Patterns of metastasis in colon and rectal cancer

Cerebral metastasis from anal squamous cell carcinoma: A case report and literature review

Anal cancer comprises only 3% of all gastrointestinal malignancies, of which only a small proportion of patients will experience distant metastasis; very few of these cases will metastasise to the brain. The present case report details the clinical course of a 56-year-old female patient who was previously diagnosed with anal squamous cell carcinoma (SCC) and subsequently developed an isolated cerebral metastasis ~5 years later. The patient was initially diagnosed with anal SCC after presenting with a non-tender lump in the groin and had no other signs or symptoms. After undergoing a lumpectomy in 2017, the patient was lost to follow-up. In 2022, the patient presented with a perforated rectal tumour and consequently underwent a loop colostomy followed by chemoradiotherapy. The patient was considered to be in remission at the end of 2023 until subsequent presentation months later with vague neurological symptoms, which led to the diagnosis of a large metastatic lesion in the right temporal lobe. Following resection via craniotomy and additional radiation therapy, there was no evidence to suggest recurrence of either the anal primary tumour or cerebral metastasis from follow-up imaging 5 months post-operatively. The present report highlights the potentially aggressive nature of anal SCC, late-onset cerebral metastasis and the need for further investigation into standardising treatment protocols and surveillance strategies for gastrointestinal metastatic disease.

Iterative Screening of Vitamin E-Based Functional Lipid Nanoparticles for mRNA Delivery

Ionizable lipids are crucial for the effective delivery of mRNA by using lipid nanoparticles (LNPs). Endowing ionizable lipids with tailored biological properties could potentially augment the therapeutic efficacy of mRNA-based treatments. Herein, a functional vitamin E (VE)-based lipid library with distinct head groups was designed and synthesized. Due to the presence of VE, these lipids inherently exhibited immunomodulatory properties, including the promotion of cellular uptake, dendritic cells maturation, and antigen presentation. Through iterative optimization of the LNP components and the architecture of ionizable lipids, the correlation between the structure of ionizable lipids and their mRNA delivery efficiency has been established, leading to the finding of the most effective delivery formulation. Benefiting from the high mRNA delivery efficiency and the immunomodulatory function of LNPs themselves, VE-based LNPs have demonstrated complete remission in colon cancer by delivering mIL-12, which offered a beneficial combination with immune checkpoint blockade. The proposed functional LNPs were anticipated to furnish potential delivery systems for mRNA-based cancer treatments.

Deciphering the role of acetylation-related gene NAT10 in colon cancer progression and immune evasion: implications for overcoming drug resistance

BACKGROUND

Colon cancer (CC) is one of the most common and lethal cancers worldwide, with rising incidence rates in both developed and developing countries. Although advances in treatments such as surgery, chemotherapy, and targeted therapies have been made, prognosis for advanced colon cancer, particularly with metastasis, remains poor. Recent studies highlight the significant role of post-transcriptional modifications like acetylation in cancer biology, affecting processes like gene transcription, metabolism, and tumor progression.

METHODS

This study applied multi-omics analyses, including single-cell RNA sequencing (scRNA-seq), spatial transcriptomics, and Mendelian randomization. Data were obtained from public datasets like GSE132465, UCSC Xena, and GeneCards. We focused on acetylation-related genes, specifically NAT10 and GNE, using scoring methods, cell-cell interaction models, and survival analyses to investigate their role in colon cancer development, metastasis, and immune evasion.

RESULTS

This study identifies that NAT10 is highly expressed in epithelial cells of colorectal cancer (CC) and is closely associated with tumor progression and metastasis. Single-cell RNA sequencing analysis revealed that NAT10-positive epithelial cells exhibited strong interactions with myeloid cells and T cells, with significant differences in cell-cell communication (p < 0.05). Based-on-summary-data Mendelian randomization (SMR) analysis further supports a causal relationship between NAT10 and colorectal cancer. In the MR analysis, a significant positive correlation was observed between NAT10 and colorectal cancer risk using summary data from genome-wide association studies (GWAS) and expression quantitative trait loci (eQTL) studies (β_SMR = 0.004, p_SMR = 0.041, p_HEIDI = 0.737). These findings suggest that NAT10 may serve as a pathogenic factor in colorectal cancer development, providing additional genetic evidence that links this acetylation-related gene to colorectal cancer. Survival analysis further demonstrated that NAT10-positive epithelial cells are associated with poorer prognosis. In the TCGA dataset, patients with NAT10-positive epithelial cells exhibited a significantly shorter disease-free survival (DFS) (p = 0.012). Unlike GNE-positive cells, NAT10-positive epithelial cells exhibited immune escape characteristics, and TIDE analysis indicated that NAT10-positive epithelial cells were associated with a lower response to immune checkpoint blockade therapy (p = 1.3e-5), suggesting that they may impair the efficacy of immunotherapy by promoting immune evasion. In contrast, GNE was also significantly expressed in epithelial cells of colorectal cancer, but its role differs from that of NAT10. GNE-positive epithelial cells demonstrated strong communication with immune cells, particularly in interactions between myeloid cells and T cells through receptor-ligand pairs. Despite the important role of GNE-positive epithelial cells in the tumor microenvironment, their association with immune escape is weaker compared to NAT10. Survival analysis revealed that GNE-positive epithelial cells were associated with a better prognosis (p = 0.015). In the TCGA dataset, patients with GNE-positive epithelial cells displayed longer disease-free survival (DFS), contrary to the results from the SMR analysis.

CONCLUSIONS

Leveraging SMR and multi-omics analysis, this study highlights the significant role of acetylation-related genes, particularly NAT10, in colon cancer. The findings suggest that acetylation modifications in epithelial cells contribute to immune evasion and cancer progression. NAT10 could serve as a promising biomarker and therapeutic target for early diagnosis and targeted therapy, offering new avenues for improving colon cancer treatment and patient outcomes.

Neoadjuvant chemotherapy improves overall survival in stage III but not in stage II colon cancer: A propensity score-matched analysis of the National Cancer Database

BACKGROUND

Neoadjuvant chemotherapy has been recently suggested for advanced colon cancer, but little is known about the impact on short-term outcomes and overall survival. In this study, we aimed to evaluate the effect of neoadjuvant chemotherapy on survival in stage II-III colonic adenocarcinoma.

METHODS

A retrospective analysis of the colon cancer US National Cancer Database from 2006 to 2019 was performed. Patients treated with neoadjuvant chemotherapy were matched using propensity score to controls (ratio 1:1). The primary outcome was 5-year overall survival.

RESULTS

In total, 1,275 patients (1.3%) with clinical stage II-III colonic adenocarcinoma received neoadjuvant chemotherapy. After matching, the neoadjuvant chemotherapy group included 783 patients. The restricted mean 5-year overall survival in the neoadjuvant chemotherapy group was significantly higher compared with controls (48.9 vs 44.9 months, P = .003). Stratified by disease stage, neoadjuvant chemotherapy was associated with a significantly longer overall survival (47.5 vs 41.2 months; P = .001) in stage III while showing an equivalent overall survival in stage II (50.3 vs 48.6 months; P = .2). The benefit in overall survival was pronounced in stage T4 and positive nodal disease. Cox regression analysis in patients with stage III revealed that neoadjuvant chemotherapy was associated with a 21% reduction in mortality risk (hazard ratio, 0.79; 95% confidence interval, 0.65-0.96; P = .01). Neoadjuvant chemotherapy was associated with lower rates of 30-day readmission (3.5% vs 7.4%, P = .001), 30-day mortality (0.9% vs 3.8%, P < .001), and 90-day mortality (2.9% vs 8.5%, P < .001).

CONCLUSION

Preoperative neoadjuvant chemotherapy is associated with improved overall survival in patients with stage III colon cancer, mainly in patients with T4 disease.

Biweekly dosing of trifluridine-tipiracil reduces rates of myelosuppression while maintaining efficacy in patients with metastatic colorectal cancer

BACKGROUND

Trifluridine-tipiracil (TAS-102) is approved as monotherapy and in combination with bevacizumab for refractory unresectable metastatic colorectal cancer (mCRC). The recommended dose is 35 mg/m2 twice daily on days 1-5 and days 8-12 of 28-day cycles commonly resulting in grade 3-4 neutropenia, dose delays/reductions, and requiring GCSF support. To maintain efficacy and reduce toxicity, we analyzed a biweekly dosing schedule (days 1-5 and days 15-19 q28 days).

PATIENTS AND METHODS

A retrospective analysis was performed in patients with mCRC and appendiceal cancer who completed >12 days of TAS-102 therapy and underwent surveillance imaging every 8-12 weeks. ECOG performance status (PS), prior lines of therapy, use of bevacizumab, CTCAE grade of treatment-related myelotoxicity, dose reductions/delays, and use of GCSF were assessed. Among patients with mCRC, survival analyses were performed.

RESULTS

61 patients met inclusion criteria, with mCRC:appendiceal CA ratio of 56:5. Median ECOG PS = 1; median number of prior therapies = 3; Reduction in grade ≥3 neutropenia (16.3%, 1 patient with grade 4) and grade ≥3 anemia (8.2%) relative to the historic controls of the RECOURSE and SUNLIGHT trials. No neutropenic fever was noted; GCSF was not required. Eight patients required a dose delay. In the mCRC patients, the median progression-free survival (PFS) was 4.2 months, with a median overall survival (OS) of 9.2 months.

CONCLUSIONS

Biweekly dosing of TAS-102 demonstrated a reduction in myelosuppression, with similar PFS and OS. With an improved toxicity profile, this alternative dosing schedule may potentially broaden the utilization of TAS-102 in patients with borderline PS and provide a favorable option for future combination studies.

Ribonucleotide-diphosphate reductase subunit M2 (RRM2) expression and colorectal cancer invasiveness: a potential prognostic biomarker

BACKGROUND

By evaluating serum Ribonucleotide-diphosphate Reductase subunit M2 (RRM2) levels and mRNA tissue expression, we aimed to investigate the potential role of RRM2 as a prognostic biomarker in Colorectal Cancer (CRC) patients.

METHODS

This descriptive-analytic cohort study was conducted on 50 newly diagnosed CRC patients (stage II, III). Real-time PCR determined the mRNA tissue expression of RRM2. Fifty healthy individuals who came to the hospital of Golestan University of Medical Sciences and Tehran University of Medical Sciences for routine check-ups were considered the control group. Serum RRM2 protein was measured using an ELISA method in the patient group before, one month, and three months after the surgery, and in the control group just on the day of a routine check-up. The tumor metastasis node (TMN) classification system and occurrence of liver metastasis were evaluated in CRC patients.

RESULTS

The RRM2 gene expression ratio and 95% confidence interval (CI) of the cancerous tissue was 6.56 times higher than the normal tissue (p < 0.001). Blood Sugar level (BS) (p < 0.001) and platelet level (PLT [range 0.004-499 × 103 /mm3]; p = 0.010) were higher in the case group compared with the control group significantly, while Mean Corpuscular Volume (MCV) was significantly lower in the case group (p = 0.015). Overall, the mean serum of RRM2 protein levels in patients was remarkably diminished from before surgery until three months after surgery (p < 0.001).

CONCLUSION

Serum RRM2 level and mRNA expression were significantly higher among CRC patients which could be considered a biomarker regarding CRC progression.

Perspectives on the role of "-Omics" in predicting response to immunotherapy

The annual Immuno-Oncology "Think Tank" held in October 2023 in Siena reviewed the rapidly evolving systems-biological approaches which are now providing a deeper understanding of tumor and tumor microenvironment heterogeneity. Based on this understanding opportunities for novel therapies may be identified to overcome resistance to immunotherapy. There is increasing evidence that malignant disease processes are not limited to purely intracellular or genetic events but constitute a dynamic interaction between the host and disease. Tumor responses are influenced by many host tissue determinants across different cellular compartments, which can now be investigated by high-throughput molecular profiling technologies, often labelled with a suffix "-omics". "Omics" together with ever increasing computational power, fast developments in machine learning, and high-resolution detection tools offer an unrivalled opportunity to connect high-dimensional data and create a holistic view of disease processes in cancer. This review describes advances in several state-of-the-art "-omics" approaches with perspectives on how these can be applied to the clinical development of new immunotherapeutic strategies and ultimately adopted in clinical practice.

Comprehensive cohort study: computer tomography-guided high-dose rate brachytherapy as metastasis-directed therapy for liver metastases from colorectal cancer in repeat oligoprogression

PURPOSE

The standard treatment for oligometastatic colorectal cancer includes systemic therapy, with surgery and metastasis-directed therapy as options. The optimal strategy, especially for repeat oligoprogression (rOP), remains unclear. We report outcomes of liver computer tomography-guided high-dose rate brachytherapy (CT-BRT) in this setting.

METHODS

This retrospective cohort study included colorectal cancer patients with liver-only oligoprogression during systemic therapy, meeting criteria of up to 5 liver metastases, CT-BRT eligibility, and ECOG status ≤ 2. Patients were followed for local response, progression-free survival (PFS), overall survival (OS), and toxicity. Response, according to RECIST 1.1, was initiated 6 months post-CT-BRT.

RESULTS

A total of 262 metastases were treated in 127 patients, with 67.7% receiving third-line or later systemic therapies. One to four liver metastases were found in 29.1%, 42.5%, 21.2%, and 7.1% of patients, respectively, with a median volume of 128 cm3. A median of 3 applicators was used, with CT-BRT doses of 15 Gy, 20 Gy, and 25 Gy given to 29.9%, 41.7%, and 28.3% of patients. At 6 months complete response occurred in 3.1%, progressive disease in 23.6%, partial response in 19.7%, and stable disease in 53.5%. Median PFS was 9 months, median OS was 16 months, with 1-year and 2-year OS rates of 65% and 16%, respectively. Liver-only metastases and objective response were associated with longer PFS. The G3 toxicity was 4.0%; no events > G3 were reported.

CONCLUSIONS

This largest study documents favorable outcomes of liver CT-BRT for rOP, establishing this method as a viable option in this indication.

Unusual skull metastasis in colorectal adenocarcinoma

Colorectal cancer ranks as the third most commonly diagnosed cancer globally. Research suggests that colon cancer and rectal cancer differ in terms of aetiology and risk factors. Follow-up is essential due to the detrimental impact of metastasis on patient survival (5-year survival rate of less than 20%). Routine use of positron emission tomography (PET-CT) is not recommended. This case report describes an elderly woman diagnosed who had previously been treated for rectal cancer. CT scans of the abdomen and chest showed no evidence of metastatic disease. During the second year of follow-up, a PET-CT was performed and a new active osseous lesion in the skull was identified. Current follow-up guidelines for colorectal carcinoma may not encompass all potential metastatic sites. Incorporating full body PET-CT scans into the follow-up protocol could be beneficial for detecting additional metastatic sites.

Dual prophylactic and therapeutic potential of iPSC-based vaccines and neoantigen discovery in colorectal cancer

Rationale: Induced pluripotent stem cells (iPSCs) share transcriptomic similarities with cancer cells and express tumor-specific and tumor-associated antigens, highlighting their potential as cancer vaccines. Our previous study demonstrated that an iPSC-based vaccine effectively prevented tumor growth in various mouse models, including melanoma, breast, lung, and pancreatic cancers. However, the underlying mechanisms and the therapeutic efficacy of the iPSC-based vaccine remain unclear. Colorectal cancer (CRC), the third most common cancer with a rising incidence worldwide, presents an urgent need for novel strategies to prevent and treat CRC. Methods: Allograft mouse models were established to evaluate the antitumor effects of the iPSC-based vaccine. CpG oligonucleotide (ODN) 1826 served as a vaccine adjuvant. Bulk RNA-Sequencing (RNA-Seq) and the Microenvironment Cell Population counter (MCP-Counter) algorithm were performed to analyze transcriptomic changes. Liquid chromatography-mass spectrometry (LC-MS) combined with in silico strategies was employed to identify potential antigen proteins. Chinese Hamster Ovary (CHO-K1) models were utilized to express candidate neoantigen proteins. Mouse bone marrow-derived dendritic cells (BMDCs) were used to investigate T cell priming in response to iPSC-associated proteins. Immune cell profiles were characterized by flow cytometry. Results: The combination of CpG and iPSC vaccination demonstrated both prophylactic and therapeutic efficacy in reducing tumor growth in CRC mouse models. Vaccination significantly increased CD8+ T cell infiltration within tumor regions, while T cell depletion abrogated the antitumor effects, underscoring the critical role of T cells in mediating these responses. Proteomic analysis identified two iPSC-associated proteins, heterogeneous nuclear ribonucleoprotein U (HNRNPU) and nucleolin (NCL), as key drivers of the observed immune responses. Vaccination with HNRNPU or NCL, in combination with CpG, enhanced dendritic cell activation, induced antigen-specific CD8+ T cell cytotoxicity, and promoted the formation of central memory CD8+ T cells, collectively leading to significant CRC tumor shrinkage. Conclusions: Our findings reveal potential mechanisms underlying the efficacy of iPSC-based vaccines in cancer immunotherapy. Additionally, HNRNPU and NCL were identified as key antigen proteins in iPSC, demonstrating promise for the development of peptide-based vaccines for both the prevention and treatment of CRC.

Translation and validation of the Swedish version of the EORTC LMC-21, the disease-specific questionnaire for assessing health-related quality of life in patients with colorectal liver metastases

PURPOSE

The aim of this study was to translate the health-related quality-of-life questionnaire EORTC QLQ-LMC21 into Swedish and to test its clinical and psychometric reliability and validity in patients with liver metastases from colorectal cancer (CRC) undergoing surgical treatment.

METHODS

The Swedish versions of the EORTC QLQ-C30 and EORTC QLQ-LMC21 were administered to 250 patients with liver metastases from CRC in four Swedish hospitals before and 3 months after surgical treatment. Psychometric validation of the questionnaire´s structure, reliability, and convergent and divergent validity was performed.

RESULTS

Data from 242 (97%) patients were suitable for analysis. The QLQ-LMC21 was found to be sensitive to changes over time. Cronbach´s alpha coefficient indicated good internal consistency, ranging from 0.84 to 0.89. Test-retest reliability was evaluated in 120 patients (49%), and the intraclass correlation coefficient (ICC) indicated good reproducibility, ranging from 0.67 to 0.93. Convergent and discriminant validity were demonstrated adequately in the multitrait scaling analysis. There were weak correlations between the QLQ-C30 and QLQ-LMC21, which confirms that the health problems addressed by the QLQ-LMC21 are different from those addressed by the QLQ-C30.

CONCLUSIONS

The Swedish version of the EORTC QLQ-LMC21 proved to be a valid and reliable questionnaire to use in conjunction with the EORTC QLQ-C30.

Evolutionary paths towards metastasis

The evolution of metastasis in humans is considerably less well understood than the biology of early carcinogenesis. For over a century, clinicians and scientists have been debating whether metastatic potential is the intrinsic property of a cancer, pre-determined by the molecular characteristics of the tumour founder cell, or whether metastatic capacity evolves in a stepwise fashion as the tumour grows, akin to the multistage accumulation of oncogenic alterations that give rise to the first cancer cell. In this Perspective, I examine how genetic analyses of primary tumours and matched metastases can distinguish between these two competing metastasis evolution models, with particular emphasis on the utility of metastatic randomness - a quantitative measure that reflects whether metastases arise from a random selection of primary tumour subclones or whether they are enriched for descendants of privileged lineages that have acquired pro-metastatic traits. Probable metastasis evolution trajectories in tumours with high and low baseline metastatic capacity are discussed, along with the role of seeding rates and selection at different metastatic host sites. Finally, I argue that trailblazing insights into human metastasis biology are immediately possible if we make a concerted effort to apply existing experimental and theoretical tools to the right patient cohorts.

Colorectal cancer progression to metastasis is associated with dynamic genome-wide biphasic 5-hydroxymethylcytosine accumulation

BACKGROUND

Colorectal cancer (CRC) progression from adenoma to adenocarcinoma is associated with global reduction in 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC). DNA hypomethylation continues upon liver metastasis. Here we examine 5hmC changes upon progression to liver metastasis.

RESULTS

5hmC is increased in metastatic liver tissue relative to the primary colon tumour and expression of TET2 and TET3 is negatively correlated with risk for metastasis in patients with CRC. Genes associated with increased 5-hydroxymethylcytosine show KEGG enrichment for adherens junctions, cytoskeleton and cell migration around a core cadherin (CDH2) network. Overall, the 5-hydroxymethylcyosine profile in the liver metastasis is similar to normal colon appearing to recover at many loci where it was originally present in normal colon and then spreading to adjacent sites. The underlying sequences at the recover and spread regions are enriched for SALL4, ZNF770, ZNF121 and PAX5 transcription factor binding sites. Finally, we show in a zebrafish migration assay using SW480 CRISPR-engineered TET knockout and rescue cells that reduced TET expression leads to a reduced migration frequency.

CONCLUSIONS

Together these results suggest a biphasic trajectory for 5-hydroxymethyation dynamics that has bearing on potential therapeutic interventions aimed at manipulating 5-hydroxymethylcytosine levels.

Dormancy in Metastatic Colorectal Cancer: Tissue Engineering Opportunities for In Vitro Modeling

Colorectal cancer (CRC) recurs at a striking rate, specifically in patients with liver metastasis. Dormant CRC cells disseminated following initial primary tumor resection or treatment often resurface years later to form aggressive, therapy-resistant tumors that result in high patient mortality. Routine imaging-based screenings often fail to detect dormant cancer cell clusters, and there are no overt symptomatic presentations, making dormant CRC a major clinical challenge to diagnose and treat. Tissue engineering approaches are ideally suited to model dormant cancer cells and enable the discovery of therapeutic vulnerabilities or unique mechanistic dependencies of dormant CRC. Emerging evidence suggests that tissue-engineered approaches have been successfully used to model dormant breast and lung cancer. With CRC responsible for the second most cancer-related deaths worldwide and CRC patients commonly experiencing recurrence, it is essential to expand dormancy models to understand this phenomenon in the context of CRC. Most published in vitro models of CRC dormancy simplify the complex tumor microenvironment with two-dimensional culture systems to elucidate dormancy-driving mechanisms. Building on this foundation, future research should apply tissue engineering methods to this growing field to generate competent three-dimensional models and increase mechanistic knowledge. This review summarizes the current state of in vitro CRC dormancy models, highlighting the techniques utilized to give rise to dormant CRC cells: nutrient depletion, anticancer drugs, physical extracellular matrix interactions, and genetic manipulation. The metrics used to validate dormancy within each model are also consolidated to demonstrate the lack of established standards and the ambiguity around comparing studies that have been validated differently. The methods of these studies are organized in this review to increase comprehensibility and identify needs and opportunities for future bioengineered in vitro models to address dormancy-driven mortality in patients with CRC liver metastasis. Impact Statement Dormant cancer drives high patient mortality, especially in metastatic colorectal cancer, owing to the clinical inability to identify dormant cells prior to their overt recurrence. Lacking clinical insights, in vitro modeling for mechanistic and therapeutic discovery is hindered. Here, we review models and methods of inducing colorectal cancer dormancy with the goal of consolidating findings for reference. We also highlight the need for advanced, tissue-engineered models to better mimic the organ-specific 3D microenvironment of metastatic colorectal cancer. New models would enable breakthroughs in understanding mechanisms driving dormancy progression and reversal, thereby providing context for therapeutic advances to improve patient survival.

Cytogenetic signatures favoring metastatic organotropism in colorectal cancer

Colorectal carcinoma (CRC) exhibits metastatic organotropism, primarily targeting liver, lung, and rarely the brain. Here, we study chromosomal imbalances (CIs) in cohorts of primary CRCs and metastases. Brain metastases show the highest burden of CIs, including aneuploidies and focal CIs, with enrichment of +12p encoding KRAS. Compared to liver and lung metastases, brain metastases present with increased co-occurrence of KRAS mutation and amplification. CRCs with concurrent KRAS mutation and amplification display significant metabolic reprogramming with upregulation of glycolysis, alongside upregulation of cell cycle pathways, including copy number gains of MDM2 and CDK4. Evolutionary modeling suggests early acquisition of many organotropic CIs enriched in both liver and brain metastases, while brain-enriched CIs preferentially emerge later. Collectively, this study supports a model where cytogenetic events in CRCs favor site-specific metastatic colonization. These site-enriched CI patterns may serve as biomarkers for metastatic potential in precision oncology.

Altered metabolic profiles in colon and rectal cancer

Colorectal cancer (CRC) is the third most commonly diagnosed malignant tumour in worldwide populations. Although colon cancer (CC) and rectal cancer (RC) are often discussed together, there is a global trend towards considering them as two separate disease entities. It is necessary to choice the appropriate treatment for CC and RC based on their own characteristics. Hence, it is a great importance to find effective biomarkers to distinguish CC from RC. In the present study, a total of 343 participants were recruited, including 132 healthy individuals, 101 patients with CC, and 110 patients with RC. The concentrations of 93 metabolites were determined by using a combination of dried blood spot sampling and direct infusion mass spectrometry technology. Multiple algorithms were applied to characterize altered metabolic profiles in CC and RC. Significantly altered metabolites were screened for distinguishing RC from CC in training set. A biomarker panel including Glu, C0, C8, C20, Gly/Ala, and C10:1 was tested with tenfold cross-validation and an independent test set, and showed the potential to distinguish between RC and CC. The metabolomics analysis makes contribution to summarize the metabolic differences in RC and CC, which might provide further guidance on novel clinical designs for the two diseases.

Prognostic significance of the retroperitoneal surgical resection margin on computed tomography colonography in retroperitonealized colon cancer

BACKGROUND

A positive pathologic retroperitoneal surgical resection margin in the retroperitonealized colon is reported to predict distant metastases. However, no studies have investigated retroperitoneal surgical resection margin positivity on computed tomography colonography and its prognostic significance.

METHODS

Patients who underwent primary resection for ascending or descending colon cancer at our institution between 2013 and 2018 were retrospectively evaluated (n = 206). Retroperitoneal surgical resection margin on computed tomography colonography was defined on the basis of the relationship between the advanced tumor area and the retroperitoneum. The relationship between retroperitoneal surgical resection margin on computed tomography colonography and relapse-free survival was analyzed by dividing the patients into positive and negative retroperitoneal surgical resection margin on computed tomography colonography groups.

RESULTS

Two doctors independently evaluated the images. The interobserver agreement rate was 93.7% with a kappa coefficient of 0.78 (95% confidence interval, 0.66-0.90). Retroperitoneal surgical resection margin on computed tomography colonography positivity was observed in 32 of the 206 patients (15.5%). Univariate analysis showed that a positive retroperitoneal surgical resection margin on computed tomography colonography was a poor prognostic factor for relapse-free survival (hazard ratio, 7.07; 95% confidence interval, 2.77-18.0, P < .001). Multivariate analysis with carcinoembryonic antigen, clinical T and N stage as covariates (all P < .10 in univariate analysis) identified only retroperitoneal surgical resection margin on computed tomography colonography positive as a significant independent poor prognostic factor for relapse-free survival (hazard ratio, 3.99; 95% confidence interval, 1.30-12.3, P = .02).

CONCLUSION

In conclusion, this study revealed that retroperitoneal surgical resection margin on computed tomography colonography positivity is a poor prognostic factor. In cases in which retroperitoneal surgical resection margin on computed tomography colonography is positive, it is recommended not only to secure a wider margin, such as by resecting the Gerota fascia, but also to consider retroperitoneal surgical resection margin on computed tomography colonography positivity as a potential indication for preoperative chemotherapy.

Torsion of Metastatic Ovarian Tumor Originating From Sigmoid Colon Cancer

Metastasis of colorectal cancer (CRC) to the ovaries is relatively rare, and torsion of metastatic ovarian tumors is even rarer. Here, we report the case of a patient with CRC who developed torsion of ovarian metastases and underwent abdominal adnexectomy following chemotherapy with bevacizumab. A 51-year-old premenopausal woman presented with abdominal distension and was referred to our hospital after ultrasonography revealed abdominal tumors. Imaging showed bilateral ovarian masses (maximum diameters: right, 10 cm; left, 14 cm), subserosal leiomyomas, and a circumferential sigmoid colon tumor with peritoneal nodules and ascites. A colonoscopy confirmed moderately differentiated adenocarcinoma. The patient was diagnosed with stage IV sigmoid colon cancer, including ovarian metastasis, peritoneal metastases, and pleural effusion. The patient began chemotherapy with tegafur, gimeracil, oteracil potassium, oxaliplatin, and bevacizumab, resulting in a decrease in carbohydrate antigen 19-9 levels, though carcinoembryonic antigen levels increased. After the fourth chemotherapy cycle, the patient experienced sudden left-sided abdominal pain accompanied by nausea. Computed tomography revealed torsion of the left ovarian tumor (maximum diameter: 19 cm) with suspected hemorrhage. A drop in hemoglobin levels required a blood transfusion. Emergency laparotomy revealed a three-turn torsion of the left ovarian pedicle and an intra-tumoral hemorrhage. A bilateral adnexectomy was performed, and ovarian metastases from colon cancer were confirmed pathologically. Despite bevacizumab treatment, the patient's postoperative course was uneventful, and she was discharged on day 12. Chemotherapy was resumed. In patients with metastatic ovarian tumors who present with sudden abdominal pain, ovarian torsion should be considered in the differential diagnosis, even in the context of malignancy.

Real-world treatment outcomes from nationwide Onco-colon Turkey registry in RAS wild-type patients treated with biologics second-line mCRC

Backgrounds and ObjectivesColorectal cancer is one of the leading causes of mortality both globally and in our country. In Turkey, we conducted a multicenter investigation into the effectiveness of second-line treatments and real-life data for patients with RAS wild-type metastatic colorectal cancer (NCT04757311).Materials and MethodsIn this retrospective analysis, records from 28 centers were collected, and histopathological, molecular, and clinical characteristics were documented. Patients were categorized into groups based on their second-line biological treatments: anti-EGFR (Group A and Group B, panitumumab and cetuximab) and anti-VEGF (Group C, bevacizumab and aflibercept). They were then compared within these groups.ResultsA total of 588 patients with documented RAS wild-type status were evaluated. The median OS was 15.7, 14.3 and 14.7 months in Group A, Group B and Group C, respectively (p  =  0.764). The median PFS of the patients in second-line setting that received panitumumab, cetuximab and bevacizumab/aflibercept were 7.8, 6.6 and 7.4 months, respectively (p  =  0.848).ConclusionAccording to the results of our real-life data study, there is no significant difference in efficiency between the combination of biological agent and chemotherapy used in the second-line treatments.

Epidemiological and anatomopathological profile of colorectal cancer: A cross-sectional study

Background

Colorectal cancer (CRC) remains one of the leading causes of cancer-related deaths globally, with incidence and mortality rates exhibiting geographical disparities.

Aim

This study aims to outline the pathological profile of CRC.

Setting

The study was conducted in the anatomopathological laboratories of the Souss Massa region (SMR) in Morocco.

Methods

The study examined the epidemiological and anatomopathological profile of CRC among patients diagnosed. We reviewed 238 anatomopathological results during the study period. Fisher's exact test and analysis of variance were performed using Statistical Package for Social Sciences (SPSS) version 20.

Results

Rectum and sigmoid colon were the most common sites for CRC (76.9%), with adenocarcinomas emerging as the predominant histological variant (93.3%). Most tumours were moderately differentiated (96.6%), with many (83.1%) in advanced stages (T3, T4). The presence of vascular embolism in 31.9% of patients indicates aggressive disease progression. Additionally, the study discerned a slight male dominance (52.9%) in the prevalence of CRC and an average age of 59 among patients. Notably, sex showed a significant association with the manifestation of CRC across various organs (p = 0.028), as did histological types across different organs (p = 0.010). Age-related analysis found older patients (over 50 years) with advanced-stage CRC more frequently.

Conclusion

The histopathological features of these tumours are associated with an alarming delay in diagnosis and a significant presence of vascular embolism in patients.

Contribution

Delay in diagnosis of CRC is significant in the SMR. There is an urgent need to strengthen screening strategies and examine social determinants of health for earlier diagnosis.

Health Outcomes and Resource Consumption Analysis of Radioembolization with Y90 Glass Microspheres (TARE-Y90) Versus Transarterial Chemoembolization with Irinotecan (DEBIRI) in Patients with Liver Metastases from Colorectal Cancer in Spain

Background: The present study aims to investigate the superiority of TARE-Y90 in the treatment of liver metastases from colorectal cancer in comparison to DEBIRI and perform a parallel resource consumption study to demonstrate a possible favorable cost-effectiveness balance. Methods: The number of subjects included in this study was 46 for TARE-Y90 and 56 in the DEBIRI group. The variables of interest in this study were collected for all selected subjects. Time-to-endpoint outcomes (overall survival, time to progression and time to extra-hepatic progression) were calculated by Kaplan-Meier analysis, reported as medians with 95% confidence intervals and compared between groups by log-rank testing. Values for median time-to-event and 95% confidence intervals were calculated using bootstrapping. Results: Categorization into overall response (OR) and no overall response (NOR) revealed a higher percentage of overall responses in the DEBIRI group (52%) compared to TARE-Y90 (24%). The numerical differences observed in certain response categories did not reach statistical significance, indicating a comparable overall response to treatment between the two cohorts based on the m-RECIST criteria. Median overall survival for the TARE-Y90 cohort was 11.3 (95% CI 10.9-18.6) months and 15.8 (95% CI 14.8-22.7) months for the DEBIRI cohort. Log-rank testing showed no statistically significant differences (p = 0.53). Median time to hepatic disease progression for the TARE-Y90 cohort was 3.5 (95% CI 3.4-8.1) months and 3.8 (95% CI 3.7-11.1) months for the DEBIRI cohort. Log-rank testing showed no statistically significant differences (p = 0.82). An important result of the resource utilization analysis is that TARE-Y90 patients had 1.33 treatments on average per patient, while DEBIRI patients had 3.16 treatments per patient. TARE-Y90 patients also needed fewer days of hospitalization than those in the DEBIRI group. The consequence is that the overall use of resources was higher for DEBIRI in comparison to TARE-Y90. Conclusions: Our analysis of the TARE-Y90 and DEBIRI treatments for CRC liver metastases contributes valuable insights into their comparative effectiveness, revealing no significant differences in radiological responses and overall survival. TARE-Y90 showed higher resource utilization, and its potential advantages in patient comfort and average resource consumption per patient warrant consideration.

Prioritization of prognostic biomarkers regulated by calorie restriction in colon cancer through integrated biosignature analysis

Colorectal cancer (CRC) remains a critical global health challenge, ranking second in cancer-related mortality and third in cancer incidence as of 2018, with risk increasing with age. Addressing its rising burden requires early diagnosis, prognostic biomarkers, and effective therapeutic strategies. Emerging evidence suggests that calorie restriction may mitigate aging-related functional decline and influence CRC progression, yet the molecular markers and mechanisms remain poorly understood. In this study, we analyzed the GSE24432 dataset, using multiple computational databases to screen differentially expressed genes (DEGs) associated with calorie restriction in CRC. Functional annotations, including Gene Ontology (GO), KEGG pathway analysis, and gene set enrichment analysis (GSEA), were undertaken to explore potential underlying mechanisms and pathways in CRC pathogenesis. Kaplan Meier and Cox proportional hazards regression analyses were conducted to establish the diagnostic and prognostic significance of the hub genes. The validation test was conducted via multiple databases. Our investigation identified 50 DEGs, using the cutoff criteria, p. adj < 0.05, |log2FC|> 0.3. GO and functional analysis results revealed extensive crosstalk of cellular and molecular components and pathways associated with mRNA and ribosome biogenesis, AMPK signaling, and p53 signaling pathway following calorie restriction. To understand how these DEGs drive biological reactions, we sorted the genes according to gene score > 3 and GO term > 3 and obtained 14 DEGs most relevant to the GO terms. Further analysis with GO CHORD showed that most genes are enriched in ribosome biogenesis and protein synthesis. Gene set enrichment analysis (GSEA) revealed the involvement of the hub genes in several hallmarks, such as tissue invasion and metastasis (p < 0.001), tumor-promoting inflammation (p < 0.001), resisting cell death (p < 0.01), and replicative immortality (p < 0.05). Survival analysis showed that higher expression of 7 hub genes, CDKN2A (p < 0.05), RPL9 (p < 0.02), TUBB6 (p < 0.01), and RPS15A (p < 0.01), and lower expression of CDKN1B (p < 0.01), NPM1 (p < 0.01), and RALA (p < 0.01), correlated to shorter survival of colon cancer. However, cross-reference of these genes revealed that calorie restriction decreased the expressions of CDKN2A and TUBB6 while CDKN1B and NPM1 were increased (p < 0.05). Several validation tests from multiple databases showed that high CDKN2A is associated with shorter overall survival rates, indicating CDKN2A is a therapeutic target and could serve as a more reliable biomarker for CRC prognosis. These findings could potentially facilitate the development of precision-based energy restriction interventions for CRC management, offering promising prospects for targeted therapeutic strategies for CRC patients.

Value of hospital administrative data linked to national cancer registry records to identify metastatic disease at time of primary diagnosis in colorectal cancer patients: a study using national data in England

BACKGROUND

Routinely collected data are increasingly being used for cancer research and health service evaluation. For both purposes, accurately identifying metastatic disease at diagnosis is essential. We developed an approach to identify metastatic disease at time of primary diagnosis according to national hospital administrative data (HAD) in patients identified with colorectal cancer (CRC) in the English national cancer registry (CR).

METHODS

A national cohort of CRC patients diagnosed between 2013 and 2018 in England identified in CR data were linked to HAD. Metastatic disease was assumed to be present at diagnosis according to HAD if at least one of a set of pre-specified diagnostic ICD-10 codes appeared in a record of a hospital admission between one month before and six months after CRC diagnosis date.

RESULTS

Of 186,236 patients, 40,421 (21.7%) had metastatic cancer according to HAD, 42,843 (23.0%) according to CR data, 49,827 (26.8%) according to either data source, and 33,437 (18.0%) according to both. Metastatic information was missing in CR data in 14,065 patients and 1,930 of these (13.7%) had metastatic cancer according to HAD. 1-year mortality was 59.3% (95%-CI: 58.8 - 59.8%) in patients with metastatic disease and 7.4% (7.2 - 7.5%) in patients without if HAD and CR data agreed. Mortality fell between these results if HAD and CR data disagreed. High mortality was seen in patients with missing metastatic data in the CR: 74.4% (72.4 - 76.3%) in patients with metastatic disease and 45.2% (44.3-46.1%) in patients without metastatic disease according to HAD.

CONCLUSIONS

HAD should be linked to CR data to provide more accurate information on metastatic CRC at diagnosis including sites of metastasis. Linkage to HAD increased the number of patients identified with metastatic CRC by 14%, compared to CR data alone. Patients with metastatic disease at diagnosis in either data source had mortality outcomes expected for patients with metastatic cancer. CRC patients with missing metastasis data in CR data are likely to have metastatic disease and linkage to HAD provides important prognostic information.

Advances in Targeted and Chemotherapeutic Strategies for Colorectal Cancer: Current Insights and Future Directions

Colorectal cancer (CRC) remains one of the leading causes of cancer-related mortality worldwide, necessitating the continuous evolution of therapeutic approaches. Despite advancements in early detection and localized treatments, metastatic colorectal cancer (mCRC) poses significant challenges due to low survival rates and resistance to conventional therapies. This review highlights the current landscape of CRC treatment, focusing on chemotherapy and targeted therapies. Chemotherapeutic agents, including 5-fluorouracil, irinotecan, and oxaliplatin, have significantly improved survival but face limitations such as systemic toxicity and resistance. Targeted therapies, leveraging mechanisms like VEGF, EGFR, and Hedgehog pathway inhibition, offer promising alternatives, minimizing damage to healthy tissues while enhancing therapeutic precision. Furthermore, future directions in CRC treatment include exploring innovative targets such as Wnt/β-catenin, Notch, and TGF-β pathways, alongside IGF/IGF1R inhibition. These emerging strategies aim to address drug resistance and improve patient outcomes. This review emphasizes the importance of integrating molecular insights into drug development, advocating for a more personalized approach to combat CRC's complexity and heterogeneity.

An observational study of the causes of an isolated elevated alkaline phosphatase level of unclear etiology

BACKGROUND

Serum alkaline phosphatase (ALP) is a commonly obtained laboratory test, but its diagnostic specificity is limited because it is found in multiple tissues. We investigated patients with isolated, elevated, ALP levels without an obvious etiology at presentation to determine the frequency of different causes of an isolated elevated ALP.

METHODS

This was a retrospective, cohort study of adults (age >18 years old) from January 1st, 2013, to June 30th, 2020 in both the in- and outpatient setting at the Medical University of South Carolina. 260 patients with an isolated, elevated ALP of unknown etiology (patients with known biliary obstruction, underlying parenchymal liver disease, or pregnancy were excluded) were included. A secondary outcome was mean survival time from the ALP result.

RESULTS

The most common cause of ALP elevation was due to underlying malignancy (147, 57 %), with 61 patients having infiltrative intrahepatic malignancy, 52 patients having bony metastasis, and 34 patients having both hepatic and bone metastasis. Bone disease (75, 29 %), unsuspected parenchymal liver disease (18, 7 %), non-malignant infiltrative liver disease (7, 2 %), and other disorders (13, 5 %) accounted for the remainder of the cohort. Notably, 123 of 260 (47 %) patients died within an average of 58 months after identification of isolated, elevated ALP.

CONCLUSIONS

An isolated, elevated ALP of unclear etiology is associated with several very specific and important disorders, in particular metastatic intrahepatic malignancy - and is uncommonly associated with primary parenchymal liver disease. Providers should be aware of the potential clinical significance of an elevated ALP.

Follow-Up Adherence After Treatment With Curative Intent for Stage II and III Colorectal Cancer Patients

INTRODUCTION

After colorectal cancer (CRC) treatment, patients undergo five-year follow-up involving carcinoembryonic antigen (CEA) tests, imaging, and colonoscopies. This retrospective cohort study explores adherence to the CRC follow-up guideline in the Netherlands until 2021 and its association with treatment of recurrences with curative intent.

METHODS

Stage II/III CRC patients with recurrent disease within 3 years after diagnosis were selected from the Netherlands Cancer Registry (n = 430). Adherence to CEA tests, imaging, and colonoscopy was classified as 'according to/more follow-up' or 'less follow-up' than recommended. Logistic regression analyses examined factors associated with receiving less follow-up and the relationship between 'follow-up adherence' and 'treatment with curative intent', potentially mediated by 'mode of detection' (symptomatically vs. routine test).

RESULTS

In total, 18.3% patients had fewer CEA tests, 41.4% fewer imaging, and 56.1% fewer colonoscopies than recommended. Factors associated with fewer follow-up moments were tumor localization, age (≥ 75 years), comorbidities, tumor differentiation and adjuvant chemotherapy. Patients receiving fewer CEA tests faced 4.8 times higher odds (95% CI: 2.9-8.1) of symptom-detected recurrence and were less likely to be curatively treated (OR = 0.5; 95% CI: 0.3-0.9). Mediation analysis indicated a significant average causal mediation effect (p = 0.003), emphasizing the mediating role of mode of detection. Receiving fewer imaging and colonoscopies showed insignificant total effects on treatment with curative intent.

CONCLUSION

Our findings offer insights into follow-up adherence, detection mode, and treatment with curative intent. The discovery that adherence was highest for CEA, along with the correlation between CEA adherence and treatment with curative intent, aligns with the recent adaptation of guidelines emphasizing CEA measurement over imaging.

Early-Onset Colorectal Adenocarcinoma and Multiple Metastases in an 11-Year-Old Patient With KRAS Mutation: A Case Report

Early-onset colorectal cancer (EO-CRC), defined as colorectal adenocarcinoma diagnosed before age 50, is increasing globally, with distinct clinicopathologic and molecular features compared to adult-onset disease. While risk factors such as genetic mutations and lifestyle influences are implicated, pediatric cases remain exceptionally rare. This report presents a unique case of colorectal adenocarcinoma with multiple metastases in an 11-year-old patient, contributing critical insights into the molecular pathogenesis and diagnostic challenges of EO-CRC in pediatric populations. Furthermore, the aggressive nature of this disease underscores significant treatment challenges, ranging from limited evidence-based therapeutic protocols for young patients to variable responses to multimodal therapies, resulting in a generally poor prognosis.

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.

Invasion and metastasis in cancer: molecular insights and therapeutic targets

The progression of malignant tumors leads to the development of secondary tumors in various organs, including bones, the brain, liver, and lungs. This metastatic process severely impacts the prognosis of patients, significantly affecting their quality of life and survival rates. Research efforts have consistently focused on the intricate mechanisms underlying this process and the corresponding clinical management strategies. Consequently, a comprehensive understanding of the biological foundations of tumor metastasis, identification of pivotal signaling pathways, and systematic evaluation of existing and emerging therapeutic strategies are paramount to enhancing the overall diagnostic and treatment capabilities for metastatic tumors. However, current research is primarily focused on metastasis within specific cancer types, leaving significant gaps in our understanding of the complex metastatic cascade, organ-specific tropism mechanisms, and the development of targeted treatments. In this study, we examine the sequential processes of tumor metastasis, elucidate the underlying mechanisms driving organ-tropic metastasis, and systematically analyze therapeutic strategies for metastatic tumors, including those tailored to specific organ involvement. Subsequently, we synthesize the most recent advances in emerging therapeutic technologies for tumor metastasis and analyze the challenges and opportunities encountered in clinical research pertaining to bone metastasis. Our objective is to offer insights that can inform future research and clinical practice in this crucial field.

BRAF mutant appendiceal adenocarcinoma differs from colorectal cancer but responds to BRAF-targeted therapy

Appendiceal Adenocarcinoma (AA) is a rare gastrointestinal cancer with no FDA-approved targeted therapies. Here, we retrospectively compare BRAF-mutant AA and colorectal cancer (CRC). BRAF mutation is rare in AA (3%). Unlike CRC, BRAFV600E AA is not associated with poor prognosis, female sex, microsatellite instability, mucinous histology, or poor differentiation. In both cancers, BRAFV600E but not atypical BRAF mutations are mutually exclusive with other Ras-activating mutations. BRAFV600E + EGFR inhibition shows efficacy in BRAFV600E AA (disease control rate = 80%, median progression-free survival = 7.1 months).

Bifidobacterium animalis ssp. lactis BX-245-fermented milk alleviates tumor burden in mice with colorectal cancer

Colorectal cancer (CRC) arises from the accumulation of abnormal mutations in colorectal cells during prolonged inflammation. This study aimed to investigate the potential of probiotic fermented milk containing the probiotic strain, Bifidobacterium animalis ssp. lactis BX-245 (BX-245), in alleviating tumor burden in CRC mice induced by azoxymethane and dextran sodium sulfate. The study monitored changes in tumor size and number, gut microbiota, metabolomics, and inflammation levels before and after the intervention. Our findings indicate that intragastric administration of BX245-fermented milk effectively modulated the intratumor microbiota, as well as the gut microbiota and its metabolism. We also observed a decreased relative abundance of intratumor Akkermansia in the CRC mice, while the intratumor Parabacteroides exhibited a significant positive correlation with tumor number and weight. Moreover, administering BX245-fermented milk significantly reduced gut barrier permeability, alleviated gut barrier damage, and increased serum IL-2 and IFN-γ levels compared with the ordinary fermented milk group. Collectively, our data suggest that administering probiotic fermented milk containing specific functional strains such as BX245 could result in a reduction in tumor burden in CRC mice. Conversely, ordinary fermented milk did not show the same tumor-inhibiting effects. The current results are preliminary, and further confirmation is necessary to establish the causal relationship among probiotic milk, changes in gut microbiota, and disease alleviation.

Exploring the Role of Epithelial-Mesenchymal Transition During Colorectal Cancer Peritoneal Metastasis: Update on Their Mechanisms

Colorectal cancer is a common malignant tumor worldwide. The prognosis of patients with colorectal cancer peritoneal metastasis is very poor. The study of the specific mechanisms of colorectal cancer peritoneal metastasis plays an important role in the treatment of patients with this disease. The mechanisms of colorectal cancer peritoneal metastasis are mainly pathological and biological. Biologically, the epithelial-mesenchymal transition process is an important precursor to tumor cell metastasis. Therefore, it is necessary to study the mechanisms of colorectal cancer peritoneal metastasis, especially the epithelial-mesenchymal transition, to identify new methods for the prevention and treatment of colorectal cancer peritoneal cancer, reduce the incidence of colorectal cancer peritoneal metastasis, and improve patient prognosis.

External Beam Radiation Therapy for Liver Metastases

Stereotactic ablative radiotherapy (SABR) commonly is used for small liver metastases. Modern conformal radiotherapy techniques, including 3-dimensional conformal radiotherapy and intensity-modulated radiation therapy, enable the safe delivery of SABR to small liver volumes. For larger tumors, the safe delivery of SABR can be challenging due to a more limited volume of healthy normal liver parenchyma and the proximity of the tumor to radiosensitive organs, such as the stomach, duodenum, and large intestine. Controlling respiratory motion, the use of image guidance, and increasing the number of radiation fractions sometimes are necessary for the safe delivery of SABR in these situations.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

Efficacy of laparoscopic parenchyma-sparing hepatectomy using augmented reality navigation combined with fluorescence imaging for colorectal liver metastases: a retrospective cohort study using inverse probability treatment weighting analysis

BACKGROUND

Laparoscopic parenchyma-sparing hepatectomy (PSH) is an effective treatment for colorectal liver metastases (CRLMs), but ensuring the safety and radicality of the procedure, particularly for deep-seated tumors, remains challenging. Surgical navigation technologies such as augmented reality navigation (ARN) and indocyanine green fluorescence imaging (ICG-FI) are increasingly utilized to guide surgery, yet their efficacy for CRLMs is unclear. This study aims to evaluate the short-term and long-term outcomes of ARN combined with ICG-FI-guided (ARN-FI) laparoscopic PSH for CRLMs.

METHODS

Between January 2020 and December 2022, 89 consecutive patients who underwent laparoscopic PSH for CRLMs were included in the study. Patients were divided into an ARN-FI group ( n = 38) and a non-ARN-FI group ( n = 51) based on the use of ARN-FI. Inverse probability treatment weighting (IPTW) was used to balance baseline characteristics and minimize potential selection bias. Short-term and long-term outcomes were compared between the two groups. Cox regression analysis was conducted to identify risk factors associated with recurrence-free survival (RFS) and hepatic RFS.

RESULTS

After IPTW, there were 87 patients in the ARN-FI group and 89 patients in the non-ARN-FI group. Shorter parenchymal transection time, postoperative hospital stays, and wider margins were observed in the ARN-FI group. There was no significant difference in RFS or hepatic RFS between the groups. Mutant KRAS status was an independent risk factor for both RFS and hepatic RFS, while tumor diameter ≥ 5 cm and deep-seated location were risk factors for hepatic RFS. In the subgroup analysis of deep-seated tumors, the ARN-FI group also showed less intraoperative blood loss, a lower rate of strategy change, shorter postoperative recovery times, a higher R0 resection rate, and improved RFS and hepatic RFS.

CONCLUSIONS

In laparoscopic PSH for CRLMs, ARN-FI may improve surgical efficiency and accuracy. Especially for deep-seated tumors, it has the potential to reduce blood loss and attain higher R0 resection rates.

Radioresistance in rectal cancer: can nanoparticles turn the tide?

Rectal cancer accounts for over 35% of the worldwide colorectal cancer burden representing a distinctive subset of cancers from those arising in the colon. Colorectal cancers exhibit a continuum of traits that differ with their location in the large intestine. Due to anatomical and molecular differences, rectal cancer is treated differently from colon cancer, with neoadjuvant chemoradiotherapy playing a pivotal role in the control of the locally advanced disease. However, radioresistance remains a major obstacle often correlated with poor prognosis. Multifunctional nanomedicines offer a promising approach to improve radiotherapy response rates, as well as to increase the intratumoral concentration of chemotherapeutic agents, such as 5-Fluorouracil. Here, we revise the main molecular differences between rectal and colon tumors, exploring the complex orchestration beyond rectal cancer radioresistance and the most promising nanomedicines reported in the literature to improve neoadjuvant therapy response rates.

Factors Affecting the Prognosis after Primary Tumor Resection for Patients with Metastatic Colorectal Cancer with Synchronous Peritoneal Metastasis: A Multi-center, Prospective, Observational Study

Objectives

To clarify the risk factors affecting prognosis after primary tumor resection (PTR) in patients with metastatic colorectal cancer with synchronous peritoneal metastasis (mCRC-SPM).

Methods

Patients were enrolled prospectively in the JSCCR project "Grading of Peritoneal Seeding in Colorectal Cancer." Factors that may influence overall survival-age, sex, location of the primary tumor, lymph node metastasis, presence of liver metastasis, degree of peritoneal metastasis, peritoneal cancer index (PCI), cancer cure, and postoperative chemotherapy-in the PTR group were examined using multivariate analysis.

Results

Of the 133 enrolled patients with mCRC-SPM, 112 patients underwent PTR. Among them, 26 (23.2%) had mCRC-SPM of grade P1, 47 (42.0%) of P2, and 39 (34.8%) of P3. The median PCI was 4 (range, 1-28); no surgery-related deaths occurred. Postoperative complications of Clavien-Dindo classification ≥grade 2 were observed in 20 (17.9%) patients. R0 surgery became more difficult as the degree of dissemination increased, and the PTR group had a significantly better prognosis than the non-PTR group. In the multivariate analysis, age ≥75 years, rectal cancer, presence of liver metastasis, higher PCI, non-curative resection, and non-treatment with systemic chemotherapy were associated with poor prognosis in patients after PTR.

Conclusions

In patients with mCRC-SPM, postoperative complications are infrequent for P1 with localized peritoneal dissemination, and PTR may be considered as aggressive treatment. Factors including age ≥75 years, rectal cancer, presence of liver metastasis, increased PCI, non-curative resection, and non-treatment with systemic chemotherapy are associated with a reduced survival benefit from PTR.

Donors With Previous Malignancy: When Is It Safe to Proceed With Organ Transplantation?

The growing number of organ donors in the United States, from 14,011 in 2012 to 21,374 in 2022, highlights progress in addressing the critical issue of organ shortages. However, the demand remains high, with 17 patients dying daily while on the waiting list. As of August 2023, over 103,544 individuals are awaiting transplants, predominantly for kidneys (85.7%). To expand the donor pool, the inclusion of elderly donors, including those with a history of malignancies, is increasingly considered. In 2022, 7% of all donors were aged 65 and above, despite the complexities their medical histories may introduce, particularly the risk of donor-transmitted cancer (DTC). This review examines the challenges and potential benefits of using donors with known malignancy histories, balancing the risks of DTC against the urgency for transplants. A critical analysis is presented on current knowledge and the decision-making processes that consider cancer types, stages, and patient survival outcomes. The goal is to identify missed opportunities and improve strategies for safe and effective organ transplantation from this donor demographic.

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.

A Rare Case of Colorectal Cancer With Delayed Metastasis to the Duodenum

Colorectal cancer (CRC) continues to be a significant global health issue contributing to a high mortality rate. Despite advancements in treatment, the risk of recurrence remains due to inherent mutations and the rapid turnover of intestinal mucosa. We present an exceptionally rare case of CRC metastasis to the duodenum in a 42-year-old female who has been compliant with postsurgical surveillance. Despite previous negative surveillance results, elevated CEA levels and a 3-cm mesenteric mass were detected, raising concerns for carcinoma, which was later confirmed by biopsy. The tumor board deemed her ineligible for surgery due to vascular involvement, leading to palliative care and an attempt at neoadjuvant therapy. Vigilant monitoring is crucial for early detection and intervention.

The role of microalgal extracts and their combination with tamoxifen in the modulation of breast cancer immunotherapy (Review)

Cancer is one of the deadliest health menaces humans have ever witnessed. It is a leading cause of human mortality. Today, it remains a main leading cause of death globally primarily due to lifestyle changes and population ageing. A total of ~12.7 million cancer cases and 7.6 million cancer deaths were reported in 2008. In developing countries, cancer accounted for 56% of cases and 64% of deaths. Tamoxifen is the most reputable and recommended specific oestrogen receptor modulator drug used for the treatment of breast cancer. In the past decade, algae have demonstrated remarkable potency for advanced life applications. They can remain a focus of interest in the coming decades because they are one of the most diverse organisms in the entire ecosystem with immense bio nutritional benefits. Algae and their extracts play a pivotal role in the pharmaceutical industry as bioactive compounds and new drugs and nutraceutical industry as probiotics and antioxidants. However, a broad range of the health benefits of these organisms remains to be explored. The present review highlights the applications and co-application of microalgal crude extracts with tamoxifen for breast cancer immunotherapy. Given that recent studies have suggested that tamoxifen is an essential and primary treatment for breast cancer, the present review focused on the identification of a new treatment approach involving the co-application of tamoxifen and microalgal extracts to provide promising anticancer activity with few side effects on normal cells. The present review includes a general background and blueprint for the use of microalgal extracts as potential and affordable treatments or adjuncts for breast cancer management.

Isolated Temporal Bone Metastasis With Inner Ear Invasion as Manifestation of Rectal Cancer

Temporal bone metastasis is a rare find. The most common sites of origin of temporal bone metastases are breast, lungs, and prostate. The main route of dissemination appears to be hematogenic. We present a case report of an 81-year-old male patient with locally advanced rectal cancer, without evidence of distant metastasis on CT of the chest, abdomen, and pelvis, presenting with rapidly progressive hearing loss, facial palsy, and loss of balance. Initial imaging is inconclusive, with meningioma being the leading hypothesis. However, histological analysis confirms the presence of carcinoma of colorectal origin, revealing an isolated temporal bone metastasis with inner ear invasion. The objective of this case report is to bring to attention that although metastasis of the temporal bone is rare, it should be considered in patients with otologic symptoms or facial palsy with a history of malignant tumors, even ones not usually associated with this metastasis location.

Observed Changes in the Distribution of Colon Cancer Metastasis: A National Cancer Database Review and Institutional Experience

BACKGROUND

The University of Louisville has observed a near 70% drop in resectable/borderline resectable metastatic colorectal cancer in the past 5 years. The aim of this study was to evaluate the distribution of colon cancer metastasis at diagnosis and at recurrence.

PATIENTS AND METHODS

Stage was defined by the American joint committee on cancer (AJCC) eighth edition. Institutional review board approval was granted for post hoc review of stage II and III patients with colon cancer from the University of Louisville prospective hepatic database from 2002 to 2023, as well as for the National cancer database (NCDB) Participant user file (PUF) 2021. The Surveillance epidemiology and end-results (SEER) 22 database was also utilized to corroborate the findings in the NCDB.

RESULTS

Between 2018 and 2021 pathological M1a decreased annually (51.9-46.3%), while M1c increased year-over-year (26.6-32.4%) and M1b stayed relatively the same (21.4-21.3%). These differences were significant on chi-squared analysis with a p value of < 0.001. Univariate analysis of the post hoc review between 2017 and 2020 revealed significant differences between stage 4a and 4c in terms of race (p value 0.018), carcinoembryonic antigen (CEA) at diagnosis (p value 0.037), CEA at recurrence (p value 0.012), presence of liver metastasis (p value 0.003), and referral pattern (p value 0.014). Multivariate analysis identified stage 4b as an independent predictor for hepatic metastasis (odds ratio; OR 4.69, p value 0.011).

CONCLUSIONS

A significant change in the distribution of colon cancer metastases has occurred at an institutional and national level over the past 3-5 years. Interdisciplinary treatment strategies will have to be modified accordingly.

The impact of preoperative treatments on the immune environment of rectal cancer

To improve local disease control, the use of preoperative radiotherapy either alone or combined with chemotherapy has become standard practice in rectal cancer, but it is unclear how these treatments modify the antitumoral immune response. We aimed to evaluate tumor histopathologic features and the prognostic effect of host immune response in rectal cancer with variable treatment modalities. Ninety-five rectal cancers with short-course radiotherapy (SRT), 97 with long-course chemoradiotherapy (CRT), and 154 without preoperative treatments, were evaluated for histopathologic features including Crohn's-like reaction (CLR). CD3+ and CD8+ immunohistochemistry and tumor cells were analyzed from tumor tissue microarray samples to calculate T-cell densities and G-cross function values to estimate cancer cell-T-cell co-localization (proximity score). We found that lymphocyte densities were diminished after SRT, but CLR was scarcer after CRT. Proximity score and CLR density were prognostic for survival in cancer without preoperative treatments and could be combined into an enhanced prognostic score (immune grade). In the irradiated tumors, CLR density remained prognostic while the impact of T-cell infiltration was insufficient alone. In multivariable analysis, the immune grade proved to be an independent prognostic factor for survival. In conclusion, the immune contexture of rectal cancer harbors prognostic significance even after preoperative radiotherapy.

Peritoneal Carcinomatosis in Colorectal Cancer: Review and Update of Current Clinical Data

The peritoneal metastasized colorectal cancer (pmCRC) represents a serious health problem worldwide with a special emphasis in the developed countries. Several guidelines recognize the role of multimodal therapy consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of pmCRC. New data suggests that some other factors, eg, tumor biology, immune profile, neoadjuvant chemotherapy may play a predictive role for the oncological outcome of these patients.

Structure optimization and molecular dynamics studies of new tumor-selective s-triazines targeting DNA and MMP-10/13 for halting colorectal and secondary liver cancers

A series of triazole-tethered triazines bearing pharmacophoric features of DNA-targeting agents and non-hydroxamate MMPs inhibitors were synthesized and screened against HCT-116, Caco-2 cells, and normal colonocytes by MTT assay. 7a and 7g surpassed doxorubicin against HCT-116 cells regarding potency (IC50 = 0.87 and 1.41 nM) and safety (SI = 181.93 and 54.41). 7g was potent against liver cancer (HepG-2; IC50 = 65.08 nM), the main metastatic site of CRC with correlation to MMP-13 expression. Both derivatives induced DNA damage at 2.67 and 1.87 nM, disrupted HCT-116 cell cycle and triggered apoptosis by 33.17% compared to doxorubicin (DNA damage at 0.76 nM and 40.21% apoptosis induction). 7g surpassed NNGH against MMP-10 (IC50 = 0.205 μM) and MMP-13 (IC50 = 0.275 μM) and downregulated HCT-116 VEGF related to CRC progression by 38%. Docking and MDs simulated ligands-receptors binding modes and highlighted SAR. Their ADMET profiles, drug-likeness and possible off-targets were computationally predicted.

Cholecystectomy Is a Risk Factor for Proximal Colon Cancer That May Also Relate to its Aggressiveness

INTRODUCTION

There are studies with mixed conclusions about the role cholecystectomy plays as a risk factor for proximal colorectal cancer (CRC).

METHODS

We performed a multicenter retrospective cohort study where the records of patients with CRC were reviewed. Data was collected regarding affected colon subsegment (cecum, ascending, transverse, descending, sigmoid, or rectum, which were also combined into proximal or distal colon), history and time since cholecystectomy, histopathology reports (TNM classification and clinical stage), and KRAS, NRAS, and BRAF mutation analysis. Univariate and multivariate analysis adjusting for age, smoking history, body mass index, sex, and family history of cancer were performed. Logistical regression for statistical analysis was used to estimate the odds ratio for the association between cholecystectomy and tumor location.

RESULTS

Four hundred four cases were obtained, of which 52 previously had cholecystectomy. The date of surgery was recorded in 43 patients, with a 5 y median and an interquartile range of 1.5-14 y prior to CRC diagnosis. Both crude and adjusted odds ratio (2.86 and 2.42, respectively) confirmed an associated risk for developing proximal CRC after cholecystectomy. When proximal CRC cases with previous cholecystectomy were directly compared against proximal CRC without cholecystectomy and distal CRC cases, the former had a higher distribution of prevalence for T3, T4b, N1b, M1a, and M1c. KRAS mutation also presented its highest prevalence in this group with 33%.

CONCLUSIONS

Cholecystectomy was related to the development of proximal CRC in all its subsegments, seemingly associated with higher stages at diagnosis. Close surveillance should be considered in patients who undergo cholecystectomy.

Association between microsatellite instability status, clinicopathological features and mitochondrial DNA amplification in patients with colorectal cancer

The relationship between BRAF-V600E mutations, mitochondrial DNA amplification and microsatellite instability-high (MSI-H) in colorectal cancer (CRC) has yet to be fully elucidated. The aim of the present study was to assess the association between the MSI status and BRAF-V600E gene mutations/clinicopathological features/mitochondrial DNA amplification in CRC. A non-interventional study analysis was performed using the clinicopathological features of 455 patients with CRC. Immunohistochemistry was used to evaluate four mismatch repair proteins (MutS homolog 2, MutS homolog 6, MutL homolog 1 and postmeiotic segregation increased 2), Ki-67 index, and programmed cell death protein 1 (PD-1) and programmed cell death-ligand 1 (PD-L1) expression. Additionally, PCR coupled with capillary electrophoresis were used to ascertain the MSI status. Moreover, amplification refractory mutation system-PCR was used to detect BRAF-V600E gene mutation and fluorescence in situ hybridization analysis was used to assess mitochondrial DNA. A total of 455 patients were divided into the MSI high (MSI-H) group (n=52) and microsatellite stability (MSS) group (n=403) based on their MSI status. Compared with the results of immunohistochemistry of four mismatch repair proteins, the consistency rate between mismatch repair protein deficiency and MSI was 94.23%. There were significant differences in PD-L1, primary tumor site, clinical stage, degree of differentiation, tumor size, lymph node metastasis and the occurrence of multiple primary tumors between the MSI-H group and MSS group (P<0.05 or P<0.001). However, there were no significant differences for sex, age, PD-1, Ki-67 expression and BRAF-V600E. The 24-60-month survival rate of the patients in the MSI-H group was significantly higher than that of those in the MSS group (P<0.05). Furthermore, the number of mitochondrial DNA was significantly amplified in the MSI-H group. In conclusion, the present study demonstrated that the combined detection of PD-L1 and MSI in patients with CRC can provide more accurate and effective guidance for personalized treatment.

Survival Analysis and Recurrence Patterns in 555 Patients with Colorectal Peritoneal Metastases Treated by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

The presence at diagnosis, or development of, colorectal peritoneal metastases (CPM) is common in colorectal cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) show promising results in selected patients with CPM. The current study aimed to describe oncologic outcomes of patients with CPM, focusing on recurrence patterns and risk factors for adverse events.

METHODS

We conducted a retrospective review of patients with CPM treated by CRS and HIPEC at a single institution between 2000 and 2021.

RESULTS

A total of 555 patients were included, of whom 480 (86.5%) had complete cytoreduction, with a median age of 59 years and median Peritoneal Cancer Index (PCI) of 6. Following complete cytoreduction, 5-year overall survival (OS) and disease-free survival (DFS) were 51% and 31%, respectively. In multivariable Cox regression, PCI >6 (hazard ratio [HR] 2.25), pathological node positivity (pN+; HR 1.94), and perineural invasion (HR 1.85) were associated with decreased OS, while PCI >6, pN+, and previous systemic metastases resulted in reduced DFS. Overall, 284 (62%) patients developed recurrence, of whom 97 (34%) had local recurrence (LR), 100 (35%) had systemic recurrence (SR), and 87 (31%) had combined recurrence (5-year OS: 49.3%, 46%, and 37.4%, respectively). Mutated KRAS (mKRAS) was associated with lower 5-year OS (55.8%) and DFS (27.9%) compared with wild-type KRAS (wtKRAS; 70.7% and 37.6%, respectively). In multivariable analyses, mKRAS was related to decreased OS (HR 1.82), DFS (HR 1.55), and SR (OS 1.89), but not to LR.

CONCLUSIONS

Complete cytoreduction results in good survival outcomes for patients with CPM. Burden of peritoneal disease and tumor biology are the main predictors of survival. Patients with mKRAS are a high-risk cohort, with increased probability of SR and reduced survival.

Molecular biomarkers for predicting complete response to preoperative chemoradiation in people with locally advanced rectal cancer

OBJECTIVES

This is a protocol for a Cochrane Review (prognosis). The objectives are as follows: Primary objectives To identify and estimate the prognostic value of molecular biomarkers as predictors of pathological complete response to neoadjuvant chemoradiotherapy in people with locally advanced rectal cancer. summarises the review question in population, index prognostic factor, comparator prognostic factor(s), outcome, timing, and setting (PICOTS) format. [Table: see text] [Figure: see text] Secondary objectives To explore the following biomarker measurement, treatment, and study design factors as possible sources of heterogeneity in the association between the prognostic factor and pathological response: type of assay/measurement method, biomarker positivity criteria or cut-off point, chemotherapy regimen, and radiotherapy regimen.