Cancer of the colon: the influence of the no-touch isolation technic on survival rates

Complete mesocolic excision for colon cancer: current status and controversies

According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.

Radiofrequency ablation induces tumor cell dissemination in a mouse model of hepatocellular carcinoma

BACKGROUND

We tested the hypothesis that radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) promotes tumor cell release and explored a method for reducing these effects.

METHODS

A green fluorescent protein-transfected orthotopic HCC model was established in 99 nude mice. In vivo flow cytometry was used to monitor circulating tumor cell (CTC) dynamics. Pulmonary fluorescence imaging and pathology were performed to investigate lung metastases. First, the kinetics of CTCs during the periablation period and the survival rate of CTCs released during RFA were investigated. Next, mice were allocated to controls, sham ablation, or RFA with/without hepatic vessel blocking (ligation of the portal triads) for evaluating the postablation CTC level, lung metastases, and survival over time. Moreover, the kinetics of CTCs, lung metastases, and mice survival were evaluated for RFA with/without ethanol injection. Pathological changes in tumors and surrounding parenchyma after ethanol injection were noted. Statistical analysis included t-test, ANOVA, and Kaplan-Meier survival curves.

RESULTS

CTC counts were 12.3-fold increased during RFA, and 73.7% of RFA-induced CTCs were viable. Pre-RFA hepatic vessel blocking prevented the increase of peripheral CTCs, reduced the number of lung metastases, and prolonged survival (all p ≤ 0.05). Similarly, pre-RFA ethanol injection remarkably decreased CTC release during RFA and further decreased lung metastases with extended survival (all p ≤ 0.05). Histopathology revealed thrombus formation in blood vessels after ethanol injection, which may clog tumor cell dissemination during RFA.

CONCLUSION

RFA induces viable tumor cell dissemination, and pre-RFA ethanol injection may provide a prophylactic strategy to reduce this underestimated effect.

RELEVANCE STATEMENT

RFA for HCC promotes viable tumor cell release during ablation, while ethanol injection can prevent RFA induced tumor cell release.

KEY POINTS

• RFA induced the release of viable tumor cells during the ablation procedure in an animal model. • Hepatic vessel blocking can suppress tumor cells dissemination during RFA. • Ethanol injection can prevent RFA-induced tumor cell release, presumably because of the formation of thrombosis.

Liquid biopsy after resection of pancreatic adenocarcinoma and its relation to oncological outcomes. Systematic review and meta-analysis

BACKGROUND

It has been hypothesised that manipulation during surgery releases tumoral components into circulation. We investigate the effect of surgery on plasma-borne DNA biomarkers and the oncological outcomes in resectable pancreatic ductal adenocarcinoma (PDAC). We also compare non-touch isolation techniques (NTIT) with standard techniques.

MATERIALS AND METHODS

We performed a systematic review and a meta-analysis of studies analysing liquid biopsy as circulating tumour DNA (ctDNA), circulating tumour cells (CTCs), and messenger RNA (mRNA) in resectable PDAC patients who underwent surgery and its association with overall survival (OS) and disease-free survival (DFS). Research in EMBASE, Web of Science and PubMed was performed. The ctDNA shift negative-to-positive (ctDNA -/+) or ctDNA shift positive-to-negative (ctDNA +/-) before and after surgery was evaluated.

RESULTS

Twelve studies comprising 413 patients were included. Shorter OS and DFS were identified in patients with positive ctDNA status before (HR = 2.28, p = 0.005 and HR = 2.16, p = 0.006) or after surgery (HR = 3.88, p < 0.0001 and HR = 3.81, p = 0.03), respectively. Surgical resection increased the rate of ctDNA +/-. There were no differences in OS or DFS in the ctDNA +/- group compared with ctDNA +/+ or ctDNA -/+. However, there was a trend to shorter OS in the ctDNA -/+ group (HR = 5.00, p = 0.09). No differences between NTIT and standard techniques on liquid biopsy status were found.

CONCLUSION

Positive ctDNA in the perioperative period is associated with a worse prognosis. Surgical resection has a role in the negativisation of liquid biopsy status. More studies are needed to assess the potential of minimally invasive techniques on ctDNA dynamics.

Influence of the no-touch isolation technique on oncologic outcomes for patients with colon cancer undergoing curative surgery: A systematic review and meta-analysis

OBJECTIVE

To explore the influence of the no-touch isolation technique (NTIT) on oncologic outcomes for patients with colon cancer (CC) undergoing curative surgery.

BACKGROUND

Although several studies have investigated this topic, there have been no meta-analyses exploring the influence of NTIT on oncologic outcomes for these patients.

METHODS

We performed a comprehensive electronic literature search of studies published prior to March 2022 to identify those that compared oncologic outcomes for patients with CC who did or did not undergo NTIT. We conducted a meta-analysis using a random-effects model to calculate risk ratio (RRs) and 95% confidence intervals (CIs), analyzing heterogeneity using I2 statistics.

RESULTS

Four studies involving a total of 2885 patients with CC who underwent curative surgery met the inclusion criteria for this meta-analysis. The 5-year overall survival (OS) rate was 76.6% for patients with CC who underwent NTIT and 77.2% for those who did not. A meta-analysis of the 3 studies that reported 5-year OS revealed no significant difference between groups (RR, 0.84; 95% CI, 0.62-1.16; P = 0.30; I2 = 70%). In addition, there were no significant differences in 5-year recurrence-free survival (RR, 1.17; 95% CI, 0.93-1.48; P = 0.19; I2 = 45%), and 5-year liver recurrence-free survival (RR, 0.95; 95% CI 0.62, 1.46; P = 0.82; I2 = 65%).

CONCLUSIONS

The use of NTIT has no significant influence on oncologic outcomes for patients with CC undergoing curative surgery.

Pilonidal sinus disease carcinoma: Survival and recurrence analysis

BACKGROUND

The study aims to determine the survival and recurrence rates of pilonidal sinus disease (PSD) carcinoma.

METHODS

The data were collected retrospectively by searching the worldwide literature for all reports of carcinoma developing on the background of PSD. The results were presented using Kaplan-Meier curves.

RESULTS

Between 1900 and 2022, 140 cases of PSD carcinoma were published in 103 papers, with follow-up data available in 111 cases. Squamous cell carcinoma constituted 94.6% of the cases (n = 105). The disease-specific survival rate was 61.7% for 3 years, 59.8% for 5 years, and 53.2% for 10 years. There was a significant survival difference between stages: 80.0% in stages I and II, 70.8% in stage III, and 47.8% in stage IV (p = 0.01). The 5-year survival in G1-tumors was better than G2 and G3-tumors at 70.5% and 32.0%, respectively (p = 0.002). Recurrence occurred in 46.6% of the patients. The time-to-recurrence in patients treated with curative intention averaged 15.1 months (1-132 months). Local, regional, and distant recurrence was observed in 75.6%, 33.3%, and 28.9% of the recurrent tumors, respectively.

CONCLUSIONS

Pilonidal sinus carcinoma has a worse prognosis than primary cutaneous squamous cell carcinoma. Poor prognostic factors include advanced-stage disease and poor differentiation.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Inferior versus medial approach in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer: A propensity-score-matched analysis

AIM

In laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer, either an inferior approach (IA) or a medial approach (MA) is selected in our institution based on the surgeon's preference. The present study compared the treatment outcomes between IA and MA.

METHOD

This retrospective, single-centre study using propensity score matching analysed the short- and long-term outcomes of laparoscopic surgery in patients with right-sided colon cancer from 2010 to 2019 at Cancer Institute Hospital.

RESULTS

After patient selection, 1011 patients remained for the analysis, of which 67% underwent IA surgery and 33% underwent MA surgery. After propensity score matching (1:1), 325 patients in each group were analysed. Regarding the short-term outcomes, there were no significant differences in the operation time, rate of conversion to open surgery or postoperative complication rate (Clavien-Dindo Grade ≥ III) between the two groups, although the intra-operative median blood loss was significantly less in the IA group than in the MA group (IA, 13 ml vs. MA, 20 ml, P < 0.0001). Regarding the long-term outcomes, the relapse-free survival, liver-relapse-free survival, cancer-specific survival and overall survival were all similar between groups.

CONCLUSION

Both the IA and MA in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer are safe and feasible approaches; the IA may have an advantage over the MA in terms of reduced intra-operative blood loss. Based on their similar oncological outcomes, either the IA or MA can be selected, based on one's preference.

Telomere Length and Telomerase Activity in Subcutaneous and Visceral Adipose Tissues from Obese and Non-Obese Patients with and without Colorectal Cancer

To investigate the molecular mechanisms that link obesity and colorectal cancer (CRC), we analyzed parameters related to telomere function in subcutaneous and visceral adipose tissues (SAT and VAT), including subjects with and without CRC, who were classified according to their body mass index (BMI). Adipose tissues were obtained from 147 patients who had undergone surgery. A total of 66 cases corresponded to CRC patients, and 81 subjects were not affected by cancer. Relative telomere length was established by qPCR, and telomerase activity was determined by a method based on the telomeric repeat amplification protocol. Our results indicated longer telomeres in patients affected by CRC, both in SAT and VAT, when compared to the group of subjects without CRC. Tumor local invasion was associated with telomere length (TL) in SAT. Considering the BMI values, significant differences were found in the TL of both adipose tissues between subjects affected by CRC and those without cancer. Overweight subjects showed the greatest differences, with longer telomeres in the group of CRC patients, and a higher number of cases with telomerase reactivation in the VAT of subjects without cancer. In conclusion, parameters related to telomere function in adipose tissue could be considered as potential biomarkers in the evaluation of CRC and obesity.

Self-expanding metal stent placement and pathological alterations among obstructive colorectal cancer cases

BACKGROUND

Experimental studies suggest that self-expanding metal stents (SEMSs) enhance the aggressive behavior of obstructive colorectal cancer. The influence of SEMS placement on pathological alterations remains to be elucidated.

AIM

To determine whether SEMS placement is associated with molecular or pathological features of colorectal carcinoma tissues.

METHODS

Using a nonbiased molecular pathological epidemiology database of patients with obstructive colorectal cancers, we examined the association of SEMS placement with molecular or pathological features, including tumor size, histological type, American Joint Committee on Cancer (AJCC)-pTNM stage, and mutation statuses in colorectal cancer tissues compared with the use of transanal tubes. A multivariable logistic regression model was used to adjust for potential confounders.

RESULTS

SEMS placement was significantly associated with venous invasion (P < 0.01), but not with the other features examined, including tumor size, disease stage, mutation status, and lymphatic invasion. In both the univariable and multivariable models with adjustment for potential factors including tumor location, histological type, and AJCC-pT stage, SEMS placement was significantly associated with severe venous invasion (P < 0.01). For the outcome category of severe venous invasion, the multivariable odds ratio for SEMS placement relative to transanal tube placement was 19.4 (95% confidence interval: 5.24–96.2). No significant differences of disease-free survival and overall survival were observed between SEMS and transanal tube groups.

CONCLUSION

SEMS placement might be associated with severe venous invasion in colorectal cancer tissue, providing an impetus for further investigations on the pathological alterations by SEMSs in colorectal cancer development.

Robotic approach may be associated with a lower risk of lung metastases compared to laparoscopic approach for mid-low rectal cancer after neoadjuvant chemoradiotherapy: a multivariate analysis on long-term recurrence patterns

PURPOSE

Describe differences on recurrence patterns of mid-low rectal cancers treated with neoadjuvant chemoradiotherapy and low anterior resection between laparoscopic and robotic approach.

METHODS

Patients were identified from a prospectively maintained institutional database between 2006 and 2019. Demographics, clinicopathological features, recurrence, and survival were investigated. Cox regression analysis was performed for risk factor analysis.

RESULTS

A total of 160 patients (36 laparoscopic and 124 robotic) were included. Systemic recurrence rate was higher in laparoscopic group (27.8 vs 12.1%, p = 0.023). Liver recurrence was similar (11.1 vs 4.0%). Lung recurrence was higher after laparoscopy (19.4 vs 6.5%, p = 0.019). Time to lung recurrence was shorter after laparoscopy (13.0 months, IQR 4.0-20.0) compared to robotic (23.5 months, IQR 17.0-42.7) with no statistical significance. Time to liver recurrence was similar between laparoscopy (19.5 months, IQR 4.7-37.5) and robotic (19.0 months, IQR 10.5-33.0). Median overall survival after lung recurrence was different (p = 0.021) between laparoscopy (19.0 months, IQR 16.0-67.0) and robotic (74.0 months, IQR 50.2-112.2). OS after liver recurrence was similar between groups. Overall survival and lung disease-free survival were different between the two groups (p = 0.032 and p = 0.020), while liver disease-free survival and local recurrence-free survival were not. Laparoscopy (p = 0.030; HR 3.074, 95% CI: 1.112-8.496) was a risk factor for lung disease-free survival on multivariate analysis.

CONCLUSION

Lung recurrences were less frequent and with better overall survival in the robotic group. Liver recurrences were not influenced by choice of approach. Trials are needed to investigate why the robotic approach affects distant metastasis control.

From Dukes-MAC Staging System to Molecular Classification: Evolving Concepts in Colorectal Cancer

This historical review aimed to summarize the main changes that colorectal carcinoma (CRC) staging systems suffered over time, starting from the creation of the classical Duke’s classification, modified Astler–Coller staging, internationally used TNM (T—primary tumor, N—regional lymph nodes’ status, M—distant metastases) staging system, and ending with molecular classifications and epithelial–mesenchymal transition (EMT) concept. Besides currently used staging parameters, this paper briefly presents the author’s contribution in creating an immunohistochemical (IHC)-based molecular classification of CRC. It refers to the identification of three molecular groups of CRCs (epithelial, mesenchymal and hybrid) based on the IHC markers E-cadherin, β-catenin, maspin, and vimentin. Maspin is a novel IHC antibody helpful for tumor budding assessment, which role depends on its subcellular localization (cytoplasm vs. nuclei). The long road of updating the staging criteria for CRC has not come to an end. The newest prognostic biomarkers, aimed to be included in the molecular classifications, exert predictive roles, and become more and more important for targeted therapy decisions.

The Conventional Technique Versus the No-touch Isolation Technique for Primary Tumor Resection in Patients With Colon Cancer (JCOG1006): A Multicenter, Open-label, Randomized, Phase III Trial

OBJECTIVE

This phase III trial evaluated whether the no touch was superior to the conventional in patients with cT3/T4 colon cancer.

BACKGROUND

No touch involves ligating blood vessels that feed the primary tumor to limit cancer cell spreading. However, previous studies did not confirm the efficacy of the no touch.

METHODS

This open-label, randomized, phase III trial was conducted at 30 Japanese centers. The eligibility criteria were histologically proven colon cancer; clinical classification of T3-4, N0-2, andM0; and patients aged 20 to 80years. Patients were randomized (1:1) to undergo open surgery with conventional or the no touch. Patients with pathological stage III disease received adjuvant capecitabine chemotherapy. The primary endpoint was disease-free survival (DFS) according to the intention-to-treat principle.

RESULTS

Between January 2011 and November 2015, 853 patients were randomized to the conventional group (427 patients) or the no touch group (426 patients). The 3-year DFS were 77.3% [95% confidence interval (CI) 73.1%-81.0%] and 76.2% (95% CI 71.9%-80.0%) in the conventional and no touch groups, respectively. The superiority of no touch was not confirmed: hazard ratio for DFS = 1.029 (95% CI 0.800- 1.324; 1-sided P = 0.59). Operative morbidity was observed in 31 of 427 conventional patients (7%) and 26 of 426 no touch patients (6%). All grade adverse events were similar between the conventional and no touch groups. No in-hospital mortality occurred in either group.

CONCLUSION

The present study failed to confirm the superiority of the no touch.

Circulating Tumor Cells and the Non-Touch Isolation Technique in Surgery for Non-Small-Cell Lung Cancer

Circulating tumor cells (CTCs) are dislodged from the primary tumor into the bloodstream, travel within the bloodstream to distant organs, and finally extravasate and proliferate as epithelial metastatic deposits. The relationship between the existence of CTCs and tumor prognosis has been demonstrated by many researchers. In surgery for malignancies, the surgical manipulation of tumors and tissues around the tumor may lead to the release of CTCs into the bloodstream. The non-touch isolation technique (NTIT) has been advocated to prevent the release of CTCs during surgery. The concept of NTIT is the prevention of intraoperative increment of CTCs from the primary tumor by the early blockade of outflow vessels, and ‘pulmonary vein (PV)-first lobectomy’ during surgery for non-small-cell lung cancer (NSCLC) corresponds to this technique. The concept of PV-first lobectomy is well known among thoracic surgeons, but evidence of its efficacy for preventing the increase of intra- and postoperative CTCs and for improving postoperative prognosis is still uncertain. Our study summarizes evidence regarding the relationship between NTIT and CTCs in NSCLC and suggests the need for further research on CTCs and CTC-detecting modalities.

Is the anterior approach suitable for laparoscopic right hemihepatectomy in patients with large HCC (5-10 cm)? A propensity score analysis

BACKGROUND

Right hemihepatectomy via the anterior approach was initially employed to improve the survival of patients with large hepatocellular carcinoma (HCC). To date, the safety and feasibility of laparoscopic right hemihepatectomy via the anterior approach (ALRH) for patients with large HCC remains unclear; thus, we compared short-term and long-term outcomes between ALRH and open right hemihepatectomy via the anterior approach (AORH).

METHODS

161 patients with HCC who met the inclusion and exclusion criteria in our department were enrolled in this study between January 2015 and August 2018. Perioperative and oncological outcomes were compared using propensity score matching analysis (PSM).

RESULTS

There were 45 patients in the ALRH group and 116 patients in the AORH group. After 1:3 PSM, 40 ALRH patients and 95 AORH patients were well matched. The intraoperative time was longer in the ALRH group than in the AORH group after PSM (median, 297.5 vs. 205 min, P < 0.001). However, ALRH led to less intraoperative blood loss than AORH after PSM (median, 265 vs. 350 ml, P = 0.049). The rates of overall complications (12.5% vs. 30.5%, P = 0.028) in the ALRH group were significantly lower than those in the AORH group after PSM. Moreover, the survival outcomes were equivalent between the two groups with regard to 1-, 3-, and 5-year overall survival rates (P = 0.698) and disease-free survival rates (P = 0.510).

CONCLUSION

ALRH could be safe and feasible for some patients with large HCCs (5-10 cm) when performed by experienced surgeons, and it had superior perioperative outcomes and equivalent oncological outcomes to AORH.

Association of CHEK2 I157T and SULT1A1 R213H genetic variants with risk of sporadic colorectal cancer in a sample of Egyptian patients

Background

Recent research proposed an association between functional defects involving CHEK2 I157T and SULT1A1 R213H variants and increased incidence of several types of cancer. A total of 86 unrelated colorectal cancer patients attending the Surgical Oncology Department were recruited in the study. The second group of 152 healthy age- and sex-matched volunteers were included as controls. Polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) was applied for genotyping. Chi-square test was applied to compare genotype and allele frequencies in the studied groups. The purpose of the present study was to evaluate the association between CHEK2 I157T and SULT1A1 R213H polymorphisms and colorectal cancer.

Results

No significant differences in genotypes were detected between cases and controls in the present study for both CHEK2 I157T and SULT1A1 R213H polymorphisms (χ2 = 1.839; P = 0.399/χ2 = 2.831; P = 0.243), respectively. Likewise, discrepancies in allele frequency for the wild-type or mutant alleles were non-statistically significant in CHEK2 I157T and SULT1A1 R213H (χ2 = 1.231; P = 0.267/χ2 = 0.180; P = 0.671), respectively.

Conclusions

Results of the current study propose that CHEK2 I157T and SULT1A1 R213H polymorphisms are not associated with CRC development in Egyptian population. Further future studies on the functional implications of these polymorphisms are strongly recommended.

Vertical tumor margin of endoscopic resection for T1 colorectal carcinoma affects the prognosis of patients undergoing additional surgery

BACKGROUND

Vertical tumor margin-negative T1 colorectal carcinoma (CRC) is an absolute curative condition following complete endoscopic resection (ER). However, the influence on prognosis in relation to vertical tumor margin is unclear. Therefore, we evaluated the influence of the distance from vertical tumor margin to resected specimen edge (vertical margin distance) of ER for T1b (submucosal invasion depth > 1000 μm) CRC on the prognosis of patients undergoing additional surgery after ER.

METHODS

In total, 215 consecutive patients with T1b CRC who underwent additional surgery after ER at Hiroshima University Hospital between February 1992 and June 2019 were enrolled. We assessed 191 patients without lymph node metastases at the additional surgery. The specimens resected by ER were classified into three groups based on the vertical margin distance: patients with a vertical margin distance of ≥ 500 μm (Group A); patients with a vertical margin distance of < 500 μm (Group B); and patients with a positive vertical tumor margin (Group C). Subsequently, we evaluated the prognosis of the patients in relation to the clinicopathological characteristics among the three groups.

RESULTS

There were no significant differences in clinicopathological characteristics among the three groups. Group A had a significantly higher recurrence-free 5-year survival rate than Groups B and C (100%, 84.5%, and 81.8%, respectively). Similarly, Group A had a significantly higher disease-specific 5-year survival rate than Group C (100% vs. 95.5%).

CONCLUSIONS

Complete en bloc resection with sufficient submucosal layer from the invasive front (vertical margin distance > 500 μm) by ER for T1 CRC reduces the risk of metastatic recurrence after additional surgery.

A systematic review and meta-analysis of variants of the branches of the superior mesenteric artery: the Achilles heel of right hemicolectomy with complete mesocolic excision?

AIM

Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right hemicolectomy with complete mesocolic excision. This technique is technically demanding due to the highly variable arterial pattern of the right colon. Therefore, this study aims to provide a comprehensive evidence-based assessment of the arterial vascular anatomy of the right colon.

METHODS

A thorough systematic literature search through September 2020 was conducted on the electronic databases PubMed, Scopus and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaXl software.

RESULTS

A total of 41 studies (n = 4691 patients) were included. The ileocolic artery (ICA), right colic artery (RCA) and middle colic artery (MCA) were present in 99.7% (95% CI 99.4%-99.8%), 72.6% (95% CI 61.3%-82.5%) and 96.9% (95% CI 94.2%-98.8%) respectively of patients. Supernumerary RCA and MCA were observed in 3.2% and 11.4% respectively of all cases. The RCA shared a common trunk with the ICA and MCA in 13.2% and 17.7% respectively of patients. A retro-superior mesenteric vein course of the ICA and RCA was observed in 55.1% and 11.4% respectively of all cases.

CONCLUSION

The vascular anatomy of the right colon displays several notable variations, namely the absence of some branches (RCA absent in 27.4% of cases), supernumerary branches, common trunks, and retro-superior mesenteric vein courses. These variations should be taken into consideration during right hemicolectomy with complete mesocolic excision to ensure adequate oncological resection while minimizing intra-operative complications.

Obesity and telomere status in the prognosis of patients with colorectal cancer submitted to curative intention surgical treatment

The risk of colorectal cancer (CRC) development has been associated with telomere dysfunction and obesity. However, clinical relevance of these parameters in CRC prognosis is not clear. Therefore, the aim of the present study was to evaluate the impact of obesity and telomere status in the prognosis of patients affected by CRC and submitted to curative surgical treatment. According to published data, this is the first work in which obesity and telomere status are jointly considered in relation to CRC prognosis. A prospective study including 162 patients with CRC submitted to curative surgical treatment was performed. Subjects were classified according to their BMI. Telomere status was established through telomere length and telomerase activity evaluation. Statistical analyses were performed using the SPSS software package version 22. Telomere shortening was inversely associated with BMI in patients with CRC. Notably, among patients with CRC, subjects with obesity exhibited less shortening of tumor telomeres than non-obese patients (P=0.047). Patients with shorter telomeres, both in the tumor (median telomere length <6.5 kb) and their non-tumor paired tissues (median telomere length <7.1 kb), had the best clinical evolution, regardless of the Dukes' stage of cancers (P=0.025, for tumor samples; P=0.003, for non-tumor samples). Additionally, subjects with a BMI >31.85 kg/m² showed the worse clinical outcomes compared with subjects with other BMI values. Interestingly, the impact of BMI showed sex dependence, since only the group of men displayed significant differences in CRC prognosis in relation to obesity status (P=0.037). From the results of the present study, based on a multivariate prediction model to establish prognosis, it was concluded that telomere length is a useful biomarker to predict prognosis in patients with CRC. Regardless of BMI values, the improved clinical evolution was associated with shorter telomeres. The impact of BMI seems to be associated with other factors, such as sex.

Narrative review of theoretical considerations regarding HITHOC between past and future

Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.

Circulating tumor cells detected only after surgery for non-small cell lung cancer: is it a predictor of recurrence?

Background

Surgical manipulation of a tumor can lead to shedding of tumor cells that can enter the circulation and lead to metastasis. The present study evaluated the clinical relevance of circulating tumor cells (CTCs) that were identified immediately after non-small cell lung cancer resection in patients without preoperative CTCs, and whether postoperative CTC detection was associated with recurrence.

Methods

Immediate preoperative testing for CTCs was performed for 147 patients with pulmonary nodules. This study included 81 lung cancer patients (55.1%) with negative preoperative results for CTCs and who completed postoperative testing for CTCs. The clinical relevance of postoperative CTC detection was evaluated based on the clinicopathological characteristics and recurrence patterns.

Results

Among the eligible patients, the postoperative CTC results were none detected in 58 patients (71.6%, “Group N”), only a single CTC detected in 6 patients (7.4%, “Group S”), and CTC clusters detected in 17 patients (21.0%, “Group C”). The presence of postoperative CTCs was associated with tumor vessel invasion, lymph duct invasion, and pleural invasion. Distant metastasis was very common in cases with postoperatively detected CTC clusters. The 2-year recurrence-free survival rates were 94.6% for Group N, 62.5% for Group S, and 52.9% for Group C (P<0.01). Multivariate analysis revealed that recurrence was independently related to the postoperative detection of single CTCs and CTC clusters.

Conclusions

In cases without preoperative CTCs, we postoperatively detected CTCs and the postoperative CTC results were an independent predictor of recurrence.

Efficacy and Safety of Complete Mesocolic Excision in Patients With Colon Cancer: Three-year Results From a Prospective, Nonrandomized, Double-blind, Controlled Trial

OBJECTIVE

The aim of the study was to evaluate the oncological outcomes of complete mesocolic excision (CME) in colon cancer patients.

SUMMARY BACKGROUND DATA

CME is considered a standard procedure for colon cancer patients. However, previous evidence regarding the effect of CME on prognosis has fundamental limitations that prevent it from being fully accepted.

METHODS

Patients who underwent radical resection for colon cancer were enrolled between November 2012 and March 2016. According to the principles of CME, patients were stratified into 2 groups based on intraoperative surgical fields and specimen photographs. The primary outcome was local recurrence-free survival (LRFS). The clinicopathological data and follow-up information were collected and recorded. The final follow-up date was April 2016. The trial was registered in ClinicalTrials.gov (identifier: NCT01724775).

RESULTS

There were 220 patients in the CME group and 110 patients in the noncomplete mesocolic excision (NCME) group. Baseline characteristics were well balanced. Compared with NCME, CME was associated with a greater number of total lymph nodes (24 vs 20, P = 0.002). Postoperative complications did not differ between the 2 groups. CME had a positive effect on LRFS compared with NCME (100.0% vs 90.2%, log-rank P < 0.001). Mesocolic dissection (100.0% vs 87.9%, log-rank P < 0.001) and nontumor deposits (97.2% vs 91.6%, log-rank P < 0.022) were also associated with improved LRFS.

CONCLUSIONS

Our findings demonstrate that, compared with NCME, CME improves 3-year LRFS without increasing surgical risks.

Oncological Resection for Liver Malignancies: Can the Laparoscopic Approach Provide Benefits?

: Laparoscopic surgery has become an increasingly popular alternative approach to open surgery, resulting in a paradigm shift in liver surgery. Although laparoscopic liver resection (LLR) was initially indicated for small benign and peripheral tumors, at present more than half of LLRs are performed in malignant tumors. Several studies have reported the feasibility of LLR in malignant disease and suggested various short-term benefits compared to open liver resection, including decreased blood loss and postoperative complications and a shorter hospital stay. Although these benefits are important to surgeons, patients, and providers, the main goal of surgery for malignancies is to achieve a maximum oncologic benefit.The relevance of the laparoscopic approach must be assessed in relation to the possibility of respecting basic oncological rules and the expertise of the center. Easy LLRs can be safely performed by most surgeons with minimum expertise in liver surgery and laparoscopy, and can therefore probably provide an oncological benefit. On the other hand, intermediate or difficult LLRs require technical expertise and an oncological benefit can only be achieved in expert centers. Technical standardization is the only way to obtain an oncological benefit with this type of resection, and many problems must still be solved.

"Caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery for the treatment of right colon cancer: is it more in line with the principle of oncology?

OBJECTIVE

To explore the feasibility and application value of a "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery (SMA) for the treatment of right colon cancer METHODS: Clinical data consisting of 168 right colon cancer cases under going laparoscopic D3 radical resection, including 84 cases of "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA (CC + SMA group) and 84 cases of conventional medial approach plus dissection around the superior mesenteric vein (MA + SMV group), from January 2017 to March 2018 were retrospectively analyzed. For CC + SMA group, our surgical method was to isolate the mesocolon using a caudal-to-cranial pathway and ligate blood vessels along the midline of the SMA.

RESULTS

The baseline data was not significantly different between the two groups (all p > 0.05). The mean operation time and intraoperative blood loss in the CC + SMA and the MA + SMV groups were 170.04 ± 43.10 versus 172.33 ± 41.84 min and 91.07 ± 55.12 versus 77.38 ± 40.21 ml, respectively, which has no significant difference (p > 0.05). The mean number of total and positive harvested lymph nodes in the two groups were 29.44 ± 5.90 versus 26.21 ± 6.64 (p < 0.05) and 2.57 ± 1.93 versus 2.51 ± 1.05, respectively (p > 0.05). Compared with the MA + SMV group, there was no significant difference in total postoperative complication rate in the CC + SMA group. The time to pull out drainage tube in the CC + SMA group was longer than MA + SMV group (4.05 ± 1.79 versus 3.38 ± 1.99 day; p = 0.022).

CONCLUSION

It is safe and feasible for the "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA in right colon cancer. It may have some advantages in the number of lymph nodes dissection, and the long-term prognosis remains to be expected.

Effect of Vein-First vs Artery-First Surgical Technique on Circulating Tumor Cells and Survival in Patients With Non-Small Cell Lung Cancer: A Randomized Clinical Trial and Registry-Based Propensity Score Matching Analysis

Importance

It is important to develop a surgical technique to reduce dissemination of tumor cells into the blood during surgery.

Objective

To compare the outcomes of different sequences of vessel ligation during surgery on the dissemination of tumor cells and survival in patients with non-small cell lung cancer.

Design, Setting, and Participants

This multicenter, randomized clinical trial was conducted from December 2016 to March 2018 with patients with non-small cell lung cancer who received thoracoscopic lobectomy in West China Hospital, Daping Hospital, and Sichuan Cancer Hospital. To further compare survival outcomes of the 2 procedures, we reviewed the Western China Lung Cancer database (2005-2017) using the same inclusion criteria.

Interventions

Vein-first procedure vs artery-first procedure.

Main Outcomes and Measures

Changes in folate receptor-positive circulating tumor cells (FR+CTCs) after surgery and 5-year overall, disease-free, and lung cancer-specific survival.

Results

A total of 86 individuals were randomized; 22 patients (25.6%) were younger and 64 (74.4%) older than 60 years. Of these, 78 patients were analyzed. After surgery, an incremental change in FR+CTCs was observed in 26 of 40 patients (65.0%) in the artery-first group and 12 of 38 (31.6%) in the vein-first group (P = .003) (median change, 0.73 [interquartile range (IQR), -0.86 to 1.58] FU per 3 mL vs -0.50 [IQR, -2.53 to 0.79] FU per 3 mL; P = .006). Multivariate analysis confirmed that the artery-first procedure was a risk factor for FR+CTC increase during surgery (hazard ratio [HR], 4.03 [95% CI, 1.53-10.63]; P = .005). The propensity-matched analysis included 420 patients (210 with vein-first procedures and 210 with artery-first procedures). The vein-first group had significantly better outcomes than the artery-first group for 5-year overall survival (73.6% [95% CI, 64.4%-82.8%] vs 57.6% [95% CI, 48.4%-66.8%]; P = .002), disease-free survival (63.6% [95% CI, 55.4%-73.8%] vs 48.4% [95% CI, 40.0%-56.8%]; P = .001), and lung cancer-specific survival (76.4% [95% CI, 67.6%-85.2%] vs 59.9% [95% CI, 50.5%-69.3%]; P = .002). Multivariate analyses revealed that the artery-first procedure was a prognostic factor of poorer 5-year overall survival (HR, 1.65 [95% CI, 1.07-2.56]; P = .03), disease-free survival (HR, 1.43 [95% CI, 1.01-2.04]; P = .05) and lung cancer-specific survival (HR = 1.65 [95% CI, 1.04-2.61]; P = .03).

Conclusions and Relevance

Ligating effluent veins first during surgery may reduce tumor cell dissemination and improve survival outcomes in patients with non-small cell lung cancer.

Trial Registration

ClinicalTrials.gov identifier: NCT03436329.

Extent of intraluminal exfoliated malignant cells during surgery for colon cancer: Differences in cell abundance ratio between laparoscopic and open surgery

INTRODUCTION

Laparoscopic colectomy with intracorporeal anastomosis is a minimally invasive surgical procedure for patients with colon cancer. However, there are often concerns about the presence of intraluminal exfoliated malignant cells in the intracorporeal anastomosis. This study investigated the relationship between colon cancer surgery and the incidence of intraluminal exfoliated malignant cells and several factors.

METHODS

Eighty-nine consecutive patients who underwent either laparoscopic or open colectomy were prospectively studied in our department between 2007 and 2011. Before anastomosis, the proximal and distal lumens were irrigated with normal saline and subjected to cytological examination.

RESULTS

In 27 patients (30.3%), exfoliated cancer cells were detected. On the distal side, the frequency of positive cytology findings of exfoliated malignant cells was significantly lower in the laparoscopic colectomy group than in the open colectomy group (P = 0.01). In the laparoscopic colectomy group, there were no cases of positive cytology findings for exfoliated malignant cells more than 100 mm from the primary tumor. The incidence of positive cytology more than 100 mm from the primary tumor was significantly lower than the incidence of positive cytology less than 100 mm from the primary tumor (P = 0.04).

CONCLUSIONS

Exfoliated malignant cells were detected at anastomosis sites in patients with colon cancer. On the distal side, laparoscopic colectomy may prevent the development of exfoliated malignant cells.

Revised management of advanced primary colon cancer: Case series of 2 patients

•

The surgical removal of a primary colon cancer demands complete clearance and absolute containment of the malignant process.

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Not all colon cancers are the same although the resection strategy varies little or not at all with the clinical features of the disease.

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The patient may enter the operating theater with a contained malignant process and leave with disseminated disease.

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Clinical and radiologic features of colon cancer indicate a high risk for cancer dissemination as a result of the resection.

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The surgeon must document in the medical record preoperatively the likelihood of clearance and containment.

Background

The resection of a primary colon cancer has the opportunity to cure the patient of cancer by complete clearance and absolute containment of disease. Alternatively, if the cancer resection does not provide clearance and containment it will eventuate in local recurrence and peritoneal dissemination.

Methods

Culpability of recurrence of colorectal cancer is difficult to determine. Are the management strategies of the primary cancer evaluation and treatment at fault or is the underlying disease process is to be held responsible? The clinical and radiologic findings that could have been evaluated by a multidisciplinary team (MDT) were critically evaluated in 2 patients with right colon adenocarcinoma. Strategies to accomplish complete clearance and absolute containment of the primary malignancy as resectable for cure were suggested.

Results

Clinical evaluation of these 2 patients suggested that more knowledgeable preoperative evaluation by the multidisciplinary team (MDT) should have placed them in a high risk group for local recurrence and/or peritoneal dissemination. High carcinoembryonic antigen (CEA) tumor marker and by CT a large primary cancer infiltrating adjacent structures can be used to select advanced pre- and intraoperative treatment strategies.

Conclusions

Two patients who had an approximately 50% possibility of long-term survival with optimal preoperative evaluation and expert surgical resection techniques may have been converted to a greatly reduced survival because of tumor dissemination and positive margins of resection at the time of primary cancer resection. Neither patient was evaluated by an MDT preoperatively. It is possible that these two patients entered the operating room with a contained malignancy but as result of suboptimal pre- and intraoperative management left the operating room with disseminated intraperitoneal disease.

Competing risks analysis of the effect of local residual tumour on recurrence and cancer-specific death after resection of colorectal cancer: implications for staging

The pTNM staging system for colorectal cancer (CRC) is not entirely effective in discriminating between potentially curative and non-curative resections because it does not account for local residual tumour in patients with stages I, II or III. This study aimed to evaluate the prognostic importance of histologically verified tumour in any line of resection of the bowel resection specimen (TLR) in relation to pTNM stages and to demonstrate how TLR may be integrated into pTNM staging. Information on patients in the period 1995 to 2010 with complete follow-up to the end of 2015 was extracted from a prospective database of CRC resections. The outcome variables were the competing risks incidence of CRC recurrence and CRC-specific death. After exclusions, 2220 patients remained. In 1930 patients with pTNM stages I-III tumour, recurrence was markedly higher in those with TLR than in those without (HR 6.0, 95% CI 4.2-8.5, p < 0.001) and this persisted after adjustment for covariates associated with recurrence. CRC-specific death was markedly higher in the presence of TLR (HR 7.7, CI 5.3-11.2, p < 0.001), which persisted after adjustment for relevant covariates. These results justify removing patients with TLR from pTNM stages I to III and placing them in stage IV, thereby allowing the categorisation of all patients with any known residual tumour into three prognostically distinct groups. This study demonstrates how TLR may be integrated into pTNM staging, thus improving the definition of the three stages which are considered potentially curable (I, II and III).

"Top down no-touch" technique in robotic complete mesocolic excision for extended right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Proper identification of the mesocolic vessels is essential for achieving complete mesocolic excision (CME) in cases of colon cancer requiring an extended right hemicolectomy. In robotic procedures, we employed a "top down technique" to allow early identification of the gastrocolic trunk and middle colic vessels. The aim of our study was to illustrate the details of this technique in a series of 12 patients.

METHODS

The top down technique consists of two steps. First, the omental bursa was entered to identify the right gastroepiploic vein. Tracing down this vein as a landmark, the gastrocolic trunk was exposed, branches of this trunk and the middle colic vessels were divided. Second, dissection was directed to the ileocolic region and proceeded in an inferior-to-superior direction along the superior mesenteric vein to divide the ileocolic and right colic vessels consecutively. The ileotranverse anastomosis was created intracorporeally.

RESULTS

There were 8 males and 4 females with a mean age of 64.8 ± 16.9 years and a mean body mass index of 25.6 ± 3.7 kg/m². All the procedures were completed successfully. No conversions occurred. The mean operative time and blood loss were 312.1 ± 93.9 min and 110.0 ± 89.9 ml, respectively. The mean number of harvested lymph nodes was 45.2 ± 11.1. The mean length of hospital stay was 7.6 ± 4.7 days. Two patients had intraoperative complications and two had postoperative complications. There was no disease recurrence at a mean follow-up period of 10.4 ± 7.1 months.

CONCLUSIONS

The top down technique appears to be useful in robotic CME for an extended right hemicolectomy. Early identification of the gastrocolic trunk and middle colic vessels via this technique may prevent inadvertent vascular injury at the mesenteric root of the transverse colon.

Totally robotic complete mesocolic excision for right-sided colon cancer

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m². The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Session 1: Colon cancer - 10 years behind the rectum

The improvements in surgical technique brought about by the widespread adoption of total mesorectal excision plane dissection in rectal cancer has substantially improved survival and recurrence rates from this disease. For the first time in 50 years, the outcomes in rectal cancer have overtaken those of colon cancer. Professor Madoff's overview lecture and the experts' round table discussion address whether applying the surgical principles already achieved in rectal cancer can meet with similar success in colon cancer, how this can be achieved and the challenges we face.

Impact on surgical and oncological results of the use of colonic stents as a bridge to surgery for potentially curable occlusive colorectal neoplasms

INTRODUCTION

The outcomes of patients treated with colonic stents as a bridge to surgery (BTS) have recently been questioned in terms of safety and long-term oncologic outcomes. The aim of this study is to evaluate the effects on surgical and oncologic outcomes of colonic stents as a BTS for potentially resectable obstructive colorectal cancer.

METHODS

We conducted a retrospective analysis of patients operated on for potentially resectable obstructive colorectal cancer with or without distant disease between September 2002 and October 2015, comparing the patients treated with a colonic stent as a BTS (Stent group) with those directly operated on (Surgery group).

RESULTS

Twenty patients underwent urgent surgery, while stent placement as a BTS was attempted in 57 patients. The Stent group had more patients treated with a laparoscopic approach (64.9 vs. 5%, P<.001), higher primary anastomosis rate (91.2 vs. 55%, P=.001), less need for stomata (10.5 vs. 50%, P=.001) and shorter postoperative hospital stay (7 vs. 12 days, P=.014). Thirty-day morbidity was reduced in the Stent group, although not significantly (29.8 vs. 50%, P=.104). However, 30-day mortality was significantly lower (1.8 vs. 20%, P=.015). Regarding the long-term oncologic outcomes, no significant differences were found when comparing overall survival, disease-free survival, local recurrence-free survival, distant recurrence-free survival or progression-free survival.

CONCLUSIONS

Colonic stenting as a BTS for potentially resectable obstructive colorectal cancer seems to offer better surgical and equal long-term oncologic outcomes when compared to those of patients directly operated on.

Growth Fraction of Colorectal Carcinoma (Ki67): A Comparative Study

We studied the growth fraction of55 resected colorectal adenocarcinomas by means of a three-step immunoperoxidase technique (avidin-biotin-peroxidase) using the monoclonal antibody Ki67 directed against a cell proliferation-associated nuclear antigen.

The percentage of Ki67-positive cells was evaluated independently by two observers, and a Ki67 score was obtained for each case.

No correlation was observed between Ki67 staining and patient's age and sex, tumor size and localization or grading and staging according to Dukes’ method (modified by Astler-Coller and Turnbull).

The growth fraction showed extreme heterogeneity in the cases examined, within each grade of differentiation.

Serum Ferritin in Colorectal Cancer Patients and its Prognostic Evaluation

The aim of this study was to investigate the relationship between preoperative serum ferritin levels, clinicopathological parameters and survival analysis of patients with colorectal cancer. Ninety-four patients (57 males) with a mean age of 65 years (39–87 years) underwent 63 curative and 31 palliative operations. Follow-up was at least 5 years. Patients were categorized with normal (30-215 ng/mL in men and 11-148 ng/mL in women), low, or high serum ferritin levels. Prognostic evaluation was undertaken with stratified survival analysis and Cox's regression model. Twenty-nine of the patients (30.9%) had raised ferritin levels and 14 (14.9%) had low values. Comparisons of the survival curves showed significant differences in stage C disease; specifically, patients with either low or high ferritin levels had a shorter survival than patients with normal levels. Patients who underwent palliative surgery and had high ferritin serum values also had a shorter survival. In multivariate analysis, the variables with a negative effect on survival were stage, serum ferritin levels and age. Our data suggest that patients with advanced colorectal cancer having normal preoperative serum ferritin levels may have a better prognosis, although the prognostic value related to this association requires further investigation.

Assessment of the Value of Preoperative Serum Levels of CA 242 and CEA in the Staging and Postoperative Survival of Colorectal Adenocarcinoma Patients

Introduction

CEA is the most frequently used tumor marker in colorectal cancer. There may be an improvement in its efficacy when used in association with CA 242.

Aim

The purpose of this study was to evaluate the efficacy of preoperative serum levels of the tumor markers CA 242 and CEA in the staging and postoperative follow-up of colorectal adenocarcinoma patients.

Patients and Methods

Of a series of 134 patients with colorectal adenocarcinomas 90 underwent radical surgery and 44 palliative surgery. The control group consisted of 22 organ donors. The cutoff serum levels utilized were 5 ng/mL for CEA and 20 U/mL for CA 242. The mortality during follow-up was recorded in order to determine the duration of survival. The data were submitted to statistical analysis using diagnostic tests, the chi-square test, survival analysis (Kaplan and Meier) and ROC curves. A significance level of p ≤ 0.05 was applied.

Results

The sensitivity of CEA in Dukes’ stages A, B, C and D was 27.8%, 32.4%, 32.1% and 66.7%, respectively. The sensitivity of CA 242 was 11.1%, 16.2%, 30.8% and 50%. When both markers were combined, the sensitivity was 33.3%, 48.6%, 40.7% and 72.5%. In the group of patients who underwent radical surgery the mean survival was 60.47 months for those with high preoperative CEA levels, 52.22 months for those with high preoperative CA 242 levels, and 44.80 months for those with elevated levels of both markers. There was a statistically significant difference in survival between patients undergoing radical surgery with elevated CA 242 levels, especially when CEA was also elevated, and patients without elevated CA 242.

Conclusion

Preoperative serum levels of CA 242 showed less efficacy than CEA levels for the staging of colorectal adenocarcinoma patients. Elevated preoperative serum levels of CA 242 alone were related to poor survival, especially in association with high levels of CEA.

Oncological Assessment of Stent Placement for Obstructive Colorectal Cancer from Circulating Cell-Free DNA and Circulating Tumor DNA Dynamics

BACKGROUND

The self-expanding metallic stent (SEMS) provides effective decompression for patients with malignant large bowel obstruction (MLBO); however, mechanical damage to malignant cells from insertion may negatively affect prognosis, similar to surgical manipulation, and its oncological safety is unclear. We examined mechanical damage from SEMS placement using circulating cell-free DNA (cfDNA) and circulating tumor DNA (ctDNA).

METHODS

Between 1 November 2014 and 30 June 2017, 35 MLBO patients were analyzed, comprising 25 SEMS patients and 10 transanal decompression tube (TDT) patients (control). Blood samples were collected before and after decompression on days 0, 1, 3, and 7. cfDNA, ctDNA, white blood cells, C-reactive protein, and lactate dehydrogenase were analyzed.

RESULTS

The clinical success rates of SEMS and TDT were 88 and 90%, respectively (p = 1.0). The cfDNA concentration on day 7 was significantly higher in the SEMS group than in the TDT group (992 vs. 308 ng/mL; p = 0.005). A significant increase in ctDNA was observed in the SEMS group compared with the TDT group (83% vs. 22%; p = 0.002). The cfDNA concentration showed strong positive correlations with ctDNA and lactate dehydrogenase (R ² = 0.838 and 0.593, respectively), and a weak positive correlation with C-reactive protein (R ² = 0.263).

CONCLUSIONS

Despite equivalent clinical success rates, SEMS placement increased plasma levels of cfDNA and ctDNA by tumor manipulation, but TDT did not. Colonic stenting showed oncological risk in terms of molecular analysis.

Stromal and intraepithelial tumor-infiltrating lymphocytes in colorectal carcinoma

The local mechanisms of antitumor immune defense determine the development and organization of the tumor microenvironment, and the composition and relative proportions of the inflammatory cell population affect the quality and characteristics of the immune response. The aim of the present study was to conduct a quantitative morphological evaluation of two types of tumor-infiltrating lymphocyte (TILs) populations, including those located in the stroma and intraepithelial cancer structures, in the invasive front and the center of the tumor in patients with colorectal cancer (CRC). The study included 160 patients with CRC who had undergone surgery. The tissue material was stained with hematoxylin and eosin, as used in routine histopathological diagnosis, and the two TIL populations were observed and counted with light microscopy. The relative extent of infiltration of stromal and intraepithelial TILs into the front and center of the primary tumors was similar. The extent of infiltration by stromal TILs was negatively correlated with the morphological features of tumor progression including the cancer infiltration of blood vessels (P=0.016), the invasion of lymph vessels (P=0.007), perineural invasion (P=0.036), lymph node involvement (P=0.047) and distant metastases (P=0.032). The infiltration by intraepithelial TILs was positively correlated with a desmoplastic reaction (P=0.002). Disease-free survival time was statistically shorter in patients without intraepithelial TILs in the center of the primary tumor mass (P=0.049; hazard ratio = 1.45). These results confirm that the infiltration of TILs into the invasive front and center of the tumor in patients with CRC serves an important role in the invasion and progression of the disease, and should be considered in routine histopathological examinations.

Comparison between different approaches applied in laparoscopic right hemi-colectomy: A systematic review and network meta-analysis

AIM

Several different operative approaches have been applied nowadays in laparoscopic right hemi-colectomy. This study aims to evaluate the potential benefits of different approaches by conducting a network meta-analysis (NMA).

METHOD

A comprehensive literature research of the PubMed, Embase, Medline, the Cochrane Central Library, Wan Fang and China National Knowledge Infrastructure (CNKI) databases was performed. Original articles comparing two of three different approaches including medial to lateral (MtL) approach, lateral to medial (LtM) approach and cranial to caudal (CtC) approach of laparoscopic right colon resection for patients with both neoplastic and benign diseases were included.

RESULTS

3 RCTs and 3 NRCTs with a total of 571 patients were included in this NMA. The result revealed that LtM approach needs shorter postoperative flatus recovery time than both MtL approach with a WMD of 1.40 (95% CI: 0.13 to 2.67, P < 0.05) and CtC approach (WMD = -1.25, 95% CI: -1.90 to -0.61, P < 0.05). The length of hospital stay of LtM approach is shorter than that of MtL approach (WMD = 0.29, 95% CI: 0.08 to 0.50, P < 0.05). CtC approach can achieve less postoperative complications (OR = 3.37, 95% CI: 1.06 to 10.70, P < 0.05) compared with MtL approach.

CONCLUSION

All three approaches are safe and acceptable in laparoscopic right hemi-colectomy since the pooled evidence revealed that most aspects of different approaches are comparable in general. The postoperative flatus recovery time and hospitalization time of LtM approach is shorter compared with MtL approach. And CtC approach may have slight superiority in postoperative complications compared with MtL approach.

Does lung cancer surgery cause circulating tumor cells?-A multicenter, prospective study

BACKGROUND

Cancer relapse is caused by residual isolated tumor cells (ITCs) remaining in the body after surgery. It is speculated that surgical manipulation may cause circulating tumor cells (CTCs) which are the origin of ITCs in the body. The occurrence of CTCs in surgical patients with non-small cell lung cancer (NSCLC) has been shown in retrospective observation, but not prospectively, thus we conducted a multicenter prospective study regarding the occurrence of CTCs by surgical manipulation.

METHODS

Patients with T1b-2N0M0 lung cancer were studied. Blood samples were collected from the peripheral artery in the operating room at both pre- and post-lobectomy to extract CTCs by a size selection method. The CTCs detection rate, pathological findings, and background of each patient were studied.

RESULTS

The histological diagnosis of 29 patients were adenocarcinoma in 24 patients, squamous cell carcinoma in 3 patients, and other types in 2 patients. The number of pre-CTCs positive patients was 13 and the number of post CTCs positive patients was 17. Among the 16 patients who were pre-CTCs negative, 4 patients showed post CTCs positive, while all pre-CTCs positive patients remained post-CTCs positive.

CONCLUSIONS

The likelihood of CTC dislodgement by surgical manipulation is indicated based on the result that CTCs were detected after lung cancer surgery, where there were no cases of pre-CTCs positive and post CTCs negative.

A novel hand-assisted laparoscopic versus conventional laparoscopic right hemicolectomy for right colon cancer: study protocol for a randomized controlled trial

Background

Although conventional laparoscopic and hand-assisted laparoscopic surgery for colorectal cancer is widely used today, there remain many technical challenges especially for right colon cancer in obese patients. Herein, we develop a novel hand-assisted laparoscopic surgery (HALS) with complete mesocolic excision (CME), D3 lymphadenectomy, and a total “no-touch” isolation technique (HALS-CME) in right hemicolectomy to overcome these issues. According to previous clinic practice, this novel procedure is not only feasible and safe but has several technical merits. However, the feasibility, short-term minimally invasive virtues, long-term oncological superiority, and potential total “no-touch” isolation technique benefits of HALS-CME should be confirmed by a prospective randomized controlled trial.

Methods/design

This is a single-center, open-label, noninferiority, randomized controlled trial. Eligible participants will be randomly assigned to the HALS-CME group or to the laparoscopic surgery with CME, D3 lymphadenectomy, and total “no-touch” isolation technique (LAP-CME) group, or to conventional laparoscopic surgery with CME and D3 lymphadenectomy (cLAP) group at a 1:1:1 ratio using a centralized randomization list. Primary endpoints include safety, efficacy, and being oncologically clear, and 3-year disease-free, progression-free, and overall survival. Second endpoints include operative outcomes (operation time, blood loss, and incision length), pathologic evaluation (grading the plane of surgery, length of proximal and distal resection margins, distance between the tumor and the central arterial high tie, distance between the nearest bowel wall and the same high tie, area of mesentery resected, width of the chain of lymph-adipose tissue, length of the central lymph-adipose chain, number of harvested lymph nodes), and postoperative outcomes (pain intensity, postoperative inflammatory and immune responses, postoperative recovery).

Discussion

This trial will provide valuable clinical evidence for the feasibility, safety, and potential total “no-touch” isolation technique benefits of HALS-CME for right hemicolectomy. The hypothesis is that HALS-CME is feasible for the radical D3 resection of right colon cancer and offers short-term safety and long-term oncological superiority compared with conventional laparoscopic surgery.

Trial registration

ClinicalTrials.gov, NCT02625272. Registered on 8 December 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2084-3) contains supplementary material, which is available to authorized users.

Anterior Approach to Improve the Prognosis in HCC Patients Via Decreasing Dissemination of EpCAM+ Circulating Tumor Cells

BACKGROUND

It is supposed that the improvement of prognosis in hepatocellular carcinoma (HCC) patient by anterior approach for liver resection was related to the decreasing hematogenic dissemination of circulating cancer cells.

METHODS

The EpCAM⁺ circulating tumor cells (CTCs) were detected in HCC patients having liver resection with either anterior approach (AA) or conventional approach (CA). The relation of CTCs to the 2-year recurrence and survival after surgery was investigated.

RESULTS

Overall, patients with ≥3.5 CTCs had much higher recurrence rate than those with <3.5 CTCs (62.0 vs. 18.0%, P = 0.001). Less CTCs were detected in AA group than that in CA group (mean, 2.1 vs. 3.0; median, 1.2 vs. 3.5; all P = 0.001). The 2-year recurrence rate in AA group was much lower than in CA group (27.1 vs. 44.9%, P = 0.009). The 2-year survival rate in AA group was much higher than in CA group (83.3 vs. 66.7%, P = 0.001). The CTCs in >5 cm AA group were much less than that in >5 cm CA group (3.7 vs. 2.4, P = 0.002). Moreover, the 2-year recurrence rate in >5 cm AA group was much lower than that in >5 cm CA group (29.2 vs. 54.7%, P = 0.001). Also, the 2-year survival rates in >5 cm AA group were much higher than that in >5 cm CA group (72.9 vs. 49.1%, P = 0.01). By multivariate analysis, CA is one of the independent risk factors for poor prognosis in HCC patients after liver resection.

CONCLUSIONS

Like the liver-directed therapies, AA can reduce the dissemination of CTCs, especially in patients with large-size HCC (>5 cm) and successively improve the early prognosis.

Why is colon cancer survival improving by time? A nationwide survival analysis spanning 35 years

There is limited information present to explain temporal improvements in colon cancer survival. This nationwide study investigates the temporal changes in survival over a 35-year period (1970-2004) in Iceland and uses incidence, mortality, surgery rate, stage distribution, lymph node yield, tumor location and histological type to find explanations for these changes. Patients diagnosed with colon cancer in Iceland 1970-2004 were identified (n = 1962). All histopathology was reassessed. Proportions, age-standardized incidence and mortality, relative, cancer-specific and overall survival and conditional survival were calculated. When comparing first and last diagnostic periods (1970-1978 and 1997-2004), 5-year relative survival improved by 12% for men and 9% for women. At the same time surgery rate increased by 12% and the proportion of stage I increased by 9%. Stage-stratified, improved 5-year relative survival was mainly observed in stages II and III and coincided with higher lymph node yields, proportional reduction of stage II cancers and proportional increase of stage III cancers, indicating stage migration between these stages. Improvement in 1-year survival was mainly observed in stages III and IV. Five-year survival improvement for patients living beyond 1 year was minimum to none. There were no changes in histology that coincided with neither increased incidence nor possibly influencing improved survival. Concluding, as a novel finding, 1-year mortality, which previously has been identified as an important variable in explaining international survival differences, is in this study identified as also being important in explaining temporal improvements in colon cancer survival in Iceland.

Prospective multicenter registration study of colorectal cancer: significant variations in radicality and oncosurgical quality-Swiss Group for Clinical Cancer Research Protocol SAKK 40/00

PURPOSE

This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers.

METHODS

One German and nine Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. The median number of eligible patients with one primary tumor included per center was 95 (range 12-204).

RESULTS

The following variations of median values or percentages between centers were found: length of bowel specimen 20-39 cm (25.8 cm), maximum height of mesocolon 6.5-12.5 cm (9.0 cm), number of examined lymph nodes 9-24 (16), distance to nearer bowel resection margin in colon cancer 4.8-12 cm (7 cm), and in rectal cancer 2-3 cm (2.5 cm), central ligation of major artery 40-97 % (71 %), blood loss 200-500 ml (300 ml), need for perioperative blood transfusion 5-40 % (19 %), tumor opened during mobilization 0-11 % (5 %), T4-tumors not en-bloc resected 0-33 % (4 %), inadvertent perforation of mesocolon/mesorectum 0-8 % (4 %), no-touch isolation technique 36-86 % (67 %), abdominoperineal resection for rectal cancer 0-30 % (17 %), rectal cancer specimen with circumferential margin ≤1 mm 0-19 % (10 %), in-hospital mortality 0-6 % (2 %), anastomotic leak or intra-abdominal abscess 0-17 % (7 %), re-operation 0-17 % (8 %).

CONCLUSION

In colorectal cancer, surgery considerable variations between different centers were found with regard to radicality and oncosurgical quality, suggesting a potential for targeted improvement of surgical technique.