Metastasis to the sigmoid or sigmoid mesenteric lymph nodes from rectal cancer

Down-regulation of zinc finger protein 335 undermines natural killer cell function in mouse colitis-associated colorectal carcinoma

Natural killer (NK) cells constitute an active and potent anti-tumor effector population against multiple malignancies. NK cells exploit tumoricidal machinery to restrain colorectal carcinoma (CRC) expansion and invasion. Nonetheless, it is becoming increasingly evident that functional exhaustion considerably compromises the potency of NK cells in patients with CRC. To elucidate the factors that impair NK cell function in the context of CRC, we determined the role of zinc finger protein 335 (ZFP335) in modulating NK cell activity in mouse CRC induced by azoxymethane and dextran sulfate sodium. ZFP335 was profoundly decreased in NK cells in mesenteric lymph nodes of CRC-bearing mice. ZFP335 was especially diminished in NK cells that were both phenotypically and functionally exhausted. Besides, effective ZFP335 knockdown markedly undermined NK cell proliferation, tumoricidal protein production, degranulation, and cytotoxic efficacy on malignant cells, strongly suggesting that ZFP335 reinforces NK cell function. Importantly, ZFP335 knockdown lowered the expression of Janus kinase 1 (JAK1) and Janus kinase 3 (JAK3), both of which play crucial roles in NK cell homeostasis and activation. Collectively, ZFP335 down-regulation is essential for NK cell exhaustion in mesenteric lymph nodes of mice with CRC. We discovered a new ZFP335-JAK1/3 signaling pathway that modulates NK cell exhaustion.

Impact of Anatomic Extent of Nodal Metastasis on Adjuvant Chemotherapy Outcomes in Stage III Colon Cancer

BACKGROUND

An oxaliplatin-based chemotherapy regimen improves the survival outcomes of patients with stage III colon cancer. However, its complications are well-known.

OBJECTIVE

The purpose of this study was to distinguish between the survival outcomes of patients who underwent curative resection for stage III colon cancer with oxaliplatin chemotherapy and those who underwent such resection without oxaliplatin chemotherapy.

DESIGN

This was a retrospective analytical study based on prospectively collected data.

SETTINGS

This study used data on patients who underwent surgery at our hospital between January 2010 and December 2014.

PATIENTS

A cohort of 254 consecutive patients who underwent curative resection for stage III colon cancer was included in this study. The patients were divided into 2 groups: patients with isolated pericolic lymph node metastasis (n = 175) and those with extrapericolic lymph node metastasis (n = 79).

MAIN OUTCOME MEASURES

Clinicopathologic features and 3-year survival outcomes were analyzed with and without oxaliplatin therapy in the pericolic lymph node group.

RESULTS

The pericolic lymph node group showed significantly improved overall survival compared with the extrapericolic lymph node group at a median follow-up of 48.5 months (95.8% vs 77.8%; p < 0.001). In contrast, there was no significant difference in overall survival (99.0% vs 92.0%; p = 0.137) and disease-free survival (89.1% vs 88.2%; p = 0.460) between the oxaliplatin and nonoxaliplatin subgroups of the pericolic lymph node group. Multivariate analysis showed that the administration of oxaliplatin chemotherapy to the pericolic lymph node group did not lead to a significant difference in the overall survival (p = 0.594).

LIMITATIONS

The study was limited by its retrospective design and single institutional data analysis.

CONCLUSIONS

This study suggests that the anatomic extent of metastatic lymph nodes could affect patient prognosis, and the effect of oxaliplatin-based adjuvant chemotherapy may not be prominent in stage III colon cancer with isolated pericolic lymph node metastasis.

The effect of pericolic lymph nodes metastasis beyond 10 cm proximal to the tumor on patients with rectal cancer

Background

This study aims to determine the real incidence of pericolic lymph nodes metastasis beyond 10 cm proximal to the tumor (pPCN) and its prognostic significance in rectal cancer patients.

Methods

Consecutive patients with rectal cancer underwent curative resection between 2015 and 2017 were included. Margin distance was marked and measured in vivo and lymph nodes were harvested on fresh specimens. Clinicopathological characteristics and oncological outcomes (3-year overall survival (OS) and disease-free survival (DFS)) were analyzed between patients with pPCN and patients without pPCN (nPCN).

Results

There were 298 patients in the nPCN group and 14 patients (4.5%) in pPCN group. Baseline characteristics were balanced except more patients received preoperative or postoperative chemoradiotherapy in pPCN group. Preoperative more advanced cTNM stage (log-rank p = 0.005) and intraoperative more pericolic lymph nodes beyond 10 cm proximal to the tumor (PCNs) (log-rank p = 0.002) were independent risk factors for pPCN. The maximum short-axis diameter of mesenteric lymph nodes ≥8 mm was also contributed to predicting the pPCN. pPCN was an independent prognostic indicator and associated with worse 3-year OS (66% vs 91%, Cox p = 0.033) and DFS (58% vs 92%, Cox p = 0.012).

Conclusion

The incidence of pPCN was higher than expected. Patients with high-risk factors (cTNM stage III or more PCNs) might get benefits from an extended proximal bowel resection to avoid residual positive PCNs.

Oxaliplatin and molecular-targeted drug therapies improved the overall survival in colorectal cancer patients with synchronous peritoneal carcinomatosis undergoing incomplete cytoreductive surgery

PURPOSE

To estimate the feasibility and limitations of incomplete cytoreductive surgery and modern systemic chemotherapy in patients with synchronous peritoneal carcinomatosis from colorectal cancer and to identify risk factors for death and factors associated with the patient prognosis.

METHODS

Sixty-five consecutive patients underwent surgery for synchronous peritoneal carcinomatosis from colorectal cancer at Hiroshima University, Japan between 1992 and 2012. The clinical, histological, and survival data were analyzed for independent risk factors and prognostic factors. The patients were retrospectively stratified into two groups according to the extent of surgery: complete cytoreductive surgery or incomplete cytoreductive surgery.

RESULTS

The median survival times in the complete and incomplete cytoreductive surgery groups were 29.8 and 10.0 months, respectively. Receiving systemic chemotherapy alone was an independent risk factor for death in the incomplete cytoreductive surgery group (P < 0.001). Oxaliplatin and molecular-targeted drug (cetuximab or bevacizumab) therapies were also independent prognostic factors (P < 0.001), whereas irinotecan therapy was not a prognostic factor (P = 0.494).

CONCLUSION

Oxaliplatin and molecular-targeted drug therapies improved the overall survival in patients undergoing incomplete cytoreductive surgery. Future trials for patients with synchronous peritoneal carcinomatosis from colorectal cancer should be undertaken, with patients stratified according to treatment with complete cytoreductive surgery or incomplete cytoreductive surgery with modern chemotherapy.

Validation of the seventh edition of the American Joint Committee on cancer tumor node-staging system in patients with colorectal carcinoma in comparison with sixth classification

BACKGROUND

The aim of this study was to compare survival rates assessed by the seventh-staging system with those by the sixth classification.

METHODS

This was a retrospective study of 3,377 patients who underwent surgery for colorectal adenocarcinoma from three university hospitals. The overall survival (OS) and cancer-specific survival (CSS) rates were compared between patients whose stages according to the seventh-staging system remained the same and patients whose stages migrated, and between subgroups within each new stage (homogeneity analysis).

RESULTS

In seventh edition, the 5-year OS and CSS rates of patients with T3n2 tumor were significantly greater in the downstaged patients (T3N2a) than in other patients (T3N2b) (OS, P = 0.010; CSS, P = 0.009). The 5-year survival rates for patients with T4a and T4b sub-classifications according to the seventh edition did not differ from those in patients with T4N0-1. Homogeneity analysis of subgroups classified using the new system showed that some subgroups of stage IIIB (T3N2a/T4aN1) had poorer survival rates compared with patients in other sub-categories in the same stage IIIB (P < 0.001).

CONCLUSION

Overall, the seventh edition provides a more detailed classification of the prognosis than the old system. However, further study would be warranted to evaluate the validity of sub-classification in seventh TNM-staging system, especially for T4a-b and T3N2a tumors.

Extended resections for colorectal cancer - indications for supraradical lymphadenectomy

The laparoscopic approach to standard resections in colorectal cancer has proven that it may provide equal rates of R0 resections and adequate retrieval of lymph nodes as open procedures if performed by experienced hands. There might be difficulties in more advanced tumors or those with lymphatic spread beyond typical drainage areas and more extensive operations might be required. An atypical pattern of lymphatic spread often is associated with other adverse factors such as multifocality of primary cancers and adverse tumorbiological factors such as grade. Such patient subgroups may be defined beforehand and include particularly patients with underlying ulcerative colitis. Repetitively, extended lymph node dissection approaches have been advocated, however neither in randomised trails nor in meta-analysis has a more favourable outcome of patients undergoing such extended lymphatic dissections been demonstrated. Sticking to the rules of classical dissection of lymphatic drainage basins with removal of adequate lymph node numbers is one corner stone for successful treatment of colorectal cancer. The other one refers to a detailed description of the procedure performed in order to make the surgical procedure trackable.

The Feasibility of an Ex-vivo Sentinel Lymph Mapping Using Preoperative Radioisotope Injection in Cases of Extraperitoneal Rectal Cancer

PURPOSE

The purpose of this research was to evaluate the feasibility of sentinel lymph node (SLN) mapping involving transanal injection with an ex-vivo mapping in patients with rectal cancer.

METHODS

Between April 2007 and December 2009, 20 consecutive patients with T1-3, N0-1 clinical stage rectal cancer preoperatively underwent a SLN procedure using submucosal (99m)Tc-phytate injection. All the patients underwent a total mesorectal excision. After the standard surgical resection, all specimens were identified on lymphoscintigraphy, and bench work was done to pick up the sentinel node basin. All the lymph nodes (non-SLNs and SLNs) were examined using conventional hematoxylin and eosin staining and immunohistochemistry with anti-cytokeratin antibodies.

RESULTS

SLNs were identified from 19 of 20 patients with rectal cancer. The total number of sentinel nodes retrieved from the surgical specimens was 29, and the mean number per patient was 1.6 (range, 0 to 4). In three patients, the SLN was the only positive lymph node. There was one false-negative case with a sensitivity of 88.8% and two upstaged cases (20.0%). The SLN samples from rectal cancer are mainly localized in the pararectal region, but aberrant nodes receive direct drainage from the rectal cancer. On planar lymphoscintigraphy, 15.7% of all patients had aberrant lymphatic drainage to the sigmoid mesenteric or sigmoid lymph node station.

CONCLUSION

In conclusion, the intraoperative transanal injection for ex-vivo SLN navigation is a safe, feasible surgical modality in patients with rectal cancer. Large studies are warranted to determine the clinical significance of the SLN concept and micrometastasis in rectal cancer.

Case of a sigmoid colon cancer with metachronous metastases to the mesorectum and the abdominal wall

Backround

Sigmoid colon cancer metachronous metastases commonly occur in the liver and lungs with sporadic reports also to the spleen, stomach, thyroid gland, abdominal wall and upper urinary tract. This is a rare case of metachronous metastases invading the mesorectum and the abdominal wall.

Case presentation

A 72-year-old female underwent sigmoidectomy for stage I (T2N0 M0) sigmoid colon cancer in May 2008. In June 2009, an abdominal computed tomography scan revealed a tumor 2 cm in size at the lower anterior mesorectum and a second mass 2 cm in size at the anterior abdominal wall midline. Total colonoscopy showed no mucosal lesion. The serum carcinoembryonic antigen level was normal. A biopsy of the mesorectum tumor showed similar histologic characteristics with the primary tumor. Since no other site of recurrence was identified, an abdominoperineal resection was attempted. During the operation and after the removal of the incision recurrence, sinus bradycardia and signs of myocardial ischemia were noticed. A loop transverse colostomy was immediately perfomed and the operation was terminated. Postoperative cardiologic examination revealed an acute myocardium infract. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided.

Conclusion

Metachronous metastasis of the mesorectum from sigmoid colon cancer is extremely rare. Although patterns of lymphatic spread from rectal cancer to sigmoid colon have recently been demonstrated, there is no evidence of metachronous mesorectum invasion from sigmoid colon cancer. This could be the issue for future trials.