Tumour deposits in colon cancer predict recurrence and reduced survival in a nationwide population-based study

Lack of Hierarchical Survival Prognosis in AJCC Staging for Colon and Rectal Cancer-Implications for Future Summary Stage Classification

BACKGROUND

Current American Joint Committee on Cancer (AJCC) staging for colorectal cancer utilizes TNM framework groups disease based on extent and provides prognostic information, ideally with a hierarchical logic. We sought to evaluate survival as a function of stage within the 8th edition AJCC staging system for colon and rectal cancer.

METHODS

Patients with primary colon or rectal cancer diagnosed 2010-2016 were identified from the National Cancer Database (NCDB). Survival curves were used to determine staging hierarchy for colon and rectal cancer. Multivariable modeling was used to identify relative contributions of variables (z-score) to survival, and hazard ratio (HR)-based groupings were constructed.

RESULTS

Among 270,584 colon and 53,846 rectal cancer patients, AJCC summary staging was non-hierarchical (e.g. HR IIC=2.92, HR IIIA=0.85-1.31). Multivariable analysis demonstrated high T category (T4a, T4b) confers the greatest mortality (colon: T4a HR 2.76, T4b HR 3.04; rectum: T4a HR 3.29, T4b HR 3.73), while high T category as well as high N category (colon: T4a z=66.9, T4b z=64.6, N2b z=55.7; rectum: T4b z=31.1, N2b z=25.1) contributed substantially to the survival model. HR based TN groupings resulted in hierarchical stage organization.

CONCLUSIONS

Current AJCC stage groups for colorectal cancer are non-hierarchical. High T category has a greater impact on survival than N category for patients with early N disease, while high N category was more important for patients with early T disease. An organizational framework based on HR groupings is hierarchical and provides more accurate prognostic information.

A prognostic nomogram based on desmoplastic reaction/tumor deposit modified lymph node staging in colorectal cancer

Background

Tumor metastasis within the tumor microenvironment (TME) is a primary driver of tumor progression, with tumor deposit (TD) being one pathway of metastasis. However, the mechanisms underlying TD as a prognostic indicator in colorectal cancer (CRC) remain unclear. The 8th edition of the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) stage system does not account for the impact of TD quantity on prognosis in TD-positive patients. This study aims to integrate TD numbers into the existing N-stage system, develop a novel nomogram prediction model (newN), and validate its prognostic significance. Desmoplastic reaction (DR), including immature, intermediate, and mature types, is a critical indicator of TME status and a prognostic factor. While immature DR has been associated with TD presence, the relationship between TD quantity and DR type changes (mature-intermediate-immature) remains unexplored, this study seeks to elucidate this relationship.

Methods

This study enrolled 171 patients with TNM stage II or III pT3 or pT4 colorectal adenocarcinoma who underwent complete tumor resection. DR was evaluated, and TD numbers were recorded. Clinicopathological factors related to TD formation, multiple TD, and DR changes were analyzed to explore their relationships. Kaplan-Meier curves and log-rank tests were used to assess recurrence-free survival (RFS). Univariate and multivariate Cox proportional hazards analyses were performed to identify independent risk factors for overall survival (OS), and a nomogram prediction model was developed. The association between TD, DR, and the TME was investigated, along with the mechanisms underlying TD formation and DR changes.

Results

DR classification and the number of TD-positive cases were assessed using the Gamma test, yielding a statistically significant result (statistic =11.419, P<0.001) and a strong positive correlation (correlation coefficient =0.836) between TD-positive numbers and DR classification. Abnormal carcinoembryonic antigen (CEA) levels, T stage, lymph node (LN) metastasis count, vascular invasion, TD numbers, poor histologic grade, immature DR, newN stage, contrastN stage, and existing N stage were associated with reduced RFS. DR, TD, and newN stage were identified as independent risk factors for CRC prognosis. The C-index values for the newN stage model (0.759), contrastN stage model (0.748), and existing N stage model (0.742) confirmed the superior prognostic accuracy of the newN stage model.

Conclusions

This study confirmed a significant correlation between immature DR and TD, as well as an association between DR types and TD quantities. We hypothesize that tumor-cancer-associated fibroblasts (CAFs)-Twist/DR-epithelial-mesenchymal transition (EMT)-tumor budding (TB)-TD interactions within the TME are involved in the mechanism related to TD formation. The revised newN stage system, incorporating TD numbers and the current N stage, provides more accurate OS predictions, highlighting the importance of TD quantity as a critical prognostic factor.

Validated Integration of Tumor Deposits in N Staging for Prognostication in Colon Cancer

Importance

Tumor deposits have prognostic value in colon cancer, but the current American Joint Committee on Cancer (AJCC) staging only considers them if there are no concurrent positive lymph nodes.

Objective

To devise a staging system for colon cancer by integrating counts of tumor deposits with positive lymph nodes while retaining the current AJCC staging framework.

Design, Setting, and Participants

This retrospective cohort study examines data from a large-volume, tertiary care center database (January 2010 through March 2023 with follow-up until December 2023) and the population-based National Cancer Database (January 2010 through December 2020 with follow-up until December 2021). Participants were adults (age 18-75 years) with stage III colon adenocarcinoma who underwent chemotherapy, and had a specified positive lymph node count and tumor deposit count were selected.

Exposure

A real positive lymph nodes count was developed and used to derive Sassun-Mayo N/tumor, lymph node, and metastasis (TNM) stages that were compared with the AJCC N/TNM stages.

Main Outcomes and Measures

Receiver operating characteristic (ROC) curves and Kaplan-Meier analyses for 3-year overall survival were performed to assess the efficiency of the 2 staging systems. The concordance index was used for validation using the National Cancer Database.

Results

From a total patient number of 11 162 (institutional) and 848 704 (national), the final patient numbers were 788 and 77 790, respectively. The institutional database patients had a mean (SD) age of 58.5 (11.5) years; there were 433 male patients (54.9%) and 355 female (45.1%). The national database patients had a mean (SD) age of 59.3 (10.6) years; there were 40 315 male patients (51.8%) and 37 475 female (48.2%). ROC curve areas were improved using the Sassun-Mayo stages (3-year death for AJCC TMN, 0.63 [95% CI, 0.57-0.69] vs 0.66 [95% CI, for 0.60-0.72] for Sassun-Mayo TNM). Kaplan-Meier curves revealed visible overlaps among AJCC N stages, which were absent in the Sassun-Mayo N stages. The concordance index in the Sassun-Mayo N/TNM stages was 0.611 and 0.616, respectively, while in the AJCC N/TNM stages, it was 0.598 and 0.606, respectively. Patients upstaged from N1 to N2 (n = 10 307; 13.2%) had a 3-year overall survival rate nearly identical to that of AJCC N2a patients. Additionally, 3001 patients (3.9%) were upstaged from N2a to N2b, indicating that 13 308 patients (17.1%) with stage III colon cancer across cohorts were understaged.

Conclusions and Relevance

This study found that Sassun-Mayo N/TNM staging provided superior overall survival stratification compared with the current AJCC staging, suggesting that their implementation could improve prognostication in colon cancer.

Factors associated with lymph node metastasis and survival in T2 colon cancer

PURPOSE

This study aimed to explore the clinical factors associated with lymph node metastasis (LNM) and survival in T2 colon cancer.

METHOD

Patients with T2 colon cancer and receiving radical surgery from 2017 to 2021 in our hospital were retrospectively enrolled. Patients were divided into two groups according to the LN status (LNM, non-LNM). The demographic, radiological, pathological, and survival data were collected and analyzed. Logistic regression was used to find the factors associated with LNM, and cox regression was adopted to identify factors contributing to poor survival. All the data analysis was performed by SPSS 22.0 and R.

RESULTS

A total of 150 patients were included in this study, among them thirty were with LNM (20%). The LNM group had significantly higher incidence of lymph-vascular invasion (LVI) and perineural invasion. Besides, positive LNs had more proportion of irregular margin (P < 0.001) and heterogeneity (P < 0.001) than the negative ones. The multivariate analysis indicated that LVI and heterogeneity of LN were independent risk factors of LNM in T2 colon cancer. The disease-free survival (DFS) was 80% and 93.3% in the LNM and non-LNM group (P = 0.02), respectively. Besides, the overall survival (OS) was 92.9% and 95% in the LNM and non-LNM group (P = 0.103), respectively. The results indicated that elevated CA199 value and LNM were independent risk factors contributing to poorer OS and DFS.

CONCLUSION

The current data indicated LVI and LN heterogeneity were independent risk factors of LNM in T2 colon cancer. More extended surgery should be considered when these factors were detected.

The number of potential gateways determines prognostic value of tumour deposits in colon cancer

Tumour deposits (TD) are a crucial biomarker in colorectal cancer, closely associated with nearby structures such as blood vessels, lymphatic vessels, and peripheral nerves. These anatomical structures serve as pathways that facilitate the spread of tumour cells throughout the body. This study aims to investigate how TD access these anatomical gateways and how these variations impact patient survival. We analysed colon carcinoma patients who underwent surgery at Radboud University Medical Centre between 1986 and 2012 for the presence of TD. Using serial sections and immunohistochemistry with four different antibodies (CD34, D2-40, S100, and elastic van Gieson), we examined the presence and distribution of TD access to surrounding anatomical structures, including blood vessels, lymphatic vessels and peripheral nerves. In 127 patients, 280 TD were examined. Of these, 112 TD (40%) had multiple access points, 109 TD (39%) had a single access point, and 59 TD (21%) had no discernible access point. More than half of the TD (57%) demonstrated haematovascular invasion. Patients with TD featuring a single access point had a better prognosis compared to those with multiple access points (5-year overall survival, p=0.025; 5-year disease-free survival, p=0.005). TD are a heterogeneous biomarker characterised by various access points, with haematovascular invasion being the most common. Our study highlights a direct correlation between the number of TD access points and patient outcomes, indicating that an increase in access points is linked to a poorer prognosis.

Important role of lymphovascular and perineural invasion in prognosis of colorectal cancer patients with N1c disease

BACKGROUND

Lymphovascular invasion (LVI) and perineural invasion (PNI) are associated with decreased survival in colorectal cancer (CRC), but its significance in N1c stage remains to be clearly defined.

AIM

To evaluate LVI and PNI as potential prognostic indicators in N1c CRC.

METHODS

We retrospectively identified 107 consecutive patients who had CRC with N1c disease radically resected at our hospital. Tumors were reviewed for LVI and PNI by one pathologist blinded to the patients' outcomes. Disease-free survival (DFS), overall survival (OS) and cancer-specific survival (CSS) were determined using the Kaplan-Meier method, with LVI and PNI prognosis differences determined by multivariate analysis using the Cox multiple hazards model. Results were compared using log-rank test. The receiver operating characteristic (ROC) curve was used to evaluate the prognostic predictive ability.

RESULTS

The median follow-up time was 63.17 (45.33-81.37) months for DFS, with 33.64% (36/107) of patients experiencing recurrence; 21.5% of tumors were found to be LVI positive and 44.9% PNI positive. The 5-year DFS rate was greater for patients with LVI-negative tumors compared with LVI-positive tumors (74.0% vs 35.6%), and PNI was similar (82.5% vs 45.1%). On multivariate analysis, LVI [hazard ratio (HR) = 3.368, 95% confidence interval (CI): 1.628-6.966, P = 0.001] and PNI (HR = 3.055, 95%CI: 1.478-6.313, P = 0.002) were independent prognostic factors for DFS. All patients could be divided into three groups of patients with different prognosis according to LVI and PNI. The 5-year ROC curve for LVI, PNI and their combination prediction of DFS was 0.646, 0.709 and 0.759, respectively. Similar results were seen for OS and CSS.

CONCLUSION

LVI and PNI could serve as independent prognostic factors of outcomes in N1c CRC patients. Patients with LVI or PNI should be given more attention during treatment.

Association between tumor deposits and liver and lung metastases at diagnosis of colorectal cancer: A SEER-based analysis

BACKGROUND

Tumor deposits are a unique histologic feature of colorectal cancer that is associated with adverse survival outcomes. The present study aimed to assess the association between tumor deposits and liver and lung metastases and to describe the characteristics of colorectal cancer associated with tumor deposits.

METHODS

The Surveillance, Epidemiology, End Results (SEER) database was screened between 2010 and 2020 for patients with colorectal adenocarcinoma who underwent radical resection with data on tumor deposits. The primary outcome of the study was liver and lung metastases. The secondary outcome was the characteristics of patients with tumor deposits.

RESULTS

A total of 205,294 patients (52% male, mean age 66.5 years) were included in the study. Tumor deposits were detected in 20,059 (9.7%) patients. Patients with tumor deposits were younger and presented more often with larger tumors, T3/T4 tumors, N+ tumors, stage IV disease, left-sided and rectal cancers, signet-ring cell carcinomas, high-grade adenocarcinomas, and perineural invasion. Multivariable binary regression analyses showed that tumor deposits were associated with 72% higher odds of liver metastases (odds ratio 1.72, 95% confidence interval 1.62-1.82, P < .001) and 68% higher odds of lung metastases (1.68, 1.51-1.86, P < .001). The odds of liver metastases increased by 3% (odds ratio 1.03, 95% confidence interval 1.03-1.04, P < .001) and the odds of lung metastases increased by 2% (1.02, 1.01-1.03, P < .001) for each tumor deposit detected.

CONCLUSIONS

Tumor deposit-positive colorectal cancers were larger, more often on the left side or in the rectum and presented with more advanced disease and unfavorable histology than tumor deposit-negative cancers. Tumor deposits were independently associated with 72% and 68% higher odds of liver and lung metastases, respectively.

Tumour deposit count is an independent prognostic factor in colorectal cancer-a population-based cohort study

BACKGROUND

Tumour deposits are a prognostic factor for overall survival and distant metastasis in lymph node-negative colorectal cancer. However, the current TNM staging system does not account for the presence of tumour deposits in lymph node-positive colorectal cancer, or for the presence of multiple deposits. This study aimed to investigate the prognostic effect of tumour deposit count in patients with colorectal cancer.

METHODS

Patients who underwent curative surgery for colorectal cancer between 2016 and 2019 were identified nationwide from the Swedish Colorectal Cancer Registry. Patients with undisclosed tumour deposit status/count and stage IV disease were excluded. Univariable and multivariable Cox regression analyses were used to assess the prognostic effect of tumour deposit count on overall survival and distant metastasis adjusted for age, sex, neoadjuvant treatment, and number of positive lymph nodes.

RESULTS

Of 18 913 patients assessed, 14 154 patients were analysed with tumour deposits (TDs) present in 1702 (12%) patients. Patients were stratified by tumour deposit count (0, 1, 2, 3, 4, and ≥5 TDs). Increased tumour deposit count was associated with decreased 5-year overall survival (79%, 70%, 61%, 66%, 50%, 49%) and increased 5-year risk for distant metastasis (14%, 26%, 35%, 41%, 48%, 54%) respectively. Tumour deposit count remained an independent negative prognostic factor after multivariable Cox regression analysis.

CONCLUSION

Tumour deposit count is a negative prognostic predictor of both overall survival and distant metastasis in colorectal cancer, independent of positive lymph nodes or neoadjuvant treatment. These findings suggest that tumour deposit count should be integrated into the TNM staging regardless of lymph nodes status to improve prognostic accuracy.

Prognostic Value of Tumor Deposits in Patients with Colorectal Cancer

Tumor nodules or tumor deposits (TDs) are a histopathological prognostic factor that are associated with a negative evolutionary course in patients with colorectal cancer (CRC). There are still controversial aspects of TDs, including how they should be integrated into the TNM classification system. The objective of this study was to analyze the predictive value of TDs for cancer-related survival (CRS) and time-to-recurrence survival (TTR) and to evaluate the prognostic value of TDs in patients whose tumors also presented lymph node metastasis (LNM). In this retrospective observational study, all patients treated for CRC between January 2010 and December 2020 at the same hospital were included. CRS and TTR were classified by tumor stage. The results were compared between patients whose tumors had TDs and patients whose tumors did not. A total of 1426 patients met the criteria for inclusion in the analysis. TDs were detected in 178 patients (12.5%): 60 had tumors without LNM, and 118 had LNM. Patients with TD tumors had a lower CRS at 60 months after diagnosis (42% vs. 82%; p < 0.001) and a shorter TTR (34% vs. 79%; p < 0.001). Cox multiple regression analysis revealed that the presence of TD was associated with an increased risk of death from CRC (HR: 1.820; 95% CI: 1.327-2.496) and an increased risk of recurrence (HR: 2.315; 95% CI: 1.743-3.073). In each N stage category, the CRS was significantly lower in the subgroup with TD+: in patients with N1a tumors, the CRS was 44% when TD+ vs. 70% when TD- (p = 0.019); in the N1b group it was 36% vs. 66% (p < 0.001); in the N2a group it was 34% vs. 58% (p = 0.012); and in N2b tumors it was 23% vs. 53% (p = 0.031). The present study shows that the information on the presence of TDs is complementary to that provided by LNM and allows the identification of subgroups of patients in each N stage determined by two metrics, CRS and TTR. TDs should be included in the definition of TNM system categories in patients who simultaneously present with LNM.

Inhibitory Effects of the Polyphenols from the Root of Rhizophora apiculata Blume on Fatty Acid Synthase Activity and Human Colon Cancer Cells

Marine mangrove vegetation has been traditionally employed in folk medicine to address various ailments. Notably, Rhizophora apiculata Blume has exhibited noteworthy properties, demonstrating efficacy against cancer, viruses, and bacteria. The enzyme fatty acid synthase (FAS) plays a pivotal role in de novo fatty acid synthesis, making it a promising target for combating colon cancer. Our study focused on evaluating the FAS inhibitory effects of both the crude extract and three isolated compounds from R. apiculata. The n-butanol fraction of R. apiculata extract (BFR) demonstrated a significant inhibition of FAS, with an IC50 value of 93.0 µg/mL. For inhibition via lyoniresinol-3α-O-β-rhamnopyranoside (LR), the corresponding IC50 value was 20.1 µg/mL (35.5 µM). LR competitively inhibited the FAS reaction with acetyl-CoA, noncompetitively with malonyl-CoA, and in a mixed manner with NADPH. Our results also suggest that both BFR and LR reversibly bind to the KR domain of FAS, hindering the reduction of saturated acyl groups in fatty acid synthesis. Furthermore, BFR and LR displayed time-dependent inhibition for FAS, with kobs values of 0.0045 min-1 and 0.026 min-1, respectively. LR also exhibited time-dependent inhibition on the KR domain, with a kobs value of 0.019 min-1. In human colon cancer cells, LR demonstrated the ability to reduce viability and inhibit intracellular FAS activity. Notably, the effects of LR on human colon cancer cells could be reversed with the end product of FAS-catalyzed chemical reactions, affirming the specificity of LR on FAS. These findings underscore the potential of BFR and LR as potent FAS inhibitors, presenting novel avenues for the treatment of human colon cancer.