The Impact of Perioperative Risk, Tumor Pathology and Surgical Complications on Disease Recurrence Following Potentially Curative Resection of Colorectal Cancer

Five-item Modified Frailty Index in Elderly Patients Undergoing Laparoscopic Colorectal Surgery Predicts Postoperative Complications

Background/Aim

Owing to underlying diseases and decreased physiological functions, frailty in elderly patients may be associated with adverse postoperative complications and mortality. To date, there are various frailty assessment methods, with the five-item modified frailty index (mFI-5) being an objective and concise evaluation tool. This study aimed to clarify whether mFI-5 scoring, a measure of frailty, can predict postoperative outcomes in elderly patients undergoing laparoscopic colorectal surgery.

Patients and Methods

A total of 107 patients aged over 80 years who underwent laparoscopic colorectal surgery at Nagasaki University Hospital between 2011 and 2018 were included in this study. The mFI-5 was used to assess the preoperative condition of each patient, with scores compared against various postoperative outcome measures. Univariate analysis was used to determine between-group differences for pre- and post-operative variables.

Results

Of the 107 patients [median age, 83 (80-99) years], 44.9% were male. The mFI-5 score was calculated and patients were divided into three groups: 0 (n=36, 33.6%); 1 (n=44, 41.1%); and 2+ (n=27, 25.3%). The groups were significantly associated with the American Society of Anesthesiology (ASA) classification (p<0.001). Postoperative complications occurred in 43 patients (40.2%), and a higher mFI-5 score was significantly associated with postoperative complications of Clavien-Dindo grade ≥III and duration of hospital stay.

Conclusion

The mFI-5 is an objective and useful tool for predicting postoperative complications of laparoscopic surgery in elderly patients with colorectal cancer.

"Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study"

BACKGROUND

Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce.

METHODS

This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival.

RESULTS

Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%.

CONCLUSIONS

The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.

Endotoxemia and Gastrointestinal Cancers: Insight into the Mechanisms Underlying a Dangerous Relationship

Lipopolysaccharide (LPS), also known as endotoxin, is a component of the membrane of gram-negative bacteria and a well-recognized marker of sepsis. In case of disruption of the intestinal barrier, as occurs with unhealthy diets, alcohol consumption, or during chronic diseases, the microbiota residing in the gastrointestinal tract becomes a crucial factor in amplifying the systemic inflammatory response. Indeed, the translocation of LPS into the bloodstream and its interaction with toll-like receptors (TLRs) triggers molecular pathways involved in cytokine release and immune dysregulation. This is a critical step in the exacerbation of many diseases, including metabolic disorders and cancer. Indeed, the role of LPS in cancer development is widely recognized, and examples include gastric tumor related to Helicobacter pylori infection and hepatocellular carcinoma, both of which are preceded by a prolonged inflammatory injury; in addition, the risk of recurrence and development of metastasis appears to be associated with endotoxemia. Here, we review the mechanisms that link the promotion and progression of tumorigenesis with endotoxemia, and the possible therapeutic interventions that can be deployed to counteract these events.

Do postoperative infectious complications really affect long-term survival in colorectal cancer surgery? A multicenter retrospective cohort study

Aim

To investigate the impact of postoperative infection (PI), surgical site infection, and remote infection (RI), on long-term outcomes in patients with colorectal cancer (CRC).

Methods

The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 1817 curative stage I/II/III CRC patients from April 2013 to March 2015. Patients were divided into the No-PI group and the PI group. We examined the association between PI and oncological outcomes for cancer-specific survival (CSS) and overall survival (OS) using Cox proportional hazards models and propensity score matching.

Results

Two hundred and ninety-nine patients (16.5%) had PIs. The 5-year CSS and OS rates in the No-PI and PI groups were 92.8% and 87.6%, and 87.4% and 83.8%, respectively. Both the Cox proportional hazards models and propensity score matching demonstrated a significantly worse prognosis in the PI group than that in the No-PI group for CSS (hazard ratio: 1.60; 95% confidence interval: 1.10-2.34; P = .015 and P = .031, respectively) but not for OS. RI and the PI severity were not associated with oncological outcomes. The presence of PI abolished the survival benefit of adjuvant chemotherapy.

Conclusions

These results suggest that PI after curative CRC surgery is associated with impaired oncological outcomes. This survival disadvantage of PI was primarily derived from surgical site infection, not RI, and PI induced lower efficacy of adjuvant chemotherapy. Strategies to prevent PI and implement appropriate postoperative treatment may improve the quality of care and oncological outcomes in patients undergoing curative CRC surgery.

Preoperative neutrophil-to-lymphocyte ratio behaves as an independent prognostic factor even in patients with postoperative complications after curative resection for gastric cancer

PURPOSE

The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent.

METHODS

A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien-Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan-Meier method was used to assess overall survival.

RESULTS

The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien-Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p < 0.05). Patients with POC showed worse long-term survival (p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p < 0.001). Patients with preoperative NLR ≥ 2.4 (p = 0.02) had a worse prognosis. Multivariate analysis: pN (p < 0.001), postoperative complications (p < 0.001) (HR 3.04; 95% CI: 1.97-4.70) and NLR ≥ 2.4 (p = 0.04) (HR = 1.55; 95% CI: 1.02-2.3) were independent prognostic factors.

CONCLUSION

The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.

Surgical site infection after laparoscopic resection of colorectal cancer is associated with compromised long-term oncological outcome

Background

We evaluated the influence of infectious complications, particularly surgical site infection (SSI), on long-term oncological results after elective laparoscopic resection of colorectal cancer.

Methods

A total of 199 patients who underwent laparoscopic elective resection with negative resection margins for stage I–III colorectal cancer were retrospectively examined. The postoperative course was recorded based on hospital records, and cancer relapse was diagnosed based on radiological or pathological findings under a standardized follow-up program. The severity of complications was graded using Clavien-Dindo (CD) classification.

Results

SSI was found in 25 patients (12.6%), with 12 (6.0%) showing anastomotic leak. The postoperative relapse-free survival (RFS) rate was significantly lower in patients with SSI (49.2%) than in patients without SSI (87.2%, P<0.001). Differences in RFS were found after both colectomy and rectal resection (P<0.001 and P<0.001, respectively). RFS did not differ between patients who had major SSI CD (grade III) and those who had minor SSI CD (grades I or II). Multivariate Cox regression analysis identified the occurrence of SSI and pathological stage as independent co-factors for RFS (P<0.001 and P=0.003).

Conclusion

These results suggest that postoperative SSI compromises long-term oncological results after laparoscopic colorectal resection. Further improvements in surgical technique and refinements in perioperative care may improve long-term oncological results.

The Impact of Frailty on Patients Undergoing Liver Resection for Colorectal Liver Metastasis

BACKGROUND

The aim of this study is to assess the impact of frailty on short-term outcomes after hepatectomy for colorectal liver metastasis (CRLM).

METHODS

Patients were identified using the National Surgical Quality Improvement Program (NSQIP). Patients were divided into 3 categories using the 5-item Modified Frailty Index (mFI).

RESULTS

There were 5230 patients included. 52%, 35%, and 13% had mFI scores of 0, 1, and ≥ 2 respectively. Patients with a ≥ 2 mFI score were more likely to experience minor complication (OR 1.34, 95% CI 1.06-1.69), major complication (OR 1.56, 95% CI 1.15-2.12), readmission (OR 1.55, 95% CI 1.12-2.14), unfavorable discharge (OR 2.48, 95% CI 1.62-3.80), 30-day mortality (OR 3.02, 95% CI 1.02-8.95), prolonged length of stay (OR 1.47, 95% CI 1.18-1.83), and bile leak (OR 1.51, 95% CI 1.02-2.24).

CONCLUSION

Frailty is associated with increased post-operative complications. The 5-item mFI can guide risk stratification, optimization, and counseling.

Has the National Fall in Smoking Rates in Ireland Been Replicated in Cancer Patients? A 5-Year Report

Smoking among cancer patients leads to poorer outcomes, yet many patients continue smoking. As part of a feasibility study of smoking cessation for cancer patients in Ireland, smoking rates were reviewed. Hospital Inpatient Enquiry (HIPE) data on the smoking status of discharges with a cancer diagnosis (overall, breast, lung, cervical and head and neck cancer) were used (2014–2018). During 2014–2017, current smoking increased for overall (10.5–11.7%) and lung cancer (24.7–27.2%), then decreased to 11.4% and 24.1%, respectively, in 2018. Current smoking increased for cervical during 2014–2018 (11–19.8%) and initially (2014–2016) for head and neck (3–12.7%) cancer, decreasing to 7.6% in 2018; breast cancer was stable at 6 ± 0.6%. These rates are lower than the Irish (23–20%) and European (29% (average)) general population. During 2014–2017, past smoking increased among overall (15.2–21%) and specific cancers, which was lower than the Irish general population (23–28%). Current smoking was highest among 50–59-year-olds (14–16%), which contrasts with the Irish general population (24–35 years at 32–28%). HIPE data are subject to potential duplicate episodes of care and under-documentation of smoking. However, trend analysis is useful, as these limitations should be stable. Rates remain high; therefore, robust documentation and smoking cessation referrals for cancer patients are important.

Trends in Textbook Outcomes over Time: Are Optimal Outcomes Following Complex Gastrointestinal Surgery for Cancer Increasing?

BACKGROUND

The use of composite measures like "textbook outcome" (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer.

METHODS

Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time.

RESULTS

Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p < 0.001). The proportion of patients achieving a textbook outcome increased over time for all patients (2004-2007, 53.3% vs. 2008-2011, 56.5% vs. 2012-2016, 60.1%) (5-year increase: OR 1.16 95%CI 1.13-1.18) (p < 0.001). Survival at 1-year following pancreatic, liver, or colon resection for cancer had improved over time among both patients who did and did not achieve a postoperative TO. TO was independently associated with a marked reduction in hazard of death (HR 0.44, 95%CI 0.43-0.45). The association of TO and survival was consistent among patients stratified by procedure.

CONCLUSION

Less than two-thirds of patients undergoing complex gastrointestinal surgery for a malignant indication achieved a TO. The likelihood of achieving a TO increased over time and was associated with improved survival.

The Importance of the Therapeutic Care Plan in Colorectal Surgery

Introduction A therapeutic plan is elaborated based on the health needs of each user, allowing a multidisciplinary team to assess diagnoses, treatment options, bonds, and optimal hospitalization time.

Objectives To identify risk management tools already used and implemented in a reference teaching hospital in the city of São Paulo and to analyze their application and risk factors in medium and large colorectal surgery.

Method Observational, longitudinal, and prospective study, with 30 patients with colorectal disease hospitalized in the surgical ward of the coloproctology service and in need of surgical treatment. In the first group, the protocol was applied with the knowledge of the researcher only, and, in the second group, with the knowledge of both the researcher and the attending physicians.

Results Sixty percent of the patients were female with a mean age of 60.93 years and body mass index (BMI) of 26.07 Kg/m2.

After surgery, patients in the first group who did not receive venous thromboembolism (VTE) prophylaxis in the first 24 hours had an increased risk of having the event compared with those who returned to prophylaxis (p < 0.005), thus suggesting this prophylaxis was a protective factor against thromboembolic event (p = 0.006). This group also had a higher risk of hypoglycemia when no strict control was performed (p = 0.041).

Conclusion The compliance to hospital protocols with application monitoring, notedly in teaching places with annual admission of resident physicians, is a fundamental part of the adequate care of the patient combined with the implementation of therapeutic plans.

Lipopolysaccharides increase the risk of colorectal cancer recurrence and metastasis due to the induction of neutrophil extracellular traps after curative resection

BACKGROUND

Intra-abdominal infection after curative surgery for colorectal cancer is a serious complication associated with an increased risk of recurrence. Lipopolysaccharides (LPS)-an essential component of the cell wall of Gram-negative bacteria-were found to exert a protumorigenic effect by stimulating the inflammatory pathology and formation of neutrophil extracellular traps (NETs). This study was conducted to test whether LPS-induced formation of NETs promotes the development of cancer and metastasis.

METHODS

The clinical characteristics, incidence of relapse, and serum myeloperoxidase-DNA complexes of 40 patients with infection and 40 patients without infection after curative surgery were analyzed. The effects of LPS on the induction of NETs were evaluated in a mouse model of colorectal cancer and liver metastasis. The toll-like receptor 9 (TLR9)-a DNA receptor-was knocked down to assess its effect on the mitogen-activated protein kinase pathway and activities implicated in the formation of NETs.

RESULTS

Analysis of the clinical data obtained from these patients showed the significant relation of the formation of NETs and incidence of metastasis and survival rates. Subsequent in vitro experiments revealed an increased level of citrullinated-histone H3 and myeloperoxidase-DNA in LPS-injected mice with colorectal cancer. In the mimic metastatic model, injection of LPS enhanced the metastatic capacity, which was then attenuated by DNase I. This suggested that the formation of NETs was activated by LPS. Injection of TLR9-knockdown HCT116 cells in mice, followed by induction through LPS, mitigated the level of citrullinated-histone H3 and myeloperoxidase-DNA. This finding implied that the formation of NETs was suppressed.

CONCLUSION

These findings shed light on the mechanism underlying the relationship between the elevated rate of colorectal cancer recurrence in patients who underwent surgery and the incidence of infection. This mechanism involves the protumorigenic activities of LPS-induced formation of NETs. The NETs which could be mediated by the TLR9 and the mitogen-activated protein kinase signaling pathway.

Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study

AIMS

Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor-related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group.

METHODS

We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis.

RESULTS

Ninety-three patients (9.6%) had major complications. The 2-year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21-2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications.

CONCLUSIONS

Postoperative complications after primary tumor resection was associated with decreased long-term survival in patients with incurable stage IV colorectal cancer.

The Impact of Postoperative Complications on Long-Term Oncological Outcomes Following Curative Resection of Colorectal Cancer (Stage I-III): A Systematic Review and Meta-Analysis

Background and objective The incidence of post-surgical complications (PSCs) after curative resection of non-metastatic colorectal cancer (CRC) is very widespread and evident. Some studies suggest that PSCs often predict poor long-term oncological outcomes. However, the available data on the topic is often controversial. The aim of this systematic review and meta-analysis was to study the effect of postoperative complications (POCs) on long-term oncological outcomes following curative resection of non-metastatic (stage I-III) CRC. Methods A comprehensive search of MEDLINE® and Excerpta Medica dataBASE (EMBASE) databases was performed via the Ovid platform, by using controlled vocabulary as well as natural language terms for POCs, outcomes, and CRC. Two authors independently screened the studies and extracted data. Conflicts were resolved by discussion among authors and also independently with the help of a third author. Meta-analysis was performed using a random-effects model (REM) to calculate pooled estimates for overall survival (OS), disease-free survival (DFS), and overall recurrence. Results Overall, 3,836 studies were initially screened, and 16 studies involving 37,192 patients were ultimately selected for final inclusion in the analysis. Meta-analysis of these studies showed that PSCs following non-metastatic CRC surgery predicted worse OS rates [hazard ratio (HR): 1.36; 95% CI: 1.15-1.61; p<0.00001], DFS (HR: 1.41; 95% CI: 1.11-1.80; p<0.00001), and overall recurrence (HR: 1.19; 95% CI: 1.04-1.37; p=0.01). Conclusion Based on our findings, PSCs predict poor OS rates, DFS, and overall recurrence following curative resection of non-metastatic CRC.

Meta-analysis of the impact of postoperative infective complications on oncological outcomes in colorectal cancer surgery

BACKGROUND

Cancer outcomes are complex, involving prevention, early detection and optimal multidisciplinary care. Postoperative infection and surgical site-infection (SSI) are not only uncomfortable for patients and costly, but may also be associated with poor oncological outcomes. A meta-analysis was undertaken to assess the oncological effects of SSI in patients with colorectal cancer.

METHODS

An ethically approved PROSPERO-registered meta-analysis was conducted following PRISMA guidelines. PubMed and Scopus databases were searched for studies published between 2007 and 2017 reporting the effects of postoperative infective complications on oncological survival in colorectal cancer. Results were separated into those for SSI and those concerning anastomotic leakage. Articles with a Methodological Index for Non-Randomized Studies score of at least 18 were included. Hazard ratios (HRs) with 95 per cent confidence intervals were computed for risk factors using an observed to expected and variance fixed-effect model.

RESULTS

Of 5027 articles were reviewed, 43 met the inclusion criteria, with a total of 154 981 patients. Infective complications had significant negative effects on overall survival (HR 1·37, 95 per cent c.i. 1·28 to 1·46) and cancer-specific survival (HR 2·58, 2·15 to 3·10). Anastomotic leakage occurred in 7·4 per cent and had a significant negative impact on disease-free survival (HR 1·14, 1·09 to 1·20), overall survival (HR 1·34, 1·28 to 1·39), cancer-specific survival (HR 1·43, 1·31 to 1·55), local recurrence (HR 1·18, 1·06 to 1·32) and overall recurrence (HR 1·46, 1·27 to 1·68).

CONCLUSION

This meta-analysis identified a significant negative impact of postoperative infective complications on overall and cancer-specific survival in patients undergoing colorectal surgery.

Smoking Status and Survival Among a National Cohort of Lung and Colorectal Cancer Patients

INTRODUCTION

The purpose of this study was to explore the association of smoking status and clinically relevant duration of smoking cessation with long-term survival after lung cancer (LC) or colorectal cancer (CRC) diagnosis. We compared survival of patients with LC and CRC who were never-smokers, long-term, medium-term, and short-term quitters, and current smokers around diagnosis.

METHODS

We studied 5575 patients in Cancer Care Outcomes Research and Surveillance (CanCORS), a national, prospective observational cohort study, who provided smoking status information approximately 5 months after LC or CRC diagnosis. Smoking status was categorized as: never-smoker, quit >5 years prior to diagnosis, quit between 1-5 years prior to diagnosis, quit less than 1 year before diagnosis, and current smoker. We examined the relationship between smoking status around diagnosis with mortality using Cox regression models.

RESULTS

Among participants with LC, never-smokers had lower mortality risk compared with current smokers (HR 0.71, 95% CI 0.57 to 0.89). Among participants with CRC, never-smokers had a lower mortality risk as compared to current smokers (HR 0.79, 95% CI 0.64 to 0.99).

CONCLUSIONS

Among both LC and CRC patients, current smokers at diagnosis have higher mortality than never-smokers. This effect should be further studied in the context of tumor biology. However, smoking cessation around the time of diagnosis did not affect survival in this sample.

IMPLICATIONS

The results from our analysis of patients in the CanCORS consortium, a large, geographically diverse cohort, show that both LC and CRC patients who were actively smoking at diagnosis have worse survival as compared to never-smokers. While current smoking is detrimental to survival, cessation upon diagnosis may not mitigate this risk.

Blood Galectin-3 Levels Predict Postoperative Complications after Colorectal Cancer Surgery

BACKGROUND

Recent studies suggested that galectin-3 may act as a pro-inflammatory damage-associated molecular pattern. The aim of this study is to investigate the association between blood galectin-3 and postoperative complications (POC) after colorectal cancer (CRC) surgery.

METHODS

Blood samples were taken from 35 patients with CRC before surgery, immediately after surgery, and on postoperative days (POD) 1, 3, 5, and 7. Blood galectin-3 and interleukin-6 levels were measured by commercially available ELISA. Patients were divided into those with (POC group) and without POC (no-POC group).

RESULTS

Significantly higher galectin-3 levels were observed pre- and postoperatively in the POC group (n=10) compared with those of the no-POC group (n=25). Galectin-3 levels on POD1 showed the best predictive potential for POC (cut-off: 3.18 pg/mL, area under the curve: 0.868).

CONCLUSIONS

These results indicate that increased perioperative blood galectin-3 levels may be associated with POC after CRC surgery.

Catalyst for Change: Measuring the Effectiveness of Training of All Health Care Professionals to Provide Brief Intervention for Smoking Cessation to Cancer Patients

BACKGROUND

Smoking cessation is recommended to prevent individuals from developing cancer, with additional benefits after a cancer diagnosis. Tobacco use during cancer treatments increases the risk of complications and may reduce the effectiveness of treatment; patients who quit smoking are less likely to experience recurrence. Health care professionals play a vital role in assessing and educating cancer patients on how to quit. We report on the effectiveness of peer-to-peer education of a brief smoking cessation intervention to patients.

METHODS

An interprofessional team was created to implement and integrate smoking cessation best practices into daily clinical care. Health care providers were provided with peer-to-peer training to provide brief interventions of smoking cessation to patients. After training, participants were invited to complete an electronic survey to assess the effectiveness of the peer-to-peer training sessions. The survey consisted of 3 domains: confidence, comfort, and knowledge. Participants were asked to rate a series of statement questions using a Likert scale as well as to self-assess knowledge. The survey also included open-ended questions to invite respondents to share further comments and feedback.

RESULTS

Approximately 90% of staff across the oncology program participated in a training session. This included nurses, radiation therapists, and patient and family support professionals. Sixty-one surveys were returned (30% response rate). Most respondents had >10 years of clinical experience (70%), 91% agreed it was important to support patients in their efforts to quit smoking, 88% agreed they have an impact on their patients' smoking cessation attempts, and 67% had opportunities in daily practice to support smoking cessation. Sixty-one percent would benefit from additional education. Fifty-three percent indicated they experienced challenges providing interventions and patients' responsiveness to the intervention.

CONCLUSIONS

Peer-to-peer training for smoking cessation can increase confidence, comfort, and knowledge. Challenges include comfort level of clinician, determining the best time to ask patients, and having the confidence in knowing their scope of practice.

Long-term Oncologic Outcome of Postoperative Complications After Colorectal Cancer Surgery

PURPOSE

The impact of postoperative complications on long-term oncologic outcome after radical colorectal cancer surgery is controversial. The aim of this study was to examine the risk factors and oncologic outcomes of surgery-related postoperative complication groups.

METHODS

From January 2010 to December 2010, 310 patients experienced surgery-related postoperative complications after radical colorectal cancer surgery. These stage I-III patients were classified into 2 subgroups, minor (grades I, II) and major (grades III, IV) complication groups, according to extended Clavien-Dindo classification system criteria. Clinicopathologic differences between the 2 groups were analyzed to identify risk factors for major complications. The disease-free survival rates of surgery-related postoperative complication groups were also compared.

RESULTS

Minor and major complication groups were stratified with 194 patients (62.6%) and 116 patients (37.4%), respectively. The risk factors influencing the major complication group were pathologic N category and operative method. The prognostic factors associated with disease-free survival were preoperative perforation, perineural invasion, tumor budding, and receiving neoadjuvant therapy. With a median follow-up period of 72.2 months, the 5-year disease-free survival rates were 84.4% in the minor group and 78.5% in the major group, but there was no statistical significance between the minor and major groups (P = 0.392).

CONCLUSION

Advanced cancer and open surgery were identified as risk factors for increased surgery-related major complications after radical colorectal cancer surgery. However, severity of postoperative complications did not affect disease-free survival from colorectal cancer.

Treating tumors with minimally invasive therapy: A review

With high level of morbidity and mortality, tumor is one of the deadliest diseases worldwide. Aiming to tackle tumor, researchers have developed a lot of strategies. Among these strategies, the minimally invasive therapy (MIT) is very promising, for its capability of targeting tumor cells and resulting in a small incision or no incisions. In this review, we will first illustrate some mechanisms and characteristics of tumor metastasis from the primary tumor to the secondary tumor foci. Then, we will briefly introduce the history, characteristics, and advantages of some of the MITs. Finally, emphasis will be, respectively, focused on an overview of the state-of-the-art of the HIFU-, PDT-, PTT-and SDT-based anti-tumor strategies on each stage of tumor metastasis.

Influence of Anastomotic Leak After Elective Colorectal Cancer Resection on Survival and Local Recurrence: A Propensity Score Analysis

BACKGROUND

The occurrence of anastomotic leakage is still a life-threatening complication for patients after colorectal surgery. In literature not only an impact on the short-term outcome but also on long-term survival and local recurrence of colorectal cancer patients is discussed.

OBJECTIVE

This study aimed to investigate the impact of anastomotic leakage on long-term survival and local recurrence.

DESIGN

A total of 1122 patients with resections for colorectal cancer were analyzed. In 94 patients (8.4%) there was clinical proof of anastomotic leakage. A reference group was defined as the 1028 patients without anastomotic leakage using 1:1 propensity score-matching according to the following criteria: age, sex, International Union Against Cancer stage, Karnofsky index, tumor site, and grading, as well as adjuvant chemotherapy. A calculation of overall survival, disease-free survival, and local recurrence rate was performed for both groups.

SETTINGS

The study was conducted using a retrospective matched-pairs analysis, based on a prospectively maintained institutional colorectal cancer database.

PATIENTS

Ninety-four patients with anastomotic leakage and 94 matched control subjects from a total of 1122 patients with resections for colorectal cancer were studied.

MAIN OUTCOME MEASURES

Overall survival, disease-free survival, and local recurrence rate for patients with colorectal cancer with and without anastomotic leakage were measured.

RESULTS

The propensity score matching successfully created 2 groups with no significant differences in the matching criteria. Survival analysis disclosed no significant differences between the groups in terms of overall survival, disease-free survival, and local recurrence rate. Univariate analysis identified age, Karnofsky index, International Union Against Cancer stage, and lymph node metastasis as significant prognostic factors. Multivariable analysis of these variates revealed age and positive lymph nodes as independent predictors of overall survival and disease-free survival.

LIMITATIONS

The study was limited by nature of being a retrospective analysis and monocentric study.

CONCLUSIONS

This matched-pairs analysis, comparing patients with colorectal cancer with and without anastomotic leakage, revealed no significant differences in overall survival, disease-free survival, and local recurrence rate. Contrary results in the literature might be caused by nonbalanced settings in nonmatched collectives. See Video Abstract at http://links.lww.com/DCR/A811.

Prognostic Significance of Post-Operative Morbidity Severity Score After Potentially Curative D2 Gastrectomy for Carcinoma

BACKGROUND

Survival and relapse after gastric cancer surgery are largely attributed to tumor biology and surgical radicality; yet, other prognostic factors have been reported, including respiratory sepsis and anastomotic leakage, but not global morbidity severity score (MSS). The hypothesis tested was that MSS would be associated with both disease-free (DFS) and overall survival (OS).

METHODS

Consecutive 373 patients undergoing potentially curative surgery for gastric adenocarcinoma between 2004 and 2016 in a UK cancer network were studied. Complications were defined prospectively as any deviation from a pre-determined post-operative course within 30 days of surgery and classified according to the Clavien-Dindo severity classification (CDSC). Primary outcome measures were DFS and OS.

RESULTS

Post-operative complications were identified in 127 (34.0%) patients, which was associated with 9 (2.4%) post-operative deaths. Five-year DFS and OS were 35.9 and 38.5% for patients with a post-operative complication compared with 59.5 and 61.5% in controls (p < 0.001, p = 0.001, respectively). On multivariable DFS analysis, post-operative morbidity [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.06-2.50, p = 0.026] was independently associated with poor survival. On multivariable OS analysis, post-operative morbidity HR 2.25 (95% CI 1.04-4.85, p = 0.039) and CDSC HR 1.76 (95% CI 1.35-2.29, p < 0.001) were independently associated with poor survival. These associations were also observed in patients with TNM stage I and II disease with morbidity HR 7.06 (95% CI 1.89-26.38, p = 0.004) and CDSC HR 2.93 (95% CI 1.89-4.55, p < 0.001) offering independent prognostic value.

CONCLUSION

Post-operative CDSC was an important independent prognostic factor after potentially curative gastrectomy for carcinoma associated with both DFS and OS. Prehabilitation strategies to minimize complications are warranted.

Screening-detected colorectal cancers show better long-term survival compared with stage-matched symptomatic cancers

PURPOSE

the aim of this study was to compare overall and disease-free survival among patients with colorectal cancer detected via a screening program as compared to those with symptomatic cancer.

MATERIAL AND METHODS

patients diagnosed via colonoscopy (screening group) and those with clinical symptoms (non-screening) were identified from 1995 to 2014. Demographic, clinical, surgical and pathologic variables were recorded. Stage I, II and III cancers were included. Overall and disease-free survival were calculated at five and ten years after tumor resection and survival was calculated by matching both groups for cancers at stage I, II and III.

RESULTS

two hundred and fifty patients were identified as a result of screening procedures and 1,330 patients presented with symptomatic cancers. There were no significant differences in the baseline characteristics between the two groups. Pathologic stage, degree of differentiation, perineural invasion and lymphovascular invasion were lower in the screening group (p < 0.01). Overall and disease-free survival at five and ten years were higher in the screening group (p < 0.01). However, when the subjects were matched for pathologic stage, significant differences were found between the two groups with regard to stage I and III tumors. Disease-free survival in stage III at five years (79.1 vs 61.7%; p < 0.001) and ten years (79.1% vs 58.5%; p < 0.001) were significantly higher in the screening group.

CONCLUSIONS

patients with stage I and III tumors that were diagnosed via a screening program have a higher overall and disease-free survival at five and ten years.

Long-term prognostic impact of surgical complications in the German Rectal Cancer Trial CAO/ARO/AIO-94

Background

The influence of postoperative complications on survival in patients with locally advanced rectal cancer undergoing combined modality treatment is debatable. This study evaluated the impact of surgical complications on oncological outcomes in patients with locally advanced rectal cancer treated within the randomized CAO/ARO/AIO-94 (Working Group of Surgical Oncology/Working Group of Radiation Oncology/Working Group of Medical Oncology of the Germany Cancer Society) trial.

Methods

Patients were assigned randomly to either preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME) or postoperative CRT between 1995 and 2002. Anastomotic leakage and wound healing disorders were evaluated prospectively, and their associations with overall survival, and distant metastasis and local recurrence rates after a long-term follow-up of more than 10 years were determined. Medical complications (such as cardiopulmonary events) were not analysed in this study.

Results

A total of 799 patients were included in the analysis. Patients who had anterior or intersphincteric resection had better 10-year overall survival than those treated with abdominoperineal resection (63·1 versus 51·3 per cent; P &lt; 0·001). Anastomotic leakage was associated with worse 10-year overall survival (51 versus 65·2 per cent; P = 0·020). Overall survival was reduced in patients with impaired wound healing (45·7 versus 62·2 per cent; P = 0·009). At 10 years after treatment, patients developing any surgical complication (anastomotic leakage and/or wound healing disorder) had impaired overall survival (46·6 versus 63·8 per cent; P &lt; 0·001), a lower distant metastasis-free survival rate (63·2 versus 72·0 per cent; P = 0·030) and more local recurrences (15·5 versus 6·4 per cent; P &lt; 0·001). In a multivariable Cox regression model, lymph node metastases (P &lt; 0·001) and surgical complications (P = 0·008) were the only independent predictors of reduced overall survival.

Conclusion

Surgical complications were associated with adverse oncological outcomes in this trial.

Postoperative intra-abdominal infection is an independent prognostic factor of disease-free survival and disease-specific survival in patients with stage II colon cancer

BACKGROUND

Recurrence occurs in up to 20% of patients with stage II colon cancer operated on for cure. Although postoperative intra-abdominal infection has been linked with an increased risk of recurrence, the association is controversial. The aim was to investigate the impact of postoperative intra-abdominal infection on disease-free survival and disease-specific survival in patients with stage II colon cancer.

METHODS

Patients undergoing elective surgery for colon cancer stage II, between 2003 and 2014, were included. Patients with anastomotic leak or intra-abdominal abscess were included in the infection group. We used the Kaplan-Meier method to represent the distribution of survival and the Cox proportional hazards model to estimate the contribution of relevant clinicopathological factors with prognosis.

RESULTS

Postoperative intra-abdominal infection was diagnosed in 37 of 363 (10.2%) patients. Perioperative blood transfusion was more frequent in patients with infection (p = 0.008). Overall 5-year disease-free survival rate was 85.1%. Disease-free survival at 5 years was lower in patients with postoperative intra-abdominal infection (52.8 vs 88.7%; p < 0.001), perineural invasion (p = 0.001), lymphovascular invasion (p = 0.001), pT4 (p = 0.013), and in patients with adjuvant chemotherapy (p = 0.013). Multivariate analysis showed that postoperative intra-abdominal infection (HR 4.275; p < 0.001), perineural invasion (HR 2.230; p = 0.007), and lymphovascular invasion (HR 2.052; p = 0.016) were all significant independent predictors of reduced disease-free survival. Regarding specific survival, independent significant prognostic factors were the number of lymph nodes, lymphovascular invasion, and postoperative intra-abdominal infection.

CONCLUSION

In this series of patients with stage II colon cancer, postoperative intra-abdominal infection has an independent negative impact on disease-free survival and disease-specific survival.

The right colon challenge

Colorectal cancer (CRC) is the third most common cancer and the fourth cause of cancer-related mortality worldwide. In an attempt to raise awareness on this situation, and to implement preventive measures, March 31st has been established as international colorectal cancer awareness day. Our country, with the Spanish "Alianza para la Prevención del Cáncer de Colon", pioneered in 2008 an institution that brought together scientific and civil societies to pursue this goal. A stabilization, even a decrease in the incidence and mortality of this condition has been reported in western countries for the last few years, which may be attributed to a number of highly relevant factors.

Prognostic Implications of Postoperative Infectious Complications in Non-Small Cell Lung Cancer

Background

Few studies have evaluated the long-term impact of postoperative infectious complications in patients with non-small cell lung cancer (NSCLC). We aimed to determine the impact of infectious complications on long-term outcomes after surgical resection for NSCLC.

Methods

We performed a retrospective study of 1,380 eligible patients who underwent pulmonary resection for NSCLC from 2003 to 2012. Complications were divided into infectious complications and non-infectious complications. Kaplan-Meier survival analysis was used to compare unadjusted 5-year cancer-specific survival (CSS) rates and recurrence-free survival (RFS) rates. Cox regression was used to determine the impact of infectious complications on 5-year CSS and RFS.

Results

The rate of total complications and infectious complications was 24.3% and 4.3%, respectively. In the node-negative subgroup, the 5-year CSS and RFS rates were 75.9% and 57.1% in patients who had infectious complications, compared to 87.9% and 78.4% in patients who had no complications. Infectious complications were a negative prognostic factor for 5-year RFS (hazard ratio, 1.92; 95% confidence interval, 1.00–3.69; p=0.049). In the node-positive subgroup, the 5-year CSS rate and RFS were 44.6% and 48.4% in patients who had infectious complications, compared to 70.5% and 48.4% for patients who had no complications.

Conclusion

Postoperative infectious complications had a negative impact on CSS and RFS in node-negative NSCLC. Our findings may help improve risk assessment for tumor recurrence after pulmonary resection for node-negative NSCLC.

Characterization of systemic neutrophil function in patients undergoing colorectal cancer resection

BACKGROUND

In patients with colorectal cancer, the generation and maintenance of a systemic inflammatory response is associated with poor outcomes. Neutrophils have been implicated in the prognosis of such patients, but little is known about their functional response to surgery. This study was conducted to characterize neutrophil function of patients undergoing colorectal cancer resection.

MATERIALS AND METHODS

Systemic neutrophils were isolated from patients with colorectal cancer who underwent surgical resection preoperatively (day 0) and postoperatively (day 1 and day 3). Neutrophils were stimulated to produce neutrophil extracellular traps, which were quantified by a measure of the fluorescence of the extracellular DNA. Neutrophil apoptosis and phagocytosis were measured by fluorescence-activated cell sorting.

RESULTS

Forty-five patients were evaluated. Statistically significant differences were identified in NET formation over the perioperative period (reduced NET production [day 0 to day 1] and restored NET production [day 1 to day 3]) in the absence of stimulation (P = 0.0016) and in response to stimulation with interleukin 8 (P = 0.0045), lipopolysaccharide (P = 0.0025), and N-formylmethionyl-leucyl-phenylalanine (P = 0.0014). No statistically significant differences were identified in apoptosis at 4-hour incubation; however, at 24-hours, significant differences were identified in alive (P < 0.0001), early apoptotic (P = 0.0008) and late apoptotic (P = 0.0018) stages (impaired apoptosis [day 0 to day 1] and restored apoptosis [day 1 to day 3]). Demonstrable, but nonsignificant, increases in neutrophil phagocytotic activity were revealed on sequential perioperative days, and a significant increase in phagocytosis was identified from day 1 to day 3 in response to E coli (P = 0.0078).

CONCLUSIONS

A novel neutrophil phenotype demonstrating reduced NET formation, reduced apoptosis, and increased phagocytosis has been demonstrated in patients undergoing colorectal cancer resection. As a consequence of impaired cell death, an accumulation of neutrophils in the circulation could be potentially harmful to the host following surgery and an early phenotypic switch may be desirable.

Impact of postoperative complications on the colorectal cancer survival and recurrence: analyses of pooled individual patients' data from three large phase III randomized trials

This study assessed the impact of postoperative complications on the colorectal cancer survival and recurrence after curative surgery using pooled individual patients’ data from three large phase III randomized trials. In total, 5530 patients were included in this study. The patients were classified as those with postoperative complications (C group) and those without postoperative complications (NC group). The risk factors for the overall survival (OS) and the disease‐free survival (DFS) were analyzed. Postoperative complications were found in 861 (15.6%) of the 5530 patients. The OS and DFS rates at 5 years after surgery were 68.9% and 74.8%, respectively, in the C group and 75.8% and 82.2%, respectively, in the NC group, values that were significantly different between the two groups (P < 0.001). The multivariate analysis demonstrated that postoperative complications were a significant independent risk factor for the OS and DFS. Postoperative complications can worsen the colorectal cancer survival and risk of recurrence. Surgical morbidity must be considered as a stratification factor in future phase III trials evaluating the effects of adjuvant chemotherapy on colorectal cancer.

Effect of abdominopelvic sepsis on cancer outcome in patients undergoing sphincter saving surgery for rectal cancer

BACKGROUND

In rectal cancer, the significance of abdominopelvic sepsis (APS) on metastatic tumor growth remains uncertain. We aimed to analyze the effect of abdominopelvic sepsis on long-term survival in patients undergoing restorative rectal cancer surgery.

METHODS

Data were used from the Belgian PROCARE rectal cancer registry. The effect of abdominopelvic infection on survival was assessed in uni- and multivariable Cox regression models. The effect of clinical and pathological covariates was controlled by propensity score-based matching of cases with controls. The effect of abdominopelvic sepsis on the rate of local and metastatic recurrence was evaluated using crosstabulation and the Pearson χ² test.

RESULTS

In univariable analysis, the presence of APS was associated with significantly worse overall survival (HR 1.3, P = 0.025). After propensity score matching including age, BMI, tumor level, pTstage, pN stage, CRM, tumor grade, number of lymph nodes, and presence of lymphovascular invasion, the association of APS with OS was no longer significant (HR 1.26, 95%CI 0.92-1.74, P = 0.15). No differences were observed in the risk of local or metastatic recurrence (3.6% vs 2.9% and 13% vs 16.5%).

CONCLUSIONS

In this analysis APS after rectal cancer resection was not significantly associated with OS, metastatic, or local recurrence.

Peripheral blood leucocytes show differential expression of tumour progression-related genes in colorectal cancer patients who have a postoperative intra-abdominal infection: a prospective matched cohort study

AIM

Anastomotic leak is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. We hypothesized that the infection-induced inflammatory response may induce overexpression of tumour progression-related genes in immune cells. The aim was to investigate the effect of postoperative intra-abdominal infection on the gene expression patterns of peripheral blood leucocytes (PBL) after surgery for colorectal cancer.

METHOD

Prospective matched cohort study. Patients undergoing surgery for colorectal cancer were included. Patients who had anastomotic leak or intra-abdominal abscess were included in the infection group (n = 23) and matched with patients without complications for the control group (n = 23). PBL were isolated from postoperative blood samples. Total RNA was extracted and hybridized to the Affymetrix Human Gene 1.0 ST microarray.

RESULTS

Patients in the infection group displayed 162 upregulated genes and 146 downregulated genes with respect to the control group. Upregulated genes included examples coding for secreted cytokines involved in tumour growth and invasion (S100P, HGF, MMP8, MMP9, PDGFC, IL1R2). Infection also upregulated some proangiogenic genes (CEP55, TRPS1) and downregulated some inhibitors of angiogenesis (MME, ALOX15, CXCL10). Finally, some inhibitors (HP, ORM1, OLFM4, IRAK3) and activators (GNLY, PRF1, FGFBP2) of antitumour immunity were upregulated and downregulated, respectively, suggesting that the inflammatory environment caused by a postoperative infection favours immune evasion mechanisms of the tumour.

CONCLUSION

Analysis of PBL shows differential expression of certain tumour progression-related genes in colorectal cancer patients who have a postoperative intra-abdominal infection, which in turn may promote the growth of residual cancer cells to become recurrent tumours.

Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients

BACKGROUND AND OBJECTIVES

Frailty disproportionately impacts older patients with gastrointestinal cancer, rendering them at increased risk for poor outcomes. A frailty index may aid in preoperative risk stratification. We hypothesized that high modified frailty index (mFI) scores are associated with adverse outcomes after tumor resection in older, gastrointestinal cancer patients.

METHODS

Patients (60-90 years old) who underwent gastrointestinal tumor resection were identified in the 2005-2012 NSQIP Participant Use File. mFI was defined by 11 previously described, preoperative variables. Frailty was defined by an mFI score >0.27. The postoperative course was evaluated using univariate and multivariate analysis.

RESULTS

41 455 patients (mean age 72.4 years, 47.4% female) were identified. The most prevalent form of cancer was colorectal (69.3%, n = 28 708) and 2.8% of patients were frail (n = 1,164). Frail patients were significantly more likely to have increased length of stay (11.7 vs 9.0 days), major complications (29.1% vs 17.9%), and 30-day mortality (5.6% vs 2.5%), (all P < 0.001). Multivariate analysis identified mFI as an independent predictor of major complications (OR 1.52, 95%CI 1.39-1.65, P < 0.001) and 30-day mortality (OR 1.48, 95%CI 1.24-1.75, P < 0.001).

CONCLUSIONS

mFI was associated with the incidence of postoperative complications and mortality in older surgical patients with gastrointestinal cancer.

Does postoperative morbidity worsen the oncological outcome after radical surgery for gastrointestinal cancers? A systematic review of the literature

PURPOSE

The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome.

METHODS

A literature search of PubMed/MEDLINE was performed using the keywords "esophageal cancer," "gastric cancer," and "colorectal cancer," obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed.

RESULTS

Patients with postoperative complications had significantly poorer long-term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31-2.12), 1.59 (95% CI, 1.13-2.24), and 1.55 (95% CI, 1.28-1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome.

CONCLUSIONS

Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes.

Smoking at diagnosis significantly decreases 5-year cancer-specific survival in a population-based cohort of 18 166 colon cancer patients

BACKGROUND

Accumulating evidence suggests smoking may adversely affect cancer patients' outcomes. Previous studies of smoking and survival in colon cancer have been limited by size and/or lack of a population basis and results have been inconsistent.

AIM

To investigate in a large population-based cohort whether smoking status at diagnosis is an independent prognostic factor for cancer-specific survival in colon cancer and whether treatment modifies any impact of smoking.

METHODS

Colon adenocarcinomas diagnosed between 1994 and 2012 were abstracted from the National Cancer Registry Ireland, and classified by smoking status at diagnosis. Cancer-specific death rates over 5 years were compared in current, ex- and never smokers using multivariable Cox proportional hazards models, and subgroup analyses by treatment (combinations of cancer-directed surgery and chemotherapy) were conducted.

RESULTS

Of 18 166 colon cancers, 20% of patients were current smokers, 23% ex-smokers and 57% never smokers. Compared to never smokers, current smokers had a significantly raised cancer death rate [multivariable hazard ratio (HR) = 1.14, 95% CI: 1.07-1.12]. There was a significant interaction between treatment and smoking (P = 0.03). In those who had cancer-directed surgery only, but not other groups, current smokers had a significantly increased cancer death rate compared to never smokers (HR = 1.21, 95% CI: 1.09-1.34).

CONCLUSIONS

Smoking at diagnosis is an independent prognostic factor for colon cancer. The limitation of the association to surgically-treated patients suggests that the underlying mechanism(s) may be related to surgery. While further research is needed to elucidate mechanisms, continued efforts to encourage smoking prevention and cessation may yield benefits in terms of improved survival from colon cancer.

A Postoperative Systemic Inflammation Score Predicts Short- and Long-Term Outcomes in Patients Undergoing Surgery for Colorectal Cancer

BACKGROUND

Following surgery, a significant proportion of patients develop postoperative complications that are associated with poorer long-term survival. Stereotypical markers of the systemic inflammatory response (SIR) have been shown to identify patients at increased risk of developing such complications. The aim of the present study was to examine the prognostic value of a postoperative systemic inflammation-based score in patients undergoing potentially curative surgery for colorectal cancer.

METHODS

Patients with histologically proven colorectal cancer undergoing resection between 1999 and 2013 (n = 813) were grouped into two cohorts-a retrospective test cohort (n = 402) and a prospective validation cohort (n = 411). Patients were assessed for postoperative complications and had routine blood samples taken daily. The relationship between markers of the postoperative SIR and survival was examined using Cox regression analysis.

RESULTS

In the test cohort, 87 patients developed an infective complication, while in the validation cohort, 106 patients developed an infective complication. In both cohorts, the postoperative SIR (C-reactive protein and albumin thresholds of >150 mg/L and <25 g/L, respectively) were associated with the development of infective complications (all p < 0.01). Using these thresholds, a scoring system [postoperative Glasgow prognostic score (poGPS)] was created, and on days 3 and 4 was associated with an incremental increase in the infective complication rate (all p < 0.001) and complication severity (p < 0.001). In the overall cohort, there were 175 cancer and 139 non-cancer deaths. The poGPS was also significantly associated with overall survival (p < 0.05).

CONCLUSIONS

The postoperative SIR, evidenced by the poGPS, was associated with increased complication rates and severity and a reduction in survival.

Postoperative Systemic Inflammatory Response, Complication Severity, and Survival Following Surgery for Colorectal Cancer

BACKGROUND

This study examined the relationship between the magnitude of the postoperative systemic inflammatory response (SIR), the severity of complications, and long-term outcomes following surgery for colorectal cancer.

METHODS

Data were recorded prospectively for patients undergoing potentially curative surgery for colorectal cancer in a single centre between 2008 and 2013. The magnitude of the SIR was measured using C-reactive protein (CRP). Complications were classified by Clavien-Dindo grade. The impact on disease specific and overall survival was assessed using univariate and multivariate Cox regression.

RESULTS

Of 377 patients included, the majority were male (55 %), older than age 65 years (68 %), with colonic (63 %) and node-negative disease (66 %). A total of 138 patients (37 %) had a complication, of which 26 (6 %) were Clavien-Dindo grade 3 or 4 severity. Complication severity was significantly associated with the established CRP thresholds of 150 mg/L on postoperative day (POD) 3 (p < 0.001) and POD 4 (p < 0.001). Median follow-up was 42 months with disease-specific survival 86 % and overall survival 78 %. On univariate analysis, complication severity [hazard ratio (HR) 1.66, 95 % confidence interval (CI) 1.13-2.43, p = 0.009], and POD 4 CRP > 150 mg/L (HR 2.53, 95 % CI 1.43-4.48, p = 0.001) were associated with disease-specific survival. On multivariate survival analysis, POD 4 CRP > 150 mg/L (HR 2.00, 95 % CI 1.12-3.59, p = 0.020), but not complication severity, was significantly associated with disease-specific survival independent of TNM stage (HR 2.46, 95 % CI 1.52-4.12, p < 0.001).

CONCLUSIONS

The magnitude of the postoperative SIR, evidenced by CRP, was significantly associated with long-term outcomes following surgery for colorectal cancer, independent of complications and stage.

Malignancy is a risk factor for postoperative infectious complications after elective colorectal resection

PURPOSE

Patient and technical factors influencing the postoperative infectious complications (ICs) after elective colorectal resections are satisfactorily described. However, the underlying disease-related factors have not been extensively evaluated. This study aimed to measure the effect of malignancy on postoperative surgical site and extra surgical site infections after elective colorectal resection.

METHODS

This study is a bicentric retrospective matched pair study of prospectively gathered data. Between 2004 and 2013, 1104 consecutive patients underwent colorectal resection in two centers. Patients undergoing elective resection with supraperitoneal anastomosis for benign diseases (excluding inflammatory bowel disease) (group B, n = 305) were matched to randomly selected patients with malignancy (group M, n = 305). The matching variables were age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, type of resection, and surgical approach. We compared the 30-day IC rates between patients with benign diseases (group B) and malignancy (group M). Multivariate logistic regression analysis was performed to identify the risk factors for ICs.

RESULTS

Group M had a higher overall rate of IC (25.6 vs 16.1 %, P = 0.004) as well as a higher risk of extra surgical site infections (P = 0.007) and anastomotic leakage (P = 0.039). The independent risk factors for ICs were malignancy (odds ratio (OR) = 2.02; P = 0.002), age ≥70 years (OR = 1.73, P = 0.018), tobacco history (OR = 1.87; P = 0.030), and obesity (OR = 1.68; P = 0.039).

CONCLUSION

Malignancy, age, tobacco history, and obesity increase the risk of ICs after colorectal resection. Improvement of the modifiable risk factors, increased compliance with an enhanced recovery after surgery (ERAS) program in the overall population, and optimization of immune function in patients with malignancy should be considered.

The impact of the type and severity of postoperative complications on long-term outcomes following surgery for colorectal cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review investigated the impact of complications by type (infective vs. non-infective) and severity (using the Clavien Dindo scale) on long-term outcome following surgery for colorectal cancer.

METHODS

A systematic review was performed using appropriate keywords. Meta-analysis using a random effects model was performed.

RESULTS

14 studies were included with a total 18,611 patients. Infective complications had a significant impact on disease free (HR 1.41, 95%CI 1.08-1.83, p=0.01) and overall survival (1.37 95%CI 1.22-1.55, p<0.001). Non-infective complications had no significant impact on either disease free (HR 1.21, 95%CI 0.97-1.52, p=0.09) or overall survival (HR 1.35, 95%CI 0.92-1.97, p=0.12). Complication severity had a significant impact on both disease free (HR 1.41, 95%CI 1.18-1.68, p<0.001) and overall survival (HR 1.45, 95%CI 1.25-1.69, p<0.001).

DISCUSSION

Both type and severity of postoperative complications have an impact on long-term survival following surgery for colorectal cancer.

Postoperative peritoneal infection enhances migration and invasion capacities of tumor cells in vitro: an insight into the association between anastomotic leak and recurrence after surgery for colorectal cancer

OBJECTIVE

The aim of this study was to investigate the effect of postoperative peritoneal infection on proliferation, migration, and invasion capacities of cancer cells lines in vitro after surgery for colorectal cancer.

BACKGROUND

Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. We hypothesized that the infection-induced inflammatory response may enhance tumor progression features of residual cancer cells.

METHODS

Prospective matched cohort study. Patients undergoing surgery for colorectal cancer with curative intent (January 2008-March 2012) were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group (n=47). For each case patient, another patient with an uncomplicated postoperative course was selected for the control group (n=47).In vitro treatments on cancer cell lines (MDA-MB-231 and SW620) were performed using baseline and postoperative serum and peritoneal fluid samples to determine cell proliferation and cell migration/invasion activities.

RESULTS

Postoperative peritoneal fluid from infected patients enhanced both cell migration (infection: 140±85 vs control: 94±30; P=0.016) and cell invasion (infection: 117±31 vs control: 103±16; P=0.024) capacities of cancer cell lines. With serum samples, these effects were only observed in cell migration assays (infection: 98±28 vs control: 87±17; P=0.005). Some minor activation of cell proliferation was observed by treatment with serum from infection group. Two-year cumulative disease-free survival was significantly lower in patients with postoperative peritoneal infection (infection: 77.6% vs control: 90.6%; P=0.032).

CONCLUSIONS

Our results suggest that postoperative peritoneal infection enhances the invasive capacity of residual tumor cells after surgery, thus facilitating their growth to recurrent tumors.

Oncological outcome following anastomotic leak in rectal surgery

BACKGROUND

The influence of anastomotic leak on local recurrence and survival remains debated in rectal cancer.

METHODS

This was a multicentre observational study using data from the Spanish Rectal Cancer Project database. Demographics, American Society of Anesthesiologists classification, tumour location, stage, use of defunctioning stoma, administration of neoadjuvant and adjuvant treatment, invasion of circumferential resection margin, quality of mesorectal excision and anastomotic leakage were recorded. Anastomotic leak was defined as an anastomotic event requiring surgical intervention or interventional radiology, including pelvic abscesses without radiological evidence of leakage and early rectovaginal fistulas. Variables associated with oncological outcome were assessed by multivariable Cox regression analysis.

RESULTS

A total of 1181 consecutive patients were included. Rates of anastomotic leak and 30-day postoperative mortality were 9·4 and 2·4 per cent respectively. Data from 1153 patients were analysed after a median follow-up of 5 years. Cumulative rates of local recurrence, overall recurrence, overall survival and cancer-specific survival were 4·9, 19·4, 77·5 and 84·7 per cent respectively. In the multivariable regression analysis, anastomotic leakage was not associated with local recurrence (hazard ratio (HR) 0·80, 95 per cent c.i. 0·28 to 2·26; P = 0·669), overall recurrence (HR 1·14, 0·70 to 1·85; P = 0·606), overall survival (HR 1·10, 0·73 to 1·65; P = 0·648) or cancer-specific survival (HR 1·23, 0·75 to 2·02; P = 0·421).

CONCLUSION

Anastomotic leak after low anterior resection did not affect oncological outcomes in these patients.

Postoperative intra-abdominal infection and colorectal cancer recurrence: a prospective matched cohort study of inflammatory and angiogenic responses as mechanisms involved in this association

BACKGROUND

Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications.

METHODS

Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid.

RESULTS

Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6-1473.2] versus control: 0.6 [0.6-17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4-1574.0] versus control: 90.3 [35.2.6-106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3-10000.0] versus control: 438.3 [214.1-677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0-10000.0] versus control: 477.8 [313.5-814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001).

CONCLUSIONS

Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.

Reducing tobacco-related cancer incidence and mortality: summary of an institute of medicine workshop

Tobacco use remains a serious and persistent national problem. Recognizing that progress in combating cancer will never be fully achieved without addressing the tobacco problem, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop exploring current issues in tobacco control, tobacco cessation, and implications for cancer patients. Workshop participants discussed potential policy, outreach, and treatment strategies to reduce tobacco-related cancer incidence and mortality, and highlighted a number of potential high-value action items to improve tobacco control policy, research, and advocacy.

The perioperative immune/inflammatory insult in cancer surgery: Time for intervention?

Within the tumor microenvironment, non-specific innate immune responses can suppress adaptive cytotoxic immunity and hence promote tumor progression. Surgery and trauma provokes high-grade, non-specific inflammatory responses that suppress cell-mediated immunity. Here, the surgical resection of neoplastic lesions is considered in the context of antitumor immunity, providing the rationale for development of perioperative interventions to maintain the immunological competence of the host.