-line treatment, respectively. Conclusions: This study did not show a statistically significant difference in OS with R-T versus T-R. Although limited by its retrospective nature, the study suggested R-T may be preferable to T-R given the observed reduction in neutropenia/myelosuppression-related treatments.

Effects of location of primary tumor on survival after pulmonary metastasectomy for colorectal cancer

BACKGROUND

The benefit of pulmonary metastasectomy (PM) in patients with colorectal cancer (CRC) with isolated lung metastases remains unclear, and failure to separate colon from rectal cancer may contribute. Using a large national database, we investigate whether PM is associated with survival benefits in patients presenting with CRC with synchronous lung metastases based on primary tumor location.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 was queried to identify patients with stage IV CRC with isolated synchronous lung metastases at initial diagnosis. These patients were restricted to include only those in which the location of the primary tumor being either colon or rectum could be conclusively identified, and the primary site was resected. SEER-Medicare linked claims were also queried to identify cases of PM that were not adequately recorded in SEER alone. Patients were then analyzed using Kaplan-Meier (K-M) methods and multivariate analysis was performed to identify variables associated with overall survival (OS).

RESULTS

From the SEER database 185,871 patients with metastatic CRC were identified. Only 588 had isolated synchronous lung metastases, with 441 with colon cancer and 147 with rectal cancer. PM was performed in 15.3% (n = 90) with two-thirds being colon cancer. Univariate K-M demonstrated worse OS for rectal cancer than colon cancer, which remained significant on multivariate analysis.

CONCLUSION

OS is associated with the site of primary CRC in patients undergoing PM. Distinct mutational and molecular characteristics differences between colon and rectal cancer may explain these findings and are an area for future research.

Initial Assessment of Resectability of Colorectal Cancer Liver Metastases Versus Clinical Outcome

BACKGROUND

Surgery improves long-term survival for resectable, liver-only metastatic colorectal cancer (mCRC). With no consensus definition of "resectable" disease, decisions regarding resectability are reliant on the expertise and judgement of the treating clinician working in consultation with a multidisciplinary team (MDT). This study examines the clinical outcome versus initial assessment of resectability in an Australian population with mCRC.

PATIENTS AND METHODS

Patients with liver-only mCRC diagnosed January 2009 to December 2022 were identified from the Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry. Patients were classified based on prospectively documented treatment assessment as "resectable," "potentially resectable," or "unresectable." The correlation between initial assessment of resectability and clinical outcome, and any impact of clinicopathologic factors were examined. Kaplan-Meier analysis assessed overall survival based on initial resectability assessment and resection status.

RESULTS

Of 4437 patients with mCRC identified through TRACC, 1250 (28%) had liver-only disease at presentation, with 497 (43%), 277 (24%), and 374 (33%) classified as "unresectable," "potentially resectable," and "resectable," respectively. In total, 516 (41%) ultimately underwent surgical resection, including 30 (6%) of the "initially unresectable," 148 (53%) of the "potentially resectable," and 338 (90%) of the "resectable" at a median of 9.5, 5.9, and 2.4 months from the diagnosis of liver metastases, respectively. Resection in the "unresectable" patient population was associated with younger age (mean age 63 vs. 69, P = .0006), better performance status (ECOG 0-1 100% vs. 74%, P = .0017), and fewer comorbidities (Charlson index 0-3 in 73% vs. 53%, P = .0296) compared with no resection. Median overall survival was longer for resected versus nonresected patients across all categories: "unresectable" (59.2 vs. 17.6 months, P < .0001), "potentially resectable" (57.2 vs. 22.8 months, P < .0001), and "resectable" (108 vs. 55 months, P < .0001).

CONCLUSIONS

This real-world study demonstrates the potential for "initially unresectable" patients to become surgical candidates following systemic therapy, more likely in younger and fitter patients, with overall excellent survival outcomes in resected patients. This highlights the value of routine, repeated MDT assessments for patients with liver-only disease who are continuing to respond to systemic therapy, even for those initially considered never to be surgical candidates.

Selective intra-arterial mitomycin-C infusions for treatment-refractory colorectal liver metastases

Background

Mitomycin-C is an older drug which has a synergistic mechanism of action with irinotecan. This study evaluated the outcomes of selective intra-arterial mitomycin-C infusions in combination with bi-weekly systemic irinotecan for treatment of liver-dominant metastatic colorectal cancer (CRC) which progressed after hepatic arterial infusion (HAI) pump chemotherapy with floxuridine and at least two lines of systemic chemotherapy.

Methods

An IRB-approved retrospective review of patients receiving at least two sessions of selective monthly mitomycin-C infusions in interventional radiology (IR) was performed. Anatomic and metabolic imaging was initially obtained at 4 weeks after the second infusion, and every 2-3 months thereafter. Response was evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and European Organization for Research and Treatment of Cancer (EORTC) criteria. Patient, disease and procedural parameters were recorded. Progression-free survival (PFS), liver progression-free survival (LPFS) and overall survival (OS) were assessed with Kaplan Meier methodology.

Results

From January 2019 to April 2023, 46 patients underwent a total of 190 selective infusions (range 2-10; median 4). Twenty-three/46 (50%) patients had KRAS mutations and 35/46 (76.1%) had extrahepatic disease at the time of the first infusion. On initial follow-up, liver disease control was observed in 38/46 using RECIST 1.1 (82.6%; partial response 13%, stable disease 69.6%) and 26/31 using EORTC criteria (83.9%; complete response 6.5%, partial response 48.4%, stable disease 29%). Median PFS, LPFS and OS were 4.1 [95% confidence interval (CI): 3.2-4.9], 5.5 (95% CI: 2.5-8.4) and 9.6 (95% CI: 8.2-11.1) months respectively. The infusions were discontinued in 26 (56.5%) patients due to disease progression. Eighteen patients (39.1%) discontinued the infusion protocol due to toxicities/complications, including hepatic/biliary toxicity (26.1%), hepatic arterial thrombosis (15.2%) and/or pulmonary toxicity (8.7%).

Conclusions

In this heavily pretreated population, addition of intra-arterial mitomycin-C was associated with initial liver disease control rates exceeding 80%. Toxicities were observed, particularly in patients with prolonged disease control who received ≥4 infusions.

Identification of a gene signature and prediction of overall survival of patients with stage IV colorectal cancer using a novel machine learning approach

OBJECTIVE

We sought to characterize unique gene signature patterns associated with worse overall survival (OS) among patients with stage IV colorectal cancer (CRC) using a machine learning (ML) approach.

METHODS

Data from the AACR GENIE registry were analyzed for genetic variations (somatic mutations, structural variants and copy number alterations) among patients with CRC. Adult patients (≥18 years) with histologically confirmed stage IV CRC who underwent next-generation sequencing were included. An eXtreme Gradient Boosting (XGBoost) model was developed to predict OS and the relative importance of different genetic alterations was determined using SHapley Additive exPlanations (SHAP) algorithm.

RESULTS

Among 688 patients with stage IV CRC, 54.4 % were male (n = 374) with a median age of 55 years (IQR, 46-64). An XGBoost model developed using the 200 most frequent genetic alterations demonstrated good performance to predict OS with a c-index of 0.701 (95 % CI: 0.675-0.726) on 5-fold cross-validation. The model achieved time-dependent AUC of 0.742, 0.757 and 0.793 at 12-, 24- and 36-months, respectively. The SHAP algorithm identified the top 20 genetic alterations most strongly predictive of worse OS among stage IV CRC patients. Based on the 20-gene signature, individuals at high risk had worse 12- and 36-month OS versus low-risk patients (82.6 % vs. 97.1 % and 30.1 % vs. 72.6 %, respectively; p < 0.001).

CONCLUSION

The XGBoost ML model identified a unique gene signature that accurately risk stratified stage IV CRC patients. ML models that incorporate molecular information represent an opportunity to predict long-term outcomes and potentially identify novel therapeutic targets for stage IV CRC patients.

Low-Density Lipoprotein (LDL) is Associated with Earlier Progression in Synchronous Metastatic Colorectal Cancer Treated without Curative Intent

BACKGROUND

Low-density lipoprotein cholesterol (LDL) is associated with the occurrence of colorectal cancer (CRC). This study aims to investigate its prognostic role and associated clinicopathological factors in the metastatic setting.

METHODS

Patients with newly diagnosed synchronous metastatic CRC were included. Patients were grouped according to the serum LDL levels at the diagnosis (≤ 130 mg/dL: Normal-LDL, > 130 mg/dL: High-LDL). LDL-associated clinicopathological factors, progression-free survival (PFS), and overall survival (OS) were assessed.

RESULTS

A total of 90 patients were included. 44.4% (n = 40) was in the normal-LDL and 56.6% (n = 50) in the high-LDL group. Colonic localization of the primary tumor was more frequent in the high-LDL group (90% vs. 67.5%, p = 0.009). The high-LDL group more frequently had local treatments [metastasectomy (26% vs. 2.5%, p = 0.002) and embolization-ablation (38% vs. 17.5%, p = 0.033)]. Despite higher curative intent with local treatments in the high-LDL group, PFS [10.03 months (95% Confidence Interval (CI):6.97-14.77) vs 9.63 mo. (95% CI: 7.93-14.00), p = 0.872] and OS [20.87 mo. (95% CI: 14.87-36.47) vs. 17.63 mo. (95% CI: 14.30-43.03), p = 0.925] did not differ from the normal-LDL. Among patients treated without any curative intent, high LDL was associated with significantly worse PFS [4.97 mo. (95% CI: 3.00-7.73) vs. 8.43 mo. (95% CI: 6.10-9.90), p = 0.048].

CONCLUSION

This study suggests that serum LDL is associated with colonic primary localization in synchronous metastatic CRC. Levels > 130 mg/dL at diagnosis may be associated with worse survival and may be further investigated as a biomarker. Larger, multicenter and prospective studies are needed.

Expert consensus on the optimal management of BRAFV600E-mutant metastatic colorectal cancer in the Asia-Pacific region

The burden of colorectal cancer (CRC) is high in the Asia-Pacific region, and several countries in this region have among the highest and/or fastest growing rates of CRC in the world. A significant proportion of patients will present with or develop metastatic CRC (mCRC), and BRAFV600E-mutant mCRC represents a particularly aggressive phenotype that is less responsive to standard chemotherapies. In light of recent therapeutic advances, an Asia-Pacific expert consensus panel was convened to develop evidence-based recommendations for the diagnosis, treatment, and management of patients with BRAFV600E-mutant mCRC. The expert panel comprised nine medical oncologists from Australia, Hong Kong, Singapore, and Taiwan (the authors), who met to review current literature and develop eight consensus statements that describe the optimal management of BRAFV600E-mutant mCRC in the Asia-Pacific region. As agreed by the expert panel, the consensus statements recommend molecular testing at diagnosis to guide individualized treatment decisions, propose optimal treatment pathways according to microsatellite stability status, advocate for more frequent monitoring of BRAFV600E-mutant mCRC, and discuss local treatment strategies for oligometastatic disease. Together, these expert consensus statements are intended to optimize treatment and improve outcomes for patients with BRAFV600E-mutant mCRC in the Asia-Pacific region.

CEA Rebound After Discontinuation of Pre-Hepatectomy Chemotherapy Predicts Worse Outcomes After Resection of Colorectal Cancer Liver Metastases

BACKGROUND

Carcinoembryonic antigen (CEA) levels may vary with administration and discontinuation of pre-hepatectomy chemotherapy in patients undergoing resection of colorectal cancer liver metastases (CLM). The prognostic significance of these changes, termed CEA dynamics, is unclear.

PATIENTS AND METHODS

Consecutive patients undergoing hepatectomy for CLM (2001-2021) at a comprehensive cancer center were included. CEA dynamics were classified as CEA normal (CEA < 5 ng/mL before, during, and after chemotherapy), CEA decrease (elevated CEA levels that drop during and after chemotherapy), and CEA rebound (elevated CEA levels that drop during chemotherapy but rebound upon discontinuation). Recurrence-free (RFS), hepatic-specific disease-free (hDFS), and overall survival (OS) were compared across CEA dynamics groups.

RESULTS

Of 903 patients, 254 (28%) were CEA normal, 423 (47%) were CEA decrease, and 226 (25%) were CEA rebound. Median RFS was 15.9 months, median hDFS was not reached, and median OS was 11.9 years for CEA normal patients. By comparison, CEA decrease and CEA rebound patients had shorter median RFS (12.2 months, P = 0.002 and 7.4 months, P < 0.001, respectively), shorter median hDFS (29.1 months, P = 0.003 and 14.8 months, P < 0.001, respectively), and shorter median OS (7.1 years, P = 0.131, and 4.9 years, P < 0.001, respectively). On multivariable analysis, CEA rebound was an independent predictor of worse RFS [hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16-1.93], hDFS (HR 1.39, 95% CI 1.03-1.88), and OS (HR 1.79, 95% CI 1.18-2.73). Among patients with CEA rebound, RAS-BRAF/TP53 comutation and multiple tumors predicted worse OS while APC mutation predicted improved OS.

CONCLUSION

CEA rebound between pre-hepatectomy chemotherapy discontinuation and CLM resection is associated with worse oncologic outcomes, particularly in patients with aggressive tumor biology, and may help frame patient and surgeon expectations ahead of CLM resection.

MOUNTAINEER-03 phase III study design: first-line mFOLFOX6 + tucatinib + trastuzumab for HER2+ metastatic colorectal cancer

Patients diagnosed with metastatic colorectal cancer (mCRC) have a poor prognosis with survival ranging 2-3 years. The prevalence of human epidermal growth factor receptor 2 (HER2) amplification is approximately 3-4% in mCRC and increases up to 8% in patients with KRAS/NRAS/BRAF wild-type (WT) CRC tumors. Tucatinib is a highly selective HER2-directed tyrosine kinase inhibitor that, in combination with trastuzumab, has demonstrated clinically meaningful activity in patients with chemotherapy-refractory, HER2-positive (HER2+), RAS WT mCRC in the MOUNTAINEER trial. The MOUNTAINEER-03 phase III trial is designed to investigate the efficacy and safety of first-line tucatinib in combination with trastuzumab and modified FOLFOX6 (mFOLFOX6) versus standard of care (mFOLFOX6 plus bevacizumab or cetuximab) in patients with untreated HER2+, RAS WT locally advanced unresectable or mCRC. MOUNTAINEER-03 will include two arms of approximately 400 patients randomized 1:1 to either treatment arm. The primary endpoint is progression-free survival per RECIST v1.1 by blinded independent central review (BICR). Key secondary endpoints are overall survival and confirmed objective response rate (according to RECIST v1.1 per BICR). Safety assessments will include surveillance and recording of adverse events, physical examination findings, vital signs, cardiac assessments, Eastern Cooperative Oncology Group performance status, concomitant medications, and laboratory tests.Clinical trial registration: NCT05253651 (ClinicalTrials.gov).

Liver transplantation for colorectal cancer with liver metastases

Over the last decade, multiple clinical trials have demonstrated a survival benefit for liver transplantation in colorectal cancer with liver metastases. Additionally, advances in donor organ preservation have expanded organ availability affording the opportunity to expand indications for liver transplantation, such as colorectal cancer with unresectable liver metastases. Current data support comparable overall survival (OS) for liver transplantation for colorectal cancer with liver metastases compared with general liver transplantation recipients. Supported by this data, in the United States, allocation policy is changing to include deceased donor livers for patients with unresectable colorectal cancer liver metastases. Available studies to date demonstrate improved outcomes with primary tumor R0 resection, 6-12 months of pretransplantation chemotherapy, and careful radiologic restaging (including positron emission tomography/computed tomography) to confirm lack of extrahepatic disease. A response to pretransplantation chemotherapy is a key predictor of long-term outcomes and progression during chemotherapy appears to be a contraindication to proceeding to transplant. A carcinoembryonic antigen level ≤80 µg/L and largest liver tumor dimension <5.5 cm are both associated with improved progression-free and OS in the available literature. Liver transplantation for colorectal cancer with unresectable liver metastases is associated with longer progression-free and OS compared with chemotherapy alone. Patient selection based on imaging, laboratory, and clinical findings is critical to identify patients most likely to benefit. Liver transplantation should be considered at all centers with an active transplant program to improve outcomes for patients with advanced colorectal cancer.

Treatment sequencing in metastatic colorectal cancer

Metastatic colorectal cancer (mCRC) remains a significant challenge in contemporary oncology, with treatment sequencing playing a pivotal role in reported patient outcomes. Although currently available therapeutic options have led to improved median overall survival rates, the prognosis for patients with stage IV disease still remains dismal. This article provides a comprehensive review of the current landscape of treatment sequencing strategies in mCRC, focusing on the rationale behind various approaches and the evolving evidence supporting their efficacy. We consider the roles of chemotherapy, targeted therapy, and immunotherapy agents, as well as emerging trends in personalized medicine and sequential therapy regimens. The concept of a "continuum of care" has emerged as a fundamental principle, aiming to provide all available therapies through an individualized approach to maximize clinical benefit. By elucidating the underlying complexities of treatment sequencing in mCRC, this review aims to guide clinicians in optimizing therapeutic strategies and improving patient care.

Molecular Mechanisms of Synergistic Effect of PRIMA-1met and Oxaliplatin in Colorectal Cancer With Different p53 Status

BACKGROUND

The toxicity and drug resistance associated with oxaliplatin (L-OHP) limit its long-term use for colorectal cancer (CRC) patients. p53 mutation is a common genetic trait of CRC. PRIMA-1met (APR-246, eprenetapopt) restores the DNA-binding capacity of different mutant P53 proteins. PRIMA-1met has progressed to the Phase III clinical trial. Our study explores the combination therapy of PRIMA-1met and L-OHP for CRC with different p53 status.

METHODS

Cell viability was assessed with Cell Counting Kit-8 (CCK-8) assay and combination index (CI) was calculated using The Chou-Talalay method. We also employed wound healing assay and colony formation assay to determine the effect of L-OHP, PRIMA-1met and their combination. Weighted gene co-expression network analysis (WGCNA) of RNA-seq data was conducted to identify key modules and central genes related to different treatment modalities. Xenograft CRC mouse model was used to assess the combination treatment in vivo.

RESULTS

Our findings showed heightened cytotoxicity and inhibition of migration, and colony formation in CRC cells treated with both drugs, irrespective of p53 status, presenting a promising avenue for addressing L-OHP resistance and toxicity. RNA-seq analysis revealed differential responses between p53-wide type HCT116 and p53-mutant DLD-1 cells, with pathway alterations implicated in tumorigenesis. WGCNA identified key modules and hub genes associated with combination therapy response. In vivo studies demonstrated enhanced efficacy of combined therapy over PRIMA-1met alone, while mitigating L-OHP-induced toxicity.

CONCLUSIONS

In summary, our research reveals the differential molecular mechanisms of combined PRIMA-1met and L-OHP in CRC with wild type p53 and mutant p53. Our data not only demonstrate that this combined regimen exerts synergistic anti-CRC effect in vitro and in vivo, but also suggest the benefit of PRIMA-1met on prevention of L-OHP-related side effects. These findings underscore the clinical potential of PRIMA-1met-L-OHP combination therapy in CRC, offering enhanced efficacy and reduced toxicity, warranting further clinical investigation.

Role of locoregional therapy including liver transplantation in liver-only metastatic colorectal cancer: a review paper

INTRODUCTION

Resection of primary tumor and liver metastases is the gold standard for colorectal cancer with liver-only metastases (CRLM). Although treatment options have expanded to enable conversion of unresectable to resectable CRLM, about 40% of patients will have definitively unresectable disease. Major advances in surgical techniques, immunosuppressive protocols and patient selection criteria for liver transplantation have resulted in improved outcomes.

AREAS COVERED

A literature search has been conducted in Pubmed for articles published between 2014 and 2024. This review paper comments on current liver-directed treatment options for CRLM: resection, percutaneous ablation, conversion-chemotherapy, TACE, SIRT, and SABR. We explore evidence for liver transplantation in patients with unresectable CRLM, comment on possible limitations for implementation in clinical practice and give an overview of the current guidelines on liver transplantation in the USA, Europe, the United Kingdom, and Australia/New Zealand.

EXPERT OPINION

The recent randomized TRANSMET trial, investigating liver transplantation versus chemotherapy in unresectable CRLM, shows promising 5-year OS reaching similar values as for other accepted liver transplantation indications. Further investigations with RCTs to investigate reproducibility and feasibility in clinical practice are needed. Before liver transplantation can be implemented as a standard treatment option, reorganizations at federal, regional and hospital levels would be required.

Cannabigerol Treatment Shows Antiproliferative Activity and Causes Apoptosis of Human Colorectal Cancer Cells

Objectives

To determine growth inhibitory and anti-cancer effects of Cannabigerol (CBG) in human colorectal cancer cells.

Methods

Anti-proliferative effect of CBG was examined using MTT assay and two colorectal cancer cells (SW480 and LoVo cells). Cell death ratio was analyzed using Annexin V/PI staining experiment. Cell cycle distribution was analyzed using flow cytometry. We also performed western blot analysis on apoptotic marker proteins.

Results

CBG showed growth inhibitory effect in colorectal cancer cells using MTT assay. IC50 concentration of CBG was 34.89 μM in SW480 cells and 23.51 μM in LoVo cells. Annexin V/PI staining showed that CBG treatment increased apoptotic cells from 4.8% to 31.7% in SW480 cells and from 7.7% to 33.9% in LoVo cells. Flow cytometry confirmed that CBG increased sub G1 population via G1 arrest in both SW480 and LoVo cells. Western blot analysis showed that CBG increased expression levels of cell death-related proteins such as cleaved PARP-1, cleaved caspase 9, p53, and caspase 3.

Conclusion

CBG treatment shows antiproliferative activity and causes apoptosis of colorectal cancer cells, suggesting that CBG is applicable as a promising anticancer drug.

Assessment of cardio-oncology knowledge and practice among healthcare providers in Saudi Arabia: a comprehensive nationwide survey

INTRODUCTION

The evolving field of oncology necessitates effective management of cancer-related cardiovascular diseases. In Saudi Arabia, the incidence of cancer is rising, and there is a critical need for cardio-oncology services to address cancer treatment-related cardiovascular toxicity. This study aimed to evaluate the knowledge and practices of healthcare providers (HCPs) in Saudi Arabia regarding cardio-oncology.

METHODS

A cross-sectional study was conducted from January 2024 to April 2024 using an online survey targeting cardiologists, oncologists, and clinical pharmacists. The survey assessed demographics, perceptions of cardio-oncology, availability of services, and current practices. Data were analyzed using descriptive statistics, chi-squared tests, and bivariate analyses.

RESULTS

The survey received responses from 116 HCPs, including cardiologists (63.79%), oncologists (23.28%), and clinical pharmacists (12.93%). Most participants had over six years of experience, and only one had formal cardio-oncology training. While 84.48% recognized the importance of managing cardiac complications in cancer patients, only 42.24% were familiar with existing guidelines. Limited training programs and institutional resources were significant barriers to implementing cardio-oncology services. Despite agreement on the need for cardiotoxicity management, only one-third recommended cardioprotective agents as standard care.

CONCLUSION

There is a notable deficiency in formal training and resources for cardio-oncology in Saudi Arabia. To bridge this gap, integrating cardio-oncology into training programs, establishing institutional guidelines, and adopting multidisciplinary care models are crucial. These measures will enhance the quality of care for cancer patients and improve their cardiovascular outcomes.

snRNA-seq of long-preserved FFPE samples from colorectal liver metastasis lesions with diverse prognoses

Differences in prognostic outcomes are prevalent in patients with colorectal cancer liver metastases. Comparative analysis of tissue samples, particularly applying single-cell transcriptome sequencing technology, can provide a deeper understanding of potential impacting factors. However, long-term monitoring for prognosis determination necessitates extended preservation of tissue samples using formalin-fixed and paraffin-embedded (FFPE) treatments, which can cause substantial RNA degradation, presenting challenges to single-cell or single-nucleus sequencing. In this study, employing snRandom-seq, a single-nucleus RNA sequencing (snRNA-seq) technology specifically for FFPE samples, we tested multiple lesion samples from 18 distinctive colorectal cancer liver metastasis cases with diverse prognostic outcomes that have been preserved for at least three years (mostly over five years). The process yielded expression data from 82,285 cells. The high-quality snRNA-seq data demonstrate the feasibility of single-nucleus sequencing in long-term preserved FFPE samples, offering potential insights into the heterogeneity between different prognoses of colorectal cancer liver metastases, and the relationship between the heterogeneity within different lesions of the same patient and prognosis.

Brief Report: Trends in Incidence, Mortality, and Disability-Adjusted Life Years for Early-Onset Colorectal Cancer in Canada Between 1990 and 2019

BACKGROUND

Colorectal cancer is the third most common malignancy globally. Early-onset colorectal cancer (EOCRC) is becoming a growing healthcare focus globally, particularly in North America. We estimated trends in incidence, mortality, and disability-adjusted life years (DALYs) for EOCRC in Canada between 1990 and 2019.

METHODS

We used the Global Burden of Diseases Study to evaluate trends in incidence, mortality, and DALYs for EOCRC in Canada between 1990 and 2019. Rates were estimated per 100,000 persons at risk with associated uncertainty intervals (UIs). Annual percentage changes (APC) were estimated using joinpoint regression with 95% confidence intervals (CIs).

RESULTS

In 2019, the incidence, mortality, and DALYs rates for EOCRC were 10.89 (95% UI 8.09, 14.34), 2.24 (95% UI 2.00, 2.51), and 111.37 (95% UI 99.34, 124.78) per 100,000 individuals, respectively. Incidence increased during the study period by 1.12%/year (95% CI 1.03%, 1.22%; p < 0.001). The largest increase in incidence in EOCRC occurred between 1990 and 2007, with an APC of 2.23% (95% CI 2.09%, 2.37%; p < 0.001). Mortality (APC 2.95%, 95% CI 1.89%, 4.02%; p < 0.001) and DALY (APC 2.96%, 95% CI 1.84%, 4.09%; p < 0.001) rates increased for males between 2001 and 2006.

CONCLUSIONS

Our study reveals a substantial burden in EOCRC in Canada, with a significant increase in incidence.

Perioperative and Oncologic Outcomes of Hepatic Arterial Infusion (HAI) Pump Chemotherapy for Patients with Unresectable Colorectal Liver Metastases at an Expanding HAI Program

BACKGROUND

Hepatic arterial infusion (HAI) is an established treatment for patients with unresectable colorectal liver metastases (uCRLM). Until recently, HAI was only performed at a limited number of centers. We previously reported early outcomes suggesting that implementation of a new HAI program is safe and feasible. Here, we report perioperative and oncologic outcomes from an expanded series of patients with uCRLM treated with HAI.

METHODS

We analyzed outcomes from consecutive patients with uCRLM who underwent HAI pump (HAIP) placement at Duke University Hospital from 2018 to 2023. Demographics, prior treatment, and perioperative and oncologic outcomes were assessed.

RESULTS

Overall, 102 patients underwent HAIP placement for uCRLM; 62% were male and median age was 51 years. Most patients (97%) received a median of 12 (range 0-66) prior chemotherapy cycles. Postoperative HAI-specific complications occurred in 23% of patients, including biliary sclerosis in 6%, and the 90-day mortality rate was 3%. 20% converted to resection, 4% underwent transplant, and 2% achieved complete response at 6 months after floxuridine initiation. Median hepatic and extrahepatic progression-free survival (PFS) was 15.7 months and 11.6 months, respectively. Median overall survival (OS) was 38 months from the time of pump implantation (median follow-up time: 30 months).

CONCLUSIONS

HAI for uCRLM is safe, feasible, and effective at a new center, with outcomes that recapitulate those previously reported by established centers. Future analysis of our institutional data, which includes mutation status, primary tumor sidedness, and extent of prior therapy could inform selection and treatment strategies for new HAI programs.

Precision Medicine for Metastatic Colorectal Cancer: Where Do We Stand?

Metastatic colorectal cancer is a leading cause of cancer-related death across the world. The treatment paradigm has shifted away from systemic chemotherapy alone to include targeted therapy and immunotherapy. The past two decades have been characterized by increased investigation into molecular profiling of colorectal cancer. These molecular profiles help physicians to better understand colorectal cancer biology among patients with metastatic disease. Additionally, improved data on genetic pathways allow for specific therapies to be targeted at the underlying molecular profile. Investigation of the EGFR, VEGF, HER2, and other pathways, as well as deficient mismatch repair, has led to the development of multiple targeted therapies that are now utilized in the National Comprehensive Cancer Network guidelines for colon and rectal cancer. While these new therapies have contributed to improved survival for metastatic colorectal cancer, long-term survival remains poor. Additional investigation to understand resistance to targeted therapy and development of new targeted therapy is necessary. New therapies are under development and are being tested in the preclinical and clinical settings. The aim of this review is to provide a comprehensive evaluation of molecular profiling, currently available therapies, and ongoing obstacles in the field of colorectal cancer.

Characterization of metastasis-specific macrophages in colorectal cancer for prognosis prediction and immunometabolic remodeling

This study develops a prognostic model to predict metastasis and prognosis in colorectal cancer liver metastases by identifying distinct macrophage subsets. Using scRNA-seq data from primary colorectal cancer and liver metastases, we dissected the cellular landscape to find unique macrophage subpopulations, particularly EEF1G + macrophages, which were prevalent in liver metastases. The study leveraged data from GSE231559, TCGA, and GEO databases to construct an 8-gene risk model named EMGS, based on the EEF1G + macrophage gene signature. Patients were divided into high-risk and low-risk groups using the median EMGS score, with the high-risk group showing significantly worse survival. This group also demonstrated upregulated pathways associated with tumor progression, such as epithelial-mesenchymal transition and angiogenesis, and downregulated metabolic pathways. Moreover, the high-risk group presented an immunosuppressive microenvironment, with a higher TIDE score indicating lower effectiveness of immunotherapy. The study identifies potential drugs targeting the high-risk group, suggesting therapeutic avenues to improve survival. Conclusively, the EMGS score identifies colorectal cancer patients at high risk of liver metastases, highlighting the role of specific macrophage subsets in tumor progression and providing a basis for personalized treatment strategies.

Mitotic spindle positioning protein serves as prognostic biomarker in patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) ranks among the most aggressive types of cancer globally. Currently, clinical tumor prognostic biomarkers still lack accuracy. Mitotic spindle positioning (MISP) protein connects microtubules to the actin cytoskeleton and adhesive plaques, playing a critical role in spindle positioning, orientation, and the process of cell division. MISP can regulate the malignant biological functions of pancreatic cancer and intrahepatic cholangiocarcinoma and it acts as biomarker for prognosis, but its role in CRC remains unclear.

METHODS

This study has collected 37 CRC tissue samples and 37 corresponding adjacent nontumor tissue samples, and 57 additional CRC tissues samples. Clinical data were obtained from the patients with CRC. MISP mRNA and protein expression levels were analyzed in normal control and CRC tissues using the GEPIA and Human Protein Atlas website. MISP protein levels in the collected tissues were analyzed using immunohistochemistry.

RESULTS

MISP mRNA and protein expression levels were significantly increased in CRC tissues compared to adjacent nontumor tissues. Higher MISP protein levels were associated with distant metastasis, recurrence, and lower survival rates. Kaplan-Meier analysis showed that high expression levels of MISP protein were associated with recurrence and death in CRC patients. In addition, a high expression level of MISP protein, lymph node metastasis, and distance metastasis were risk factors for recurrence and a poor prognosis in patients with CRC.

CONCLUSION

Elevated MISP protein correlated with tumor metastasis, recurrence, and lower survival rates in patients with CRC, and thus, MISP has the potential to become a prognostic marker for CRC.

N-palmitoyl-d-glucosamine limits mucosal damage and VEGF-mediated angiogenesis by PPARα-dependent suppression of pAkt/mTOR/HIF1α pathway and increase in PEA levels in AOM/DSS colorectal carcinoma in mice

Chronic intestinal inflammation and neo-angiogenesis are interconnected in colorectal carcinoma (CRC) pathogenesis. Molecules reducing inflammation and angiogenesis hold promise for CRC prevention and treatment. N-Palmitoyl-d-glucosamine (PGA), a natural glycolipid analog with anti-inflammatory properties, has shown efficacy against acute colitis. Micronized PGA (mPGA) formulations exhibit superior anti-inflammatory activity. This study investigates the in vivo anti-angiogenic and protective effects of mPGA in a mouse model of colitis-associated CRC induced by azoxymethane/dextran sodium sulfate (AOM/DSS). CRC was induced in C57BL/6J mice using intraperitoneal azoxymethane followed by three cycles of 2.5% dextran sodium sulfate (DSS) in drinking water. Mice were treated with mPGA (30-150 mg/kg) with or without the PPARα inhibitor MK886 (10 mg/kg). At Day 70 post-azoxymethane injection, mice underwent anesthetized endoscopic colon evaluation. Post-mortem analysis of tumorigenesis and angiogenesis was performed using histological, immunohistochemical, and immunoblotting techniques. mPGA improved disease progression and survival rates in a dose- and PPARα-dependent manner in AOM/DSS-exposed mice. It reduced polyp formation, decreased pro-angiogenic CD31, pro-proliferative Ki67, and pro-inflammatory TLR4 expression levels, and inhibited VEGF and MMP-9 secretion by disrupting the pAkt/mTOR/HIF1α pathway. mPGA increased colon PEA levels, restoring anti-tumoral PPARα and wtp53 protein expression. Given its lack of toxicity, mPGA shows potential as a nutritional intervention to counteract inflammation-related angiogenesis in CRC.

Consensus molecular subtyping of metastatic colorectal cancer expands biomarker-directed therapeutic benefit for patients with CMS1 and CMS2 tumors

BACKGROUND

We developed a whole transcriptome sequencing (WTS)-based Consensus Molecular Subtypes (CMS) classifier using FFPE tissue and investigated its prognostic and predictive utility in a large clinico-genomic database of CRC patients (n = 24,939).

METHODS

The classifier was trained against the original CMS datasets using an SVM model and validated in an independent blinded TCGA dataset (88.0% accuracy). Kaplan-Meier estimates of overall survival (OS) and time-on-treatment (TOT) were calculated for each CMS (p < 0.05 considered significant).

RESULTS

CMS2 tumors were enriched on left-side of colon and conferred the longest median OS. In RAS-wildtype mCRC, left-sided tumors and CMS2 classification were associated with longer TOT with anti-EGFR antibodies (cetuximab and panitumumab). When restricting to only CMS2, there was no significant difference in TOT between right- versus left-sided tumors. CMS1 tumors were associated with a longer median TOT with pembrolizumab relative to other CMS groups, even when analyzing only microsatellite stable (MSS) tumors.

DISCUSSION

A WTS-based CMS classifier allowed investigation of a large multi-institutional clinico-genomic mCRC cohort, suggesting anti-EGFR therapy benefit for right-sided RAS-WT CMS2 tumors and immune checkpoint inhibitor benefit for MSS CMS1. Routine CMS classification of CRC provides important treatment associations that should be further investigated.

Molecular, Socioeconomic, and Clinical Factors Affecting Racial and Ethnic Disparities in Colorectal Cancer Survival

Importance

Disparity in overall survival (OS) and differences in the frequency of driver gene variants by race and ethnicity have been separately observed in patients with colorectal cancer; however, how these differences contribute to survival disparity is unknown.

Objective

To quantify the association of molecular, socioeconomic, and clinical covariates with racial and ethnic disparities in overall survival among patients with colorectal cancer.

Design, Setting, and Participants

This single-center cohort study was conducted at a tertiary-level cancer center using relevant data on all patients diagnosed with colorectal cancer from January 1, 1973, to March 1, 2023. The relative contribution of variables to the disparity was determined using mediation analysis with sequential multivariate Cox regression models.

Main Outcome

OS, from diagnosis date and from start of first-line chemotherapy.

Results

The study population of 47 178 patients (median [IQR] age, 57.0 [49-66] years; 20 465 [43.4%] females and 26 713 [56.6%] males; 3.0% Asian, 8.7% Black, 8.8% Hispanic, and 79.4% White individuals) had a median (IQR) follow-up from initial diagnosis of 124 (174) months and OS of 55 (145) months. Compared with White patients, Black patients had worse OS (hazard ratio [HR], 1.16; 95% CI, 1.09-1.24; P <.001), whereas Asian and Hispanic patients had better OS (HR, 0.66; 95% CI, 0.59-0.74; P <.001; and 0.86; 95% CI, 0.81-0.92; P <.001, respectively). When restricted to patients with metastatic disease, the greatest disparity was between Black patients compared with White patients (HR, 1.2; 95% CI, 1.06-1.37; P <.001). Evaluating changes in OS disparity over 20 years showed disparity decreasing among Asian, Hispanic, and White patients, but increasing between Black patients and White patients (HRs, 1.18; 95% CI, 1.07-1.31 for 2008-2012; 1.24, 95% CI, 1.08-1.42 for 2013-2017; and 1.50; 95% CI, 1.20-1.87 for 2018-2023). Survival outcomes for first-line chemotherapy were worse for Black patients compared with White patients (median OS, 18 vs 26 months; HR, 1.30; 95% CI, 1.01-1.70). Among 7628 patients who had clinical molecular testing, APC, KRAS, and PIK3CA showed higher variant frequency in Black patients (false discovery rate [FDR], 0.01; < 0.001; and 0.01, respectively), whereas BRAF and KIT were higher among White patients (FDR, 0.001 and 0.01). Mediation analysis identified neighborhood socioeconomic status as the greatest contributor to OS disparity (29%), followed by molecular characteristics (microsatellite instability status, KRAS variation and BRAF variation, 10%), and tumor sidedness (9%).

Conclusions

This single-center cohort study identified substantial OS disparity and differing frequencies of driver gene variations by race and ethnicity. Socioeconomic status had the largest contribution but accounted for less than one-third of the disparity, with substantial contribution from tumor molecular features. Further study of the associations of genetic ancestry and the molecular pathogenesis of colorectal cancer with chemotherapy response is needed.

Liver Resection With Extrahepatic Disease: A Population-Based Analysis of Thoughtful Selection

BACKGROUND

The oncologic benefit of liver resection for colorectal liver metastases (CRLM) in the setting of concurrent extrahepatic disease (EHD) is controversial. We performed a population-based, cross-sectional study to determine the practice patterns and overall survival (OS) of patients with CRLM + EHD who underwent liver resection.

METHODS

Patients with CRLM + EHD were identified using the California Cancer Registry from 2000 to 2019. Records were linked to the Office of Statewide Health Planning Inpatient Database. Patient demographics, clinical characteristics, and survival were compared between CRLM + EHD patients with and without liver resection.

RESULTS

Of 170 978 patients with CRLM, 62 003 (36%) had concurrent EHD (CRLM + EHD). In all, 3736 (6%) of CRLM + EHD underwent liver resection compared to 22% of patients with liver limited CRLM. Compared to CRLM + EHD without liver resection, CRLM + EHD with resection were younger, had fewer comorbidities, received higher frequencies of perioperative chemotherapy, and were more likely to have only a single site of EHD rather than multiple sites. Median OS was significantly higher for CRLM + EHD with resection compared to without (52 vs. 27 months, HR 0.46 [95% CI 0.44-0.47], p < 0.001). Regarding the location of EHD, this survival benefit was observed with liver resection for lung, peritoneal, intraabdominal lymph nodes, ovarian, and bone metastases.

CONCLUSIONS

In a large population-based setting, subsets of CRLM + EHD patients that undergo liver resection are associated with prolonged survival. These results support surgery with thoughtful patient selection to optimize survival outcomes in this population.

Evaluation of two-stage hepatectomy using portal vein embolization for colorectal liver metastasis: a retrospective nationwide cohort survey in Japan

INTRODUCTION

Two-stage hepatectomy (TSH) enables patients to undergo surgery for colorectal liver metastasis (CRLM), which one-stage hepatectomy cannot remove. Although the outcome of TSH has been reported, there is no original report from Japan. The aim of this retrospective study was to evaluate the outcome of TSH in Japanese patients with CRLM.

METHODS

The authors conducted a retrospective cohort study using the nationwide database that included clinical information of 12 519 patients treated with CRLM between 2005 and 2017 in Japan. The primary outcome measure was overall survival. The second outcome measure was progression-free survival. Fisher's exact test, χ 2 test and Mann-Whitney U test were conducted to examine an intergroup difference. Univariate and multivariate analyses were performed using Cox regression model. Survival analysis was performed by Kaplan-Meier method and log-rank test.

RESULTS

Of the database, 53 patients undergoing TSH using portal vein embolization (PVE) were identified and analyzed. Their morbidity and in-hospital mortality rates at the second hepatectomy were 26.4% and 0.0%. The mean observation period was 21.8 months. The estimated 1-, 3- and 5-year overall survival rate were 92.5%, 70.8% and 34.7%. Multivariate analyses showed that more than 10 liver nodules significantly increased the mortality risk by 4.2-fold (95% CI 1.224-14.99, P = 0.023). Survival analysis revealed that repeat hepatectomy for disease progression after TSH was superior to chemotherapy in overall survival (mean: 49.6 vs. 18.7, months, P = 0.004).

CONCLUSION

In the Japanese cohort, TSH was confirmed to be a safety procedure with an acceptable survival outcome. More than 10 liver nodules may be a predictor for unfavorable outcomes of patients with CRLM undergoing TSH. Furthermore, repeat hepatectomy can be a salvage treatment for resectable intrahepatic recurrence after TSH.

Elevated BEAN1 expression correlates with poor prognosis, immune evasion, and chemotherapy resistance in rectal adenocarcinoma

BACKGROUND

The BEAN1 gene, primarily studied in neurodegenerative diseases, has been scarcely studied in the context of cancers. Our research examines BEAN1 expression specifically in rectal adenocarcinoma (READ) and its association with prognosis, immune evasion, and chemotherapy resistance.

METHODS

Data from TCGA and GEO were analyzed to assess BEAN1 levels across various cancer types, with particular emphasis on READ. Functional enrichment, immune infiltration, and treatment response analyses were conducted, followed by validation using patient tissue samples.

RESULTS

READ tissues exhibited a marked increase in BEAN1 expression compared to normal tissues. Elevated BEAN1 levels were associated with reduced overall survival and increased immune suppression, characterized by elevated M2 macrophage infiltration and reduced CD8+ T cell presence. BEAN1 expression was also linked to higher immune checkpoint genes expression and resistance to immune checkpoint inhibitors and 5-fluorouracil.

CONCLUSION

This research offers initial evidence that BEAN1 is linked to unfavorable prognosis, immune escape, and resistance to chemotherapy in READ. BEAN1 appears to be a promising new biomarker and potential therapeutic target, warranting further investigation into its potential clinical applications in improving treatment outcomes for READ patients.

Synchronous or metachronous breast and colorectal cancers in younger-than-average-age patients: a case series

BACKGROUND

The incidence of breast and colorectal cancer (CRC) in younger-than-average-age patients is rising and poorly understood. This is the largest study on patients with both cancers who are less than 60 years old and aims to characterize demographic, clinicopathologic, and genetic features and describe therapeutic dilemmas and management strategies.

MATERIALS AND METHODS

This is a retrospective medical records review of patients at the University of California San Francisco with both primary breast and CRC before age 60.

RESULTS

Fifty-one patients were identified; 41 had detailed medical records. Median age of diagnosis with breast cancer was 43 (range 27-59) and CRC was 50 (28-59). Most were Caucasian (38, 74.5%) and never smokers (23, 56.1%); about half were current alcohol consumers (20, 48.8%) and about one-third had sedentary jobs (14, 34.1%). Average BMI was 25.8 (range: 14-49), and 30% were overweight or obese. Breast was the first cancer diagnosed in 36 patients (70.6%) and 44 (86.3%) had a metachronous CRC diagnosis. Breast cancer was early stage (0-2) in 32 (78.0%) patients whereas CRC was split between early stage (1-2) in 14 (34.1%) and later stage (3-4) in 19 (46.2%). Ten patients (24.3%) had a known germline mutation, although 23 (56.1%) had a family history of cancer in a first-degree relative.

CONCLUSION

Younger patients with both breast and CRC are a unique cohort, often without known risk factors. Alcohol consumption and sedentary jobs were the most common risk factors, and about one-quarter had a known genetic predisposition. Comanagement of both cancers requires individualized, multidisciplinary care.

Synchronous Breast and Colorectal Malignant Tumors-A Systematic Review

The incidence of breast and colorectal cancers is well established in studies, but the synchronous occurrence of the two types of tumors is a rarity. In general, they are discovered during screening investigations following the diagnosis of an initial tumor.

OBJECTIVE

Our aim is to describe the main diagnostic and therapeutic challenges for synchronous breast and colorectal tumors.

MATERIALS AND METHODS

We performed a systematic review of the literature for cases or case series, using established keywords (synchronous breast and colon tumor and synonyms) for the period of 1970-2023. Five reviewers independently screened the literature, extracted data, and assessed the quality of the included studies. The results were processed according to the PRISMA 2020 guidelines.

RESULTS

A total of 15 cases were included in the study, including 2 males (age 50 and 57) and 13 females (median age 60, with range from 40 to 79). In a vast majority of the cases, the diagnosis of synchronous tumor was prompted by the first tumor's workup. The first diagnosed tumor was colorectal in nine cases and a breast tumor in six cases. The most common histopathological type of breast tumor was invasive ductal carcinoma, and the colon tumors were exclusively adenocarcinomas. All cases had a surgical indication for both breast and colorectal tumor, except one case, in which the breast tumor had multiple metastasis. In four cases, the surgery was performed concomitantly (colectomy and mastectomy). In three cases, surgery was initially carried out for the breast tumor, followed by colon surgery. Oncological treatment was indicated depending on the tumor stage.

CONCLUSIONS

For the treatment of synchronous tumors, the Tumor Board (T.B) decision is mandatory and must be personalized for each patient. Developing new methods of treatment and investigation may play an important role in the future for understanding synchronous tumor development, incidence, and outcome.

Intraoperative near infrared functional imaging of rectal cancer using artificial intelligence methods - now and near future state of the art

Colorectal cancer remains a major cause of cancer death and morbidity worldwide. Surgery is a major treatment modality for primary and, increasingly, secondary curative therapy. However, with more patients being diagnosed with early stage and premalignant disease manifesting as large polyps, greater accuracy in diagnostic and therapeutic precision is needed right from the time of first endoscopic encounter. Rapid advancements in the field of artificial intelligence (AI), coupled with widespread availability of near infrared imaging (currently based around indocyanine green (ICG)) can enable colonoscopic tissue classification and prognostic stratification for significant polyps, in a similar manner to contemporary dynamic radiological perfusion imaging but with the advantage of being able to do so directly within interventional procedural time frames. It can provide an explainable method for immediate digital biopsies that could guide or even replace traditional forceps biopsies and provide guidance re margins (both areas where current practice is only approximately 80% accurate prior to definitive excision). Here, we discuss the concept and practice of AI enhanced ICG perfusion analysis for rectal cancer surgery while highlighting recent and essential near-future advancements. These include breakthrough developments in computer vision and time series analysis that allow for real-time quantification and classification of fluorescent perfusion signals of rectal cancer tissue intraoperatively that accurately distinguish between normal, benign, and malignant tissues in situ endoscopically, which are now undergoing international prospective validation (the Horizon Europe CLASSICA study). Next stage advancements may include detailed digital characterisation of small rectal malignancy based on intraoperative assessment of specific intratumoral fluorescent signal pattern. This could include T staging and intratumoral molecular process profiling (e.g. regarding angiogenesis, differentiation, inflammatory component, and tumour to stroma ratio) with the potential to accurately predict the microscopic local response to nonsurgical treatment enabling personalised therapy via decision support tools. Such advancements are also applicable to the next generation fluorophores and imaging agents currently emerging from clinical trials. In addition, by providing an understandable, applicable method for detailed tissue characterisation visually, such technology paves the way for acceptance of other AI methodology during surgery including, potentially, deep learning methods based on whole screen/video detailing.

Evolution and current trends in the management of colorectal cancer liver metastasis

Metastatic colorectal cancer (mCRC) is a major cause of cancer-related death, with a 5-year relative overall survival of up to 20%. The liver is the most common site of distant metastasis in colorectal cancer (CRC), with about 50% of CRC patients metastasizing to their liver over the course of their disease. Complete liver resection is the primary modality of treatment for resectable colorectal cancer liver metastasis (CRLM), with an overall 5-year survival rate of up to 58%. However, only 15% to 20% of patients with CRLM are deemed suitable for resection at presentation. For unresectable diseases, the median survival of patients remains low even with the best chemotherapy. In recent decades, the management of CRLM has continued to evolve with the expansion of resection criteria, novel targeted systemic therapies, and improved locoregional therapies. However, due to the heterogeneity of the CRC patient population, the optimal evaluation of treatment options for CRLM remains complex. Therefore, effective management requires a multidisciplinary team to help define resectability and devise a personalized treatment approach, from the initial diagnosis to the final treatment.

Transfer of miR-100 and miR-125b increases 3D growth and invasiveness in recipient cancer cells

Aim

Extracellular communication via the transfer of vesicles and nanoparticles is now recognized to play an important role in tumor microenvironment interactions. Cancer cells upregulate and secrete abundant levels of miR-100 and miR-125b that can alter gene expression in donor and recipient cells. In this study, we sought to identify targets of miR-100 and miR-125b and conclusively demonstrate that microRNAs (miRNAs) can be functionally transferred from donor to recipient cells.

Methods

To identify targets of miR-100 and miR-125b, we used bioinformatic approaches comparing multiple colorectal cancer (CRC) cell lines, including knockout lines lacking one or both of these miRNAs. We also used spheroid and 3D growth conditions in collagen to test colony growth and invasiveness. We also used Transwell co-culture systems to demonstrate functional miRNA transfer.

Results

From an initial list of 96 potential mRNA targets, we identified and tested 15 targets, with 8 showing significant downregulation in the presence of miR-100 and miR-125b. Among these, cingulin (CGN) and protein tyrosine phosphatase receptor type-R (PTPRR) are downregulated in multiple cancers, consistent with regulation by increased levels of miR-100 and miR-125b. We also show that increased cellular levels of miR-100 and miR-125b enhance 3D growth and invasiveness in CRC and glioblastoma cell lines. Lastly, we demonstrate that extracellular transfer of miR-100 and miR-125b can silence both reporter and endogenous mRNA targets in recipient cells and also increase the invasiveness of recipient spheroid colonies when grown under 3D conditions in type I collagen.

Conclusion

miR-100 and miR-125b target multiple mRNAs that can regulate 3D cell-autonomous growth and invasiveness. By extracellular transfer, miR-100 and miR-125b can also increase colony growth and invasiveness in recipient cells through non-cell-autonomous mechanisms.

Physical Activity in Patients with Advanced Cancer: Sociodemographic, Clinical, and Psychological Correlates

As cancer progresses, patients may experience physical decline, which can impair their ability to carry out essential daily tasks. The aim of this study was to analyze the levels of physical activity in patients with advanced cancer undergoing systemic treatment and its relationship with sociodemographic, clinical, and psychological factors. A prospective, cross-sectional, multicenter study was carried out in 15 oncology departments in Spain. Patients with locally advanced, unresectable, or metastatic cancer who were candidates for systemic treatment were included. Participants completed demographic information and psychological scales. In total, 508 patients were included in the study, the majority of whom were male, over the age of 65, and diagnosed with bronchopulmonary tumors (36%) and metastatic disease. Based on their physical activity levels, participants were categorized as sedentary (20%, n = 190), engaging in light physical activity (43%, n = 412), or demonstrating moderate physical activity (37%, n = 351). Patients who were over 65 years old; had a worse baseline status (ECOG ≥ 1); lacked a partner; had a lower educational level; or were retired or unemployed were found to have lower levels of physical activity. Those with sedentary physical activity reported higher levels of psychological distress, anxiety, depression, somatization, and physical symptoms, as well as worse functional status, global health status, and well-being. Understanding the complex interplay between physical activity and sociodemographic, clinical, and psychological factors can help neuroscientists develop tailored exercise interventions that address the unique needs of advanced cancer patients.

Computer-aided molecular design and optimization of potent inhibitors disrupting APC‒Asef interaction

Colorectal cancer (CRC) is the second leading cause of cancer mortality worldwide. At initial diagnosis, approximately 20% of patients are diagnosed with metastatic CRC (mCRC). Although the APC‒Asef interaction is a well-established target for mCRC therapy, the discovery and development of effective and safe drugs for mCRC patients remains an urgent and challenging endeavor. In this study, we identified a novel structural scaffold based on MAI inhibitors, the first-in-class APC‒Asef inhibitors we reported previously. ONIOM model-driven optimizations of the N-terminal cap and experimental evaluations of inhibitory activity were performed, and 24-fold greater potency was obtained with the best inhibitor compared to the parental compound. In addition, the cocrystal structure validated that the two-layer π‒π stacking interactions were essential for inhibitor stabilization in the bound state. Furthermore, in vitro and in vivo studies have demonstrated that novel inhibitors suppressed lung metastasis in CRC by disrupting the APC‒Asef interaction. These results provide an intrinsic structural basis to further explore drug-like molecules for APC‒Asef-mediated CRC therapy.

BRAF mutations and survival with surgery for colorectal liver metastases: A systematic review and meta-analysis

INTRODUCTION

Mutations in the BRAF gene (BRAFmut) are associated with an unfavorable prognosis in patients with metastatic colorectal cancer (CRC). The aim of this meta-analysis was to evaluate the prognosis of colorectal cancer (CRC) patients with liver metastases and the potential benefits of liver resection in patients with BRAFmut CRC.

MATERIAL AND METHODS

A systematic search of PubMed, Cochrane Central Controlled Trials, and Embase databases was conducted on May 31, 2023. The inclusion criteria were as follows:1) reporting of outcomes in patients with BRAFmut CRC who underwent surgery for liver metastases and/or comparison of outcomes between those who underwent and those who did not undergo resection; 2) reporting of survival information as hazard ratios (HR); and 3) publication in English.

RESULTS

34 studies were included. Median follow up was 48 months for prognostic BRAF status meta-analysis. BRAFmut status showed a significantly increased risk of mortality (hazard ratio [HR] = 2.56, 95% confidence interval [CI] 2.04-3.22; P < 0.01) and relapse (HR = 1.97, 95% CI 1.44-2.71; P < 0.01). Resection of liver metastases was associated with a survival benefit (median follow up 46 months). The HR for survival was 0.44 (95% confidence interval [CI] 0.33-0.59; P < 0.01) in favor of surgery.

CONCLUSIONS

and Relevance: Our analysis indeed confirms that BRAF mutation is associated with poor survival outcomes after liver resection of CRC metastases. However, upon quantitatively assessing the survival benefit of surgical intervention in patients with BRAF-mutated CRC liver metastases, we identified a significant 56% reduction in the risk of death.

Consideration of Metastasis-Directed Therapy for Patients With Metastatic Colorectal Cancer: Expert Survey and Systematic Review

BACKGROUND

A survey of medical oncologists (MOs), radiation oncologists (ROs), and surgical oncologists (SOs) who are experts in the management of patients with metastatic colorectal cancer (mCRC) was conducted to identify factors used to consider metastasis-directed therapy (MDT).

MATERIALS AND METHODS

An online survey to assess clinical factors when weighing MDT in patients with mCRC was developed based on systematic review of the literature and integrated with clinical vignettes. Supporting evidence from the systematic review was included to aid in answering questions.

RESULTS

Among 75 experts on mCRC invited, 47 (response rate 62.7%) chose to participate including 16 MOs, 16 ROs, and 15 SOs. Most experts would not consider MDT in patients with 3 lesions in both the liver and lung regardless of distribution or timing of metastatic disease diagnosis (6 vs. 36 months after definitive treatment). Similarly, for patients with retroperitoneal lymph node and lung and liver involvement, most experts would not offer MDT regardless of timing of metastatic disease diagnosis. In general, SOs were willing to consider MDT in patients with more advanced disease, ROs were more willing to offer treatment regardless of metastatic site location, and MOs were the least likely to consider MDT.

CONCLUSIONS

Among experts caring for patients with mCRC, significant variation was noted among MOs, ROs, and SOs in the distribution and volume of metastatic disease for which MDT would be considered. This variability highlights differing opinions on management of these patients and underscores the need for well-designed prospective randomized trials to characterize the risks and potential benefits of MDT.

Survival Analysis of Metastatic Early-Onset Colorectal Cancer Compared to Metastatic Average-Onset Colorectal Cancer: A SEER Database Analysis

BACKGROUND

Early-onset colorectal cancer (EO-CRC) is defined as colorectal cancer diagnosed before the age of 50 years, and its incidence has been increasing over the last decade, now accounting for 10% of all new CRC diagnoses. Average-onset colorectal cancer (AO-CRC) has shown a steady decline in its incidence and related mortality over the past 20 years. The disparities in outcomes and overall survival (OS) between EO-CRC and AO-CRC are controversial. Our study compared OS and cause-specific survival (CSS) between metastatic EO-CRC (mEO-CRC) and metastatic AO-CRC (mAO-CRC) and identified the associated factors.

METHODS

Data on patient characteristics, tumor characteristics, incidence, and mortality were obtained from the SEER database from 2010 to 2020. We identified 23,278 individuals aged > 18 years with a confirmed diagnosis of all histological subtypes of metastatic CRC (M1 on TNM stage) using ICD-O-3 site codes. mEO-CRC and mAO-CRC were compared. OS distributions and CCS were analyzed using the Kaplan-Meier method and log-rank test to assess differences. A Cox regression model was used to assess the associations between variables.

RESULTS

mEO-CRC constituted 17.79% of the cases, whereas 82.21% had mAO-CRC. Most patients with mEO-CRC were 45-49 years old (47.66%), male (52.16%) and White (72.57%) and had adenocarcinoma histology (87.30%). Left colon tumors were most prevalent in both groups (40.26%) but were more prevalent in mEO-CRC patients than in mAO-CRC patients (49.63% vs. 38.23%, p < 0.001). Patients with mEO-CRC had higher OS (p < 0.001) and CSS (p < 0.001) than those with mAO-CRC. Patients with mEO-CRC also had significantly better median overall survival (30 months vs. 18 months, p < 0.001). The factors associated with worse OS included mAO-CRC (p < 0.001), mucinous adenocarcinoma (p < 0.001), male sex (p = 0.003), and a lack of surgical intervention (p < 0.001).

CONCLUSIONS

Most patients with mEO-CRC fall within the range of 45 to 49 years of age. Patients with mEO-CRC were more likely to receive cancer-directed therapy (including chemotherapy and radiotherapy) and had better OS and CSS than those with mAO-CRC. This is likely attributable to the better performance status, fewer comorbidities, and better tolerance to cancer-directed therapy in mEO-CRC patients. The factors associated with worse OS and CSS were age > 50 years, mucinous adenocarcinoma, male sex, and no surgical treatment.

miR-100 and miR-125b Contribute to Enhanced 3D Growth and Invasiveness and can be Functionally Transferred to Silence Target Genes in Recipient Cells

Extracellular communication via the transfer of vesicles and nanoparticles is now recognized to play an important role in tumor microenvironment interactions. Cancer cells upregulate and secrete abundant levels of miR-100 and miR-125b that can alter gene expression by both cell- and non-cell-autonomous mechanisms. We previously showed that these miRNAs activate Wnt signaling in colorectal cancer (CRC) through noncanonical pairing with 5 negative regulators of Wnt signaling. To identify additional targets of miR-100 and miR-125b , we used bioinformatic approaches comparing multiple CRC cell lines, including knockout lines lacking one or both of these miRNAs. From an initial list of 96 potential mRNA targets, we tested 15 targets with 8 showing significant downregulation in the presence of miR-100 and miR-125b . Among these, Cingulin (CGN) and Protein tyrosine phosphatase receptor type-R (PTPRR) are downregulated in multiple cancers, consistent with regulation by increased levels of miR-100 and miR-125b. We also show that increased cellular levels of miR-100 and miR-125b enhance 3D growth and invasiveness in CRC and glioblastoma cell lines. Lastly, we demonstrate that extracellular transfer of miR-100 and miR-125b can silence both reporter and endogenous mRNA targets in recipient cells and also increase the invasiveness of recipient spheroid colonies when grown under 3D conditions in type I collagen.

Surgical and multimodal treatment of metastatic oesophageal cancer: retrospective cohort study

BACKGROUND

In contrast to the well-established multimodal therapy for localized oesophageal cancer, the metastatic stage is commonly treated only with systemic therapy as current international guidelines recommend. However, evidence suggesting that multimodal therapy including surgery could benefit selected patients with metastasized oesophageal cancer is increasing. The aim of this study was to investigate the survival of patients diagnosed with metastatic oesophageal cancer after different treatment regimens.

METHODS

This was a retrospective single-centre study of patients with adenocarcinoma or squamous cell carcinoma of the oesophagus with synchronous or metachronous metastases who underwent Ivor Lewis oesophagectomy between 2010 and 2021. Each patient received an individual treatment for their metastatic burden based on an interdisciplinary tumour board conference. Survival differences between different treatments were assessed using the Kaplan-Meier method, as well as univariable and multivariable Cox regression models.

RESULTS

Out of 1791 patients undergoing Ivor Lewis oesophagectomy, 235 patients diagnosed with metastases were included. Of all of the included patients, 42 (17.9%) only underwent surgical resection of their metastatic disease, 37 (15.7%) underwent multimodal therapy including surgery, 78 (33.2%) received chemotherapy alone, 49 (20.9%) received other therapies, and 29 (12.3%) received best supportive care. Patients who underwent resection or multimodal therapy including surgery of their metastatic burden showed superior overall survival compared with chemotherapy alone (median overall survival of 19.0, 18.0, and 11.0 months respectively) (P < 0.001). This was confirmed in subcohorts of patients with metachronous solid-organ metastases and with a single metastasis. In multivariable analyses, resection with or without multimodal therapy was an independent factor for favourable survival.

CONCLUSION

Surgical resection could be a feasible treatment option for metastasized oesophageal cancer, improving survival in selected patients. Further prospective randomized studies are needed to confirm these findings and define reliable selection criteria.

Have we improved postoperative and long-term outcomes of liver surgery for colorectal cancer metastasis? Analysis of 1736 hepatectomies performed over 3 decades in a single center

INTRODUCTION

Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLM) and its indication and results have varied in the last 30 years.

METHODS

All patients operated on for CRLM in our centre from 1990 to 2021 were prospectively collected, establishing 3 subgroups based on the year of the first surgery: group A 1990-1999, group B 2000-2010, group C 2011-2021. Clinical characteristics and the results of survival, recurrence and prognostic factors were compared.

RESULTS

1736 hepatectomies were included (Group A n = 208; Group B n = 770; Group C n = 758). Patients in group C had better survival at 5 and 10 years (A 40.5%/28.2%; B 45.9%/32.2%; C 51.6%/33.1%, p = 0.013), although there were no differences between groups in overall recurrence at 5 and 10 years (A 73%/75.7%; B 67.6%/69.2%, and C 63.9%/66%, p = 0.524), nor in liver recurrence (A 46.4%/48.2%; B 45.8%/48.2%; and C 44.4%/48.4%, p = 0.899). An improvement was observed in median survival after recurrence, being 19 months, 23 months, and 31 months (groups A, B and C respectively). Prognostic factors of long-term survival changed over the 3 study periods. The only ones that remained relevant in the last decade were the presence of >4 liver metastasis, extrahepatic disease at the time of hepatectomy, and intraoperative blood transfusion.

CONCLUSIONS

Survival after surgery for CRLM has improved significantly, although this cannot be explained by a reduction in overall and hepatic recurrence, but rather by an improvement in post-recurrence survival. Involvement of the resection margin has lost prognostic value in the last decade.

Clinical Prediction Models for Prognosis of Colorectal Liver Metastases: A Comprehensive Review of Regression-Based and Machine Learning Models

Colorectal liver metastasis (CRLM) is a disease entity that warrants special attention due to its high frequency and potential curability. Identification of "high-risk" patients is increasingly popular for risk stratification and personalization of the management pathway. Traditional regression-based methods have been used to derive prediction models for these patients, and lately, focus has shifted to artificial intelligence-based models, with employment of variable supervised and unsupervised techniques. Multiple endpoints, like overall survival (OS), disease-free survival (DFS) and development or recurrence of postoperative complications have all been used as outcomes in these studies. This review provides an extensive overview of available clinical prediction models focusing on the prognosis of CRLM and highlights the different predictor types incorporated in each model. An overview of the modelling strategies and the outcomes chosen is provided. Specific patient and treatment characteristics included in the models are discussed in detail. Model development and validation methods are presented and critically appraised, and model performance is assessed within a proposed framework.

The Real-Life Impact of Primary Tumor Resection of Synchronous Metastatic Colorectal Cancer-From a Clinical Oncologic Point of View

AIM

The complex medical care of synchronous metastatic colorectal (smCRC) patients requires prudent multidisciplinary planning and treatments due to various challenges caused by the primary tumor and its metastases. The role of primary tumor resection (PTR) is currently uncertain; strong arguments exist for and against it. We aimed to define its effect and find its best place in our therapeutic methodology.

METHOD

We performed retrospective data analysis to investigate the clinical course of 449 smCRC patients, considering treatment modalities and the location of the primary tumor and comparing the clinical results of the patients with or without PTR between 1 January 2013 and 31 December 2018 at the Institute of Oncotherapy of the University of Pécs.

RESULTS

A total of 63.5% of the 449 smCRC patients had PTR. Comparing their data to those whose primary tumor remained intact (IPT), we observed significant differences in median progression-free survival with first-line chemotherapy (mPFS1) (301 vs. 259 days; p < 0.0001; 1 y PFS 39.2% vs. 26.6%; OR 0.56 (95% CI 0.36-0.87)) and median overall survival (mOS) (760 vs. 495 days; p < 0.0001; 2 y OS 52.4 vs. 26.9%; OR 0.33 (95% CI 0.33-0.53)), respectively. However, in the PTR group, the average ECOG performance status was significantly better (0.98 vs. 1.1; p = 0.0456), and the use of molecularly targeted agents (MTA) (45.3 vs. 28.7%; p = 0.0005) and rate of metastasis ablation (MA) (21.8 vs. 1.2%; p < 0.0001) were also higher, which might explain the difference partially. Excluding the patients receiving MTA and MA from the comparison, the effect of PTR remained evident, as the mOS differences in the reduced PTR subgroup compared to the reduced IPT subgroup were still strongly significant (675 vs. 459 days; p = 0.0009; 2 y OS 45.9 vs. 24.1%; OR 0.37 (95% CI 0.18-0.79). Further subgroup analysis revealed that the site of the primary tumor also had a major impact on the outcome considering only the IPT patients; shorter mOS was observed in the extrapelvic IPT subgroup in contrast with the intrapelvic IPT group (422 vs. 584 days; p = 0.0026; 2 y OS 18.2 vs. 35.9%; OR 0.39 (95% CI 0.18-0.89)). Finally, as a remarkable finding, it should be emphasized that there were no differences in OS between the smCRC PTR subgroup and metachronous mCRC patients (mOS 760 vs. 710 days, p = 0.7504, 2 y OS OR 0.85 (95% CI 0.58-1.26)).

CONCLUSIONS

The role of PTR in smCRC is still not professionally justified. Our survey found that most patients had benefited from PTR. Nevertheless, further prospective trials are needed to clarify the optimal treatment sequence of smCRC patients and understand this cancer disease's inherent biology.