Revised tumor and node categorization for rectal cancer based on surveillance, epidemiology, and end results and rectal pooled analysis outcomes

Clinical management of patients with colorectal intramucosal carcinoma compared to high-grade dysplasia and T1 colorectal cancer

BACKGROUND AND AIMS

In the colorectum, intramucosal carcinoma (IMC), like high-grade dysplasia (HGD), should be resected endoscopically. We were interested to understand how real-world treatment of IMC cases compares to management of HGD and T1 colorectal cancer (CRC).

METHODS

A multicenter cohort study was conducted. Through pathology databases, all patients diagnosed between 2010 and 2019 with HGD, IMC, or T1 CRC polyps at 3 hospitals in a regional Canadian center were identified. The primary outcome was the proportion of surgical management of IMC compared to HGD after complete endoscopic resection. Secondary outcomes were the proportion of synchronous advanced neoplasia (SAN) and the adjusted hazard ratios (aHRs) for metachronous advanced neoplasia (MAN) in the 3 groups among patients eligible for follow-up.

RESULTS

We identified 753 patients with IMC or HGD on a first pathology diagnosis, including 601 after complete endoscopic resection. Patients with IMC were more likely to undergo surgery after complete endoscopic resection compared to patients with HGD (10.5% [6 of 57] vs 0% [0 of 544], P < .001). A total of 455 patients had follow-up endoscopy and pathology (mean age, 67.1 years; 42.2% female; median follow-up, 3.4 years): 269 with HGD, 60 with IMC, and 126 with T1 CRC. Proportions of SAN were 24.2%, 26.7%, and 25.4% (P = .908). Compared to HGD, patients with IMC and T1 CRC had similar MAN risks (aHR, 0.82 [95% CI, 0.43-1.59] and aHR, 1.16 [95% CI, 0.66-2.05], respectively). No lymph node findings were positive (0 of 363), and no metastasis occurred among patients with IMC.

CONCLUSIONS

Patients diagnosed with colorectal IMC were more likely to undergo surgery after complete endoscopic resection than when HGD was diagnosed, although they were not at increased risk of SAN or MAN in this study, and the known risk of nodal metastasis with colorectal IMC is small (0%-2%). Unless a patient diagnosed with IMC is particularly concerned with this small risk, complete endoscopic resection should be considered the definitive treatment for IMC and should not be followed by surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A High-resolution T2WI-based Deep Learning Model for Preoperative Discrimination Between T2 and T3 Rectal Cancer: A Multicenter Study

RATIONALE AND OBJECTIVES

To construct a deep learning model (DL) based on high-resolution T2-weighted images for preoperative differentiation between T2 and T3 stage rectal cancer (RC), and to compare its performance with experienced radiologists.

METHODS

This retrospective study included 281 patients with pathologically confirmed RC from four centers (January 2017-December 2022). A DenseNet model was developed using 255 patients from three centers (training:validation ratio=8:2) and externally tested on 26 patients from a fourth center. Two experienced radiologists independently assessed T staging. Diagnostic performance was evaluated using accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).

RESULTS

The DL model outperformed radiologists in differentiating T2 and T3 stages across all datasets. In the training set, the DL model achieved an AUC of 0.810, compared to 0.578 and 0.625 for radiologists A and B, respectively. In the external test set, the DL model maintained superior diagnostic performance (AUC=0.715) compared to radiologist A (AUC=0.549) and radiologist B (AUC=0.493). The DL model demonstrated higher accuracy for T2 staging (0.625-0.787) and T3 staging (0.611-0.814) compared to radiologists (0.373-0.526 for T2; 0.611-0.783 for T3), who showed a tendency to over-stage T2 tumors. Inter-observer agreement between radiologists was moderate (kappa=0.451).

CONCLUSION

The DenseNet-based DL model demonstrated superior accuracy and diagnostic efficiency than radiologists in preoperative differentiation between T2 and T3 stages RC. This automated approach could potentially improve staging accuracy and support clinical decision-making in RC treatment planning.

Prognostic relevance of lymph node metastasis in pancreaticoduodenectomy for distal cholangiocarcinoma: Rational extent and number-based nodal classification for regional lymphadenectomy

BACKGROUND

We investigated the rational extent of regional lymphadenectomy and evaluated the prognostic impact of number-based regional nodal classification in patients with distal cholangiocarcinoma.

METHODS

This study included 191 patients with distal cholangiocarcinoma who underwent pancreaticoduodenectomy. The nos. 8, 12a-b-c-p, 13, 14, and 17 nodes were dissected routinely. The impact of the extent of lymphadenectomy on prognostic stratification performed using number-based nodal classification was evaluated.

RESULTS

The incidence of metastasis in the routinely dissected nodes was 1.0-25.7%, with 5-year overall survival of 0-36.4% in patients with metastasis. The incidence of metastasis in the no. 12p nodes, which were not included in regional nodes in the American Joint Committee on Cancer or International Union Against Cancer staging systems, was 5.8% with a 5-year overall survival of 36.4% in patients with metastasis. When our dissected nodes were adopted (P < .001), number-based nodal classification predicted overall survival better than when regional nodes defined by the International Union Against Cancer or American Joint Committee on Cancer staging systems were used (nos. 8, 12a-b, 13, 14, and 17 nodes with or without no. 9 nodes; P = .004 each). The 5-year overall survival in patients with pN0, pN1 (1-3 positive nodes), and pN2 (≥4 positive nodes) disease was 57.4%, 37.3%, and 13.6%, respectively (P < .001). The pN classification was an independent prognostic factor (pN1, P = .009; pN2, P < .001).

CONCLUSION

The nos. 8, 12a-b-c-p, 13, 14, and 17 nodes should be prioritized as the rational extent of regional lymphadenectomy for distal cholangiocarcinoma for accurate staging. Number-based regional nodal classification is suitable for prognostic stratification.

Shared Decision Making in the Treatment of Rectal Cancer

Background/Objectives: The management of locally advanced rectal cancer has evolved significantly, shaped by advances in multimodal neoadjuvant therapy and a growing emphasis on organ preservation through the watch-and-wait approach. These advancements, however, introduce complex treatment decisions that require careful consideration by both patients and clinicians. Methods: This narrative review explores the evolution of the management of locally advanced rectal cancer and the role of shared decision-making in guiding treatment decisions, particularly for patients facing decisions between surgical resection and watch-and-wait. Additionally, it discusses the development of tools to aid in shared-decision making, current challenges in implementing shared decision-making and future directions for improvement patient centered care in locally advanced rectal cancer management. Results: Considerations for decision making include anatomical considerations that influence surgical options, the potential benefits and risks of watch-and-wait versus surgical resection of the rectum, and the impact of treatment on bowel, urinary, and sexual function. Additionally, patients must weigh the long-term implications of their choices on quality of life. Conclusions: Shared decision-making has emerged as a critical component of patient-centered care and ensures that treatment decisions align with patients' values and priorities. Given the preference-sensitive nature of the management of locally advanced rectal cancer, shared decision-making plays an important role in helping patients navigate these decisions.

Rectal cancer - French intergroup clinical practice guidelines for diagnosis, treatment, and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR, and GRECCAR)

BACKGROUND

This article summarizes the French intergroup guidelines regarding rectal adenocarcinoma (RA) management published in September 2023, available on the French Society of Gastroenterology website.

METHODS

This work was supervised by French medical and surgical societies involved in RA management. Recommendations were rated from A to C according to the literature until September 2023.

RESULTS

Based on the pretreatment work-up, RA treatment was divided into four groups. T1N0 can be treated by endoscopic or surgical excision alone if there is no risk factor for lymph node involvement. For T2N0, radical surgery with total mesorectal excision is recommended, but rectal conservation is possible for small tumors (<4cm) after complete/subcomplete response following chemoradiotherapy. For T12N+ or T3+any N, total neoadjuvant treatment (TNT) followed by radical surgery is the gold standard, but rectal conservation is possible for small tumors after complete/subcomplete response following TNT. T3N2 or T+any N are an indication for TNT followed by radical surgery. Immunotherapy shows promise for dMMR/MSI RA. For metastatic tumors, recommendations are based on less robust evidence and chemotherapy plays a major role.

CONCLUSION

These guidelines aim at providing a personalized therapeutic strategy and are constantly being optimized. Each case should be discussed by a multidisciplinary team.

Determining the optimal number of examined lymph nodes for prognosis in colon cancer: a population-based study stratified by tumor location and T stage

Background

Clinical guidelines recommend ≥12 examined lymph nodes (ELNs) for colon cancer staging, but more may be necessary for accuracy. This study utilized nodal staging scores (NSS) to identity the optimal number of ELNs based on tumor location and T stage, and to assess its prognostic impact.

Methods

Data from 80,792 patients in the Surveillance, Epidemiology, and End Results (SEER) database (2004-2014) and 2,300 patients from the West China Hospital (WCH) cohort (2008-2014) with stage I-III resected colon cancer were analyzed. Optimal ELNs was estimated using a β-binomial distribution model, stratified by tumor location (left-sided, LS; right-sided, RS) and T stage. The primary outcome was overall survival (OS). The association between sufficient nodal staging and OS in node-negative patients was validated by multivariate Cox models.

Results

The mean number of ELN was 18.75 in the SEER and 14.58 in the WCH database. There were 57.8% and 48.8% patients who had RS colon cancer in the SEER and WCH database. Fewer T3-4 tumors were observed in the SEER cohort compared to the WCH cohort (68.4% vs. 87.2%). Sufficient nodal staging required ≥24 ELNs for T3 tumors, ≥34 nodes for T4 LS tumors, and ≥40 nodes for T4 RS tumors. For T3 lesions, examining 20-29 ELNs were more likely to have node-positive disease [odd ratio (OR) 1.07; 95% confidence interval (CI): 1.01-1.12] compared to patients with 12-15 ELNs. In the T3N0 group, ELN ≥24 was independently associated with better OS in the SEER database [hazard ratio (HR) 0.72; 95% CI: 0.68-0.75], which was validated in the WCH cohort (HR 0.54; 95% CI: 0.38-0.76).

Conclusions

Optimal ELNs for adequate colon cancer staging is related to both T stage and tumor location. We recommend that ≥24 lymph nodes be examined for T3 tumors, ≥34 for LS T4 tumors and ≥40 for RS T4 tumors for sufficient staging.

Prognostic Impact of the Postoperative Carcinoembryonic Antigen Level after Curative Resection of Locally Advanced Rectal Cancer

Objectives

This study was conducted to investigate whether preoperative or postoperative carcinoembryonic antigen (CEA) with a new cut-off value is more optimal for predicting long-term outcomes in patients with Stage II/III rectal cancer, and to investigate the effectiveness of postoperative adjuvant chemotherapy (POAC) based on the CEA values.

Methods

Serum CEA levels were measured preoperatively (pre-CEA) and postoperatively (post-CEA). The area under the receiver operating curve (AUROC) was used to determine a cut-off for CEA. The cut-off for CEA relative to recurrence-free survival (RFS) was established as that giving the highest AUROC. In comparison of superiority between pre- and post- CEA levels, Akaike's information criterion (AIC) was used in the Cox proportional-hazard regression model.

Results

The subjects were 323 patients who underwent curative surgical treatment for Stage II/III rectal cancer. AIC values indicated that RFS was better stratified by a post-CEA level with a cut-off of 2.3 ng/ml compared with other classifications of pre- or post- CEA. In Stage III or high-risk Stage II cases, there was no effect of POAC on RFS in those with post-CEA <2.3 ng/ml (p=0.39), but in those with post-CEA ≥2.3 ng/ml there was a trend for better RFS in patients who received POAC compared to those without POAC (p=0.06).

Conclusions

Patients with post-CEA ≥2.3 ng/ml had worse long-term outcomes compared with those with post-CEA <2.3 ng/ml. Post-CEA with a cut-off of 2.3 ng/ml may be useful in determining the indication for POAC for in Stage III or high-risk Stage II cases.

A nomogram for predicting the overall survival in rectal cancer patients after total neoadjuvant therapy

BACKGROUND

Total neoadjuvant therapy (TNT) has been recommended by the National Comprehensive Cancer Network for treating locally advanced rectal cancer (LARC), but extremely rare studies have focused on establishing nomograms to predict the prognosis in these patients after TNT. We aimed to develop a nomogram to predict overall survival (OS) in rectal cancer patients who underwent TNT.

METHODS

In retrospective cohort study, we extract the data of the rectal cancer patients from the SEER database between 2010 and 2015, including demographic information and tumor characteristics. The cohort was divided into training set and validation set based on a ratio of 7:3. Univariate logistic regression analysis was utilized for the comparison of variables in training set. Candidate variables with P < 0.1 in training set was entered into the best subset selection, LASSO regression and Boruta feature selection. Finally, the selected variables significantly associated with the 3-year, 5-year, and 8-year OS were used to build a nomogram, followed by validation using receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration curve.

RESULTS

A total of 3265 rectal cancer patients (training set: 2285; test set: 980) were included in the present study. A nomogram was developed to predict the 3-year, 5-year, and 8-year OS based on age, household income, total number of in situ/malignant tumors, CEA, T stage, N stage and perineural invasion. The nomogram showed good efficiency in predicting the 3-year, 5-year and 8-year OS with good AUC for the training set and test set, respectively.

CONCLUSION

We established a nomogram for predicting the 3-year, 5-year, and 8-year OS of the rectal cancer patients, which showed good prediction efficiency for the OS after TNT.

Clinical Analysis of the Efficacy and Safety of Different Neoadjuvant Strategies in the Treatment of Locally Advanced Rectal Cancer

OBJECTIVE

In this study, we retrospectively analysed the efficacy and safety of three treatment models, namely, short-course radiotherapy sequential XELOX chemotherapy, neoadjuvant mFOLFOX6 concurrent radiotherapy and long-course concurrent radiotherapy with total mesorectal excision (TME) after treatment of locally advanced rectal cancer with high-risk factors.

METHODS

We collected clinical data on 177 patients with locally advanced rectal cancer (cT3-4 and/or cN+) who were treated at the Department of Abdominal Oncology of the Affiliated Cancer Hospital of Guizhou Medical University from December 2017 to December 2022. All patients were associated with 2-3 risk factors [T4b, N2, Extramural Vascular Invasion (EMVI), Mesorectal Fascia (MRF) positivity], positive lateral lymph nodes. Among them, there were 45 cases in the short course radiotherapy sequential XELOX chemotherapy group (RT + XELOX group); 64 cases in the neoadjuvant mFOLFOX6 concurrent radiotherapy group (mFOLFOX6 + CRT group); and 68 cases in the long course concurrent radiotherapy group (CRT group). The RT + XELOX group and mFOLFOX6 + CRT group completed radiotherapy and 4 cycles of neoadjuvant chemotherapy, respectively, and then rested for 1-2 weeks before TME surgery; the CRT group completed concurrent radiotherapy and then rested for 6-8 weeks before TME surgery.Adjuvant chemotherapy was conducted after surgery in each of the three groups: 2 cycles of adjuvant chemotherapy with XELOX regimen in the RT + XELOX group, 4-6 cycles of adjuvant chemotherapy with mFOLFOX6 in the mFOLFOX6 + CRT group, and 8-12 cycles of adjuvant chemotherapy with mFOLFOX6 in the CRT group.The pathological complete response rate (pCR rate), tumour downstage rate, tumour complete resection rate (R0 resection rate), local recurrence rate, distant metastasis rate, overall survival rate, incidence of adverse reactions, surgical complications and completion rate of perioperative systemic chemotherapy were compared among patients in the three groups of cases after TME.

RESULTS

The pCR rate (21.95% vs 17.24% vs 5.00%, p = 0.034) and and tumour downstage rate (78.05% vs 68.97% vs 53.33%, p = 0.029) were higher in the RT + XELOX group and mFOLFOX6 + CRT group compared to the CRT group. The RT + XELOX group had a lower 3-year distant metastasis rate (14.63% vs 36.67%, p = 0.048) and improved 3-year overall survival (76.57% vs 48.56%, p < 0.001) compared to the CRT group. There was no significant reduction in the 3-year distant metastasis rate in the mFOLFOX6 + CRT group versus the CRT group (27.59% vs 36.67%, p = 0.719), and the 3-year overall survival was similar (51.23% vs 48.56%, p = 0.35). Multi-logistic regression analysis and stratified analysis showed that patients in the RT + XELOX group and mFOLFOX6 + CRT group were more likely to achieve pCR than the CRT group (RT + XELOX group: OR 7.3, 95% CI [2.6-20.8], p < 0.001; mFOLFOX6 + CRT group OR 2.9, 95% CI [1.1-7.9], p = 0.036). The completion rates of perioperative systemic chemotherapy in the RT + XELOX, mFOLFOX6 + CRT, and CRT groups were 82.93% vs. 84.48% vs. 61.67% (χ2=9.95, p = 0.007), respectively. And there were significant differences in grade 3-4 leukopenia and thrombocytopenia (incidence of leukopenia: 15.50% vs. 7.81% vs. 1.47%, p = 0.045; incidence of thrombocytopenia: 13.33% vs 7.81% vs 1.47%, p = 0.027). There was no significant difference in the incidence of intraoperative and postoperative complications among the three groups (p > 0.05).

CONCLUSIONS

RT + XELOX group and mFOLFOX6 + CRT group significantly improved the near-term outcome (e.g., pCR rate) in patients with locally advanced rectal cancer with high-risk factors compared with CRT group. The RT + XELOX group also reduced the 3-year distant metastasis rate, increased the 3-year overall survival rate, and did not increase the incidence of perioperative surgical complications. It provides an effective means for the comprehensive treatment of locally advanced rectal cancer and has important clinical guidance and application value.

The Causes Behind the Survival Paradox in Non-Metastatic Colorectal Cancer Patients and its Impact on the Treatment Regimen: A Retrospective Cohort Study

BACKGROUND

The survival paradox (ie, the prognosis of the population at earlier tumor stages is worse than that of the population at later stages) has been observed in colorectal cancer based on the American Joint Committee on Cancer Tumor-Nodes-Metastases staging system. We aimed to clarify the reason for the survival paradox and its impact on patient treatment.

METHODS

We conducted a retrospective study analyzing eligible patients with colorectal cancer from the Surveillance, Epidemiology, and End Results database and Zhejiang Cancer Hospital between 2010 and 2019. Adjusting for confounders using propensity score matching allowed confirmation of the effect of staging on the survival paradox.

RESULTS

Based on the Surveillance, Epidemiology, and End Results database, the subgroups with survival paradox might be IIB/C versus IIIA, IIA versus IIIA, and T4N0 (IIB/C) versus T3N1 (IIIB). After propensity score matching, stage IIB/C still had a worse prognosis than stage IIIA (5-year overall survival: 69.3% vs 78.5%, P < .001). Interestingly, the proportion of stage IIIA people receiving chemotherapy was higher than that of stage IIB/C (P < .001), and logistic regression models showed that staging was the reason for deciding whether a patient receives chemotherapy or not. These phenomena between stage IIB/C and IIIA were verified in the local database.

CONCLUSION

These results suggested that the survival paradox was mainly due to underestimation of stage T4 weights or overestimation of stage N1 weights, and the low proportion of chemotherapy in patients with T4N0M0 colorectal cancer (proven to be more malignant than stage IIIA) might be related to the assignment to earlier stages, resulting in a lack of attention and poor compliance to chemotherapy in these patients.

Clinical outcome and prognostic factors of T4N0M0 colon cancer after R0 resection: A retrospective study

BACKGROUND

Paradoxically, patients with T4N0M0 (stage II, no lymph node metastasis) colon cancer have a worse prognosis than those with T2N1-2M0 (stage III). However, no previous report has addressed this issue.

AIM

To screen prognostic risk factors for T4N0M0 colon cancer and construct a prognostic nomogram model for these patients.

METHODS

Two hundred patients with T4N0M0 colon cancer were treated at Tianjin Medical University General Hospital between January 2017 and December 2021, of which 112 patients were assigned to the training cohort, and the remaining 88 patients were assigned to the validation cohort. Differences between the training and validation groups were analyzed. The training cohort was subjected to multivariate analysis to select prognostic risk factors for T4N0M0 colon cancer, followed by the construction of a nomogram model.

RESULTS

The 3-year overall survival (OS) rates were 86.2% and 74.4% for the training and validation cohorts, respectively. Enterostomy (P = 0.000), T stage (P = 0.001), right hemicolon (P = 0.025), irregular review (P = 0.040), and carbohydrate antigen 199 (CA199) (P = 0.011) were independent risk factors of OS in patients with T4N0M0 colon cancer. A nomogram model with good concordance and accuracy was constructed.

CONCLUSION

Enterostomy, T stage, right hemicolon, irregular review, and CA199 were independent risk factors for OS in patients with T4N0M0 colon cancer. The nomogram model exhibited good agreement and accuracy.

Pathological-Features-Modified TNM Staging System Improves Prognostic Accuracy for Rectal Cancer

BACKGROUND

Variations in survival outcomes are observed in the eighth edition of the American Joint Committee on Cancer TNM staging system.

OBJECTIVE

Machine learning ensemble methods were used to develop and evaluate the effectiveness of a pathological-features-modified TNM staging system in predicting survival for patients with rectal cancer by use of commonly reported pathological features, such as histological grade, tumor deposits, and perineural invasion, to improve the prognostic accuracy.

DESIGN

This was a retrospective population-based study.

SETTINGS

Data were assessed from the database of the Surveillance, Epidemiology, and End Results Program.

PATIENTS

The study cohort comprised 14,468 patients with rectal cancer diagnosed between 2010 and 2015. The development cohort included those who underwent surgery as the primary treatment, whereas patients who received neoadjuvant therapy were assigned to the validation cohort.

MAIN OUTCOME MEASURES

The primary outcome measures included cumulative rectal cancer survival, adjusted HRs, and both calibration and discrimination statistics to evaluate model performance and internal validation.

RESULTS

Multivariable Cox regression analysis identified all 3 pathological features as prognostic factors, after which patients were categorized into 4 pathological groups based on the number of pathological features (ie, 0, 1, 2, and 3). Distinct survival differences were observed among the groups, especially with patients with stage III rectal cancer. The proposed pathological-features-modified TNM staging outperformed the TNM staging in both the development and validation cohorts.

LIMITATIONS

Retrospective in design and lack of external validation.

CONCLUSIONS

The proposed pathological-features-modified TNM staging could complement the current TNM staging by improving the accuracy of survival estimation of patients with rectal cancer. See Video Abstract .

EL SISTEMA DE ESTADIFICACIN TNM CON CARACTERSTICAS PATOLGICAS MODIFICADO MEJORA LA PRECISIN DEL PRONSTICO DEL CNCER DE RECTO

ANTECEDENTES:Se observan variaciones en los resultados de supervivencia en el sistema de estadificación TNM del Comité Conjunto Americano del Cáncer 8º ediciónOBJETIVO:Se utilizaron métodos conjuntos de aprendizaje automático para desarrollar y evaluar la eficacia de un sistema de estadificación con características patológicas modificadas de tumores, ganglios y metástasis para predecir la supervivencia de pacientes con cáncer de recto, utilizando algunas características patológicas comúnmente informadas, como el grado histológico, depósitos tumorales e invasión perineural, para mejorar la precisión del pronóstico.DISEÑO:Este fue un estudio retrospectivo de base poblacional.ENTERNO CLINICO:Se recuperaron y evaluaron datos de la base de datos de Vigilancia, Epidemiología y Resultados Finales.PACIENTES:La cohorte del estudio estuvo compuesta por 14,468 pacientes con cáncer de recto diagnosticados entre 2010 y 2015. La cohorte de desarrollo incluyó a aquellos que se sometieron a cirugía como tratamiento primario, mientras que los pacientes que recibieron terapia neoadyuvante fueron asignados a la cohorte de validación.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias incluyeron supervivencia acumulada del cáncer de recto, índices de riesgo ajustados y estadísticas de calibración y discriminación para evaluar el rendimiento del modelo y la validación interna.RESULTADOS:El análisis de regresión multivariable de Cox identificó las tres características patológicas como factores pronósticos, después de lo cual los pacientes se clasificaron en cuatro grupos patológicos según el número de características patológicas (es decir, 0, 1, 2 y 3). Se observaron distintas diferencias en la supervivencia entre los grupos, especialmente en los pacientes en estadio III. La estadificación propuesta con características patológicas modificadas de tumores-ganglios-metástasis superó a la estadificación TNM tanto en las cohortes de desarrollo como en las de validación.LIMITACIONES:Diseño retrospectivo y falta de validación externa.CONCLUSIONES:La estadificación propuesta con características patológicas modificadas de tumores-ganglios-metástasis podría complementar la estadificación TNM actual al mejorar la precisión de la estimación de supervivencia de los pacientes con cáncer de recto. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Risk Factor Analysis of Lymph Node Metastasis for Rectal Neuroendocrine Tumors: Who Needs a Radical Resection in Rectal Neuroendocrine Tumors Sized 1-2 cm?

BACKGROUND

Rectal neuroendocrine tumors (NETs) have malignant potential, and lymph node (LN) or distant metastases can occur; however, treatment of NETs 1-2 cm in size is controversial.

OBJECTIVE

This study aimed to identify predictive factors for LN metastasis and prognostic factors for recurrence of rectal NETs, especially tumors 1‒2 cm in size.

METHODS

Between October 2004 and November 2020, 453 patients underwent endoscopic or surgical treatment for rectal NETs in Seoul National University Hospital. The data on these patients were prospectively collected in our database and reviewed retrospectively. In cases of local excision, we evaluated LN metastasis with radiologic imaging, including computed tomography or magnetic resonance imaging before treatment and during the follow-up periods.

RESULTS

LN metastasis was observed in 40 patients (8.8%). A higher rate of LN metastasis was observed in larger-sized tumors, advanced T stage, lymphovascular invasion (LVI), perineural invasion (PNI), and high tumor grade. In multivariable analysis, the significant risk factors for LN metastasis were tumor size (1 ≤ size < 2 cm: hazard ratio [HR] 64.07; size ≥2 cm: HR 102.37, p < 0.001) and tumor grade (G2: HR 3.63, p = 0.034; G3: HR 5.09, p = 0.044). In multivariable analysis for tumors 1-2 cm in size, the risk factor for LN metastasis was tumor grade (G2: HR 6.34, p = 0.013).

CONCLUSIONS

Tumor grade and size are important predictive factors for LN metastasis. In NETs 2 cm in size, tumor grade is also important for LN metastasis, and radical resection should be considered.

Risk Factors for Distant Metastasis in T3 T4 Rectal Cancer

Background

Distant metastasis is the leading cause of death in patients with rectal cancer. This study aims to comprehensively analyze the risk factors of distant metastasis in T3 T4 rectal cancer using magnetic resonance imaging (MRI), pathological features, and serum indicators.

Methods

The clinicopathological data of 146 cases of T3 T4 rectal cancer after radical resection from January 2015 to March 2023 were retrospectively analyzed. Pre- and postoperative follow-up data of all cases were collected to screen for distant metastatic lesions. Univariate and multivariate Logistic regression methods were used to analyze the relationship between MRI features, pathological results, serum test indexes, and distant metastasis.

Results

Of the 146 included patients, synchronous or metachronous distance metastasis was confirmed in 43 (29.4%) cases. The patients' baseline data and univariate analysis showed that mrEMVI, maximum tumor diameter, mr T Stage, pathological N stage, number of lymph node metastasis, cancer nodules, preoperative serum CEA, (Carcinoembryonic antigen) and CA199 were associated with distant metastasis. In the multiple logistic regression model, mrEMVI, pathological N stage, number of lymph node metastasis, maximum tumor diameter, and preoperative serum CEA were identified as independent risk factors for distant metastasis: mrEMVI [odds ratio (OR) = 3.06], pathological N stage (OR = 6.52 for N1 vs N0; OR = 63.47 for N2 vs N0), preoperative serum CEA (OR = 0.27), tumor maximum diameter (OR = 1.03), number of lymph nodes metastasis (OR = 0.62). And, the receiver operating characteristic (ROC) curve was plotted and the area under the curve was calculated (area under the curve [AUC) = 0.817, 95% CI = 0.744-0.890, P < .001].

Conclusions

mrEMVI, pathological N stage, number of lymph node metastasis, maximum tumor diameter and preoperative serum CEA are the independent risk factors for distant metastasis in T3 T4 rectal cancer. A comprehensive analysis of the risk factors for distant metastasis in rectal cancer can provide a reliable basis for formulating individualized treatment strategies, follow-up plans, and evaluating prognosis.

Acetone compression improves lymph node yield and metastasis detection in colorectal cancer

Lymph node status is one of the most important prognostic factors in colorectal cancer, and accurate pathological nodal staging and detection of lymph node metastases is crucial for determination of post-operative management. Current guidelines, including the TNM staging system and European Society for Medical Oncology (ESMO) guidelines, recommend examination of at least 12 lymph nodes. However, identification of an adequate number of lymph nodes can be challenging, especially in the setting of neoadjuvant treatment, which may reduce nodal size. In this study, we investigated 384 colorectal cancer resections that were processed at our department of pathology between January 2012 and December 2022, in which the number of detected lymph nodes was less than 12 subsequent to conventional preparation of mesocolic fat tissue. By means of acetone compression, lymph node harvest increased significantly (p < 0.0001), and the intended number of ≥ 12 lymph nodes was achieved in 98% of resection specimens. The number of nodal positive cases increased significantly from n = 95 (24.7%) before versus n = 131 (34.1%) after acetone compression due to additionally identified lymph node metastases (p < 0.001). In 36 patients (9.4%) initially considered as nodal negative, acetone compression led to a staging adjustment to a nodal positive category and thereby drove a recommendation to offer post-operative therapy. In conclusion, acetone compression is a reliable and useful method implementable in routine surgical pathology for the retrieval of lymph nodes in colorectal cancer specimen, allowing for an adequate lymph node sampling and an increase in nodal staging reliability.

Implication of MRI Risk Stratification System on the Survival Benefits of Adjuvant Chemotherapy After Neoadjuvant Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer

RATIONALE AND OBJECTIVES

To investigate the implication of a Magnetic resonance imaging (MRI) risk stratification system on the selection of patients with locally advanced rectal cancer (LARC) who can benefit from adjuvant chemotherapy (ACT) after neoadjuvant chemoradiotherapy (NCRT).

MATERIALS AND METHODS

This retrospective study included 328 patients with LARC who underwent NCRT and surgery. The median follow-up duration was 79 months (Interquartile range, 66-94 months). Cox logistic regression analysis was used to identify MRI risk factors and develop a risk stratification system to stratify patients into groups with high and low risks. Kaplan-Meier curves of distant metastasis-free survival (DMFS) and overall survival (OS) were used to show the benefits of ACT and stratify results based on the MRI risk stratification system and postoperative pathological staging.

RESULTS

An MRI risk stratification system was built based on four MRI risk factors, including MRI-identified T3b-T4 stage, N1-N2 stage, extramural venous invasion, and tumor deposits. 74 (22.6%) patients with 3-4 MRI risk factors were classified into the MRI high-risk group. ACT could significantly improve 5-year DMFS (19.2% versus 52.1%; p < 0.001) and OS (34.6% versus 75.0%; p < 0.001) for patients in the MRI high-risk group, while ACT had no survival benefit for patients in the MRI low-risk group. The benefits of ACT were not observed in patients with any pathological staging subgroups (ypT0-2N0, ypT3-4N0, and ypN+).

CONCLUSION

Patients in the MRI high-risk group could benefit from ACT, regardless of postoperative pathological staging. Baseline MRI should be considered more in ACT decision-making.

Rational Extent of Regional Lymphadenectomy and the Prognostic Impact of the Number of Positive Lymph Nodes for Perihilar Cholangiocarcinoma

BACKGROUND

The definition and classification of regional nodes are not standardized for perihilar cholangiocarcinoma. This study aimed to clarify the rational extent of regional lymphadenectomy and to elucidate the impact of number-based regional nodal classification on survival of patients with this disease.

METHODS

Data of 136 patients with perihilar cholangiocarcinoma who underwent surgery were reviewed. The incidence of metastasis and the survival of patients with metastasis were calculated for each node group.

RESULTS

The incidence of metastasis for the node groups in the hepatoduodenal ligament (denoted as no. 12) ranged from 3.7% to 25.4%, with 5-year disease-specific survival of 12.9% to 33.3% for patients with metastasis. The incidences of metastasis in the common hepatic artery (no. 8) and posterior superior pancreaticoduodenal (no. 13a) node groups were 14.4% and 11.2%, respectively, with 5-year disease-specific survival rates of 16.7% and 20.0% for the patients with metastasis. When these node groups were defined as regional nodes, the 5-year disease-specific survival rates for the patients with pN0 (n = 80), pN1 (1-3 positive nodes, n = 38), and pN2 (≥ 4 positive nodes, n = 18) were 61.4%, 22.9%, and 17.6%, respectively (p < 0.001). The pN classification was independently associated with disease-specific survival (p < 0.001). When only the no. 12 node groups were regarded as regional nodes, pN classification failed to stratify the patients prognostically.

CONCLUSIONS

No. 8 and no. 13a node groups should be considered regional nodes in addition to no. 12 node groups and should be dissected. The number-based regional nodal classification allows patients with this disease to be stratified prognostically.

Value of pre-treatment 18F-FDG PET/CT radiomics in predicting the prognosis of stage III-IV colorectal cancer

Background and purpose

To investigate the value of radiomics features extracted from pre-treatment ¹⁸F-FDG PET/CT in predicting the outcomes of stage III-IV colorectal cancer (CRC), which may assist in clinical management strategies and precise treatment of stage III-IV CRC.

Materials and methods

124 patients with pathologically confirmed stage III-IV CRC who underwent pre-treatment ¹⁸F-FDG PET/CT scans were enrolled in this study. The least absolute shrinkage and selection operator Cox regression (LASSO-Cox) was used to select radiomics features, and the radiomics scores (Rad-scores) were calculated to build radiomics models. The performance of radiomics models was represented by the concordance index (C-index) and compared with clinical models and complex model. The bootstrap resampling method was used to create validation sets. Additionally, nomograms were developed based on complex models.

Results

The C-indices of the radiomics model for predicting PFS and OS were 0.712 (95%CI: 0.680-0.744) and 0.758 (0.728-0.789), respectively. In the clinical model, these values were 0.690 (0.664-0.0.717) and 0.738 (0.709-0.767), respectively. However, in the complex model were 0.734 (0.705-0.762) and 0.780 (0.754-0.807), respectively. The Kaplan-Meier curves demonstrated that the radiomics model could effectively separate patients with stage III-IV stage CRC into high- and low-risk groups (p < 0.001). Multivariate Cox regression analysis confirmed the independent prognostic value of Rad-scores.

Conclusion

Pre-treatment ¹⁸F-FDG PET/CT radiomics features can stratify the risk of patients with stage III-IV CRC and accurately predict their outcomes. These findings could be clinically valuable for precision treatment and management decisions in stage III-IV CRC.

Changes of serum metabolites levels during neoadjuvant chemoradiation and prediction of the pathological response in locally advanced rectal cancer

INTRODUCTION

Previous studies have explored prediction value of serum metabolites in neoadjuvant chemoradiation therapy (NCRT) response for rectal cancer. To date, limited literature is available for serum metabolome changes dynamically through NCRT.

OBJECTIVES

This study aimed to explore temporal change pattern of serum metabolites during NCRT, and potential metabolic biomarkers to predict the pathological response to NCRT in locally advanced rectal cancer (LARC) patients.

METHODS

Based on dynamic UHPLC-QTOF-MS untargeted metabolomics design, this study included 106 LARC patients treated with NCRT. Biological samples of the enrolled patients were collected in five consecutive time-points. Untargeted metabolomics was used to profile serum metabolic signatures from LARC patients. Then, we used fuzzy C-means clustering (FCM) to explore temporal change patterns in metabolites cluster and identify monotonously changing metabolites during NCRT. Repeated measure analysis of variance (RM-ANOVA) and multilevel partial least-squares discriminant analysis (ML-PLS-DA) were performed to select metabolic biomarkers. Finally, a panel of dynamic differential metabolites was used to build logistic regression prediction models.

RESULTS

Metabolite profiles showed a clearly tendency of separation between different follow-up panels. We identified two clusters of 155 serum metabolites with monotonously changing patterns during NCRT (74 decreased metabolites and 81 increased metabolites). Using RM-ANOVA and ML-PLS-DA, 8 metabolites (L-Norleucine, Betaine, Hypoxanthine, Acetylcholine, 1-Hexadecanoyl-sn-glycero-3-phosphocholine, Glycerophosphocholine, Alpha-ketoisovaleric acid, N-Acetyl-L-alanine) were further identified as dynamic differential biomarkers for predicting NCRT sensitivity. The area under the ROC curve (AUC) of prediction model combined with the baseline measurement was 0.54 (95%CI = 0.43 ~ 0.65). By incorporating the variability indexes of 8 dynamic differential metabolites, the prediction model showed better discrimination performance than baseline measurement, with AUC = 0.67 (95%CI 0.57 ~ 0.77), 0.64 (0.53 ~ 0.75), 0.60 (0.50 ~ 0.71), and 0.56 (0.45 ~ 0.67) for the variability index of difference, linear slope, ratio, and standard deviation, respectively.

CONCLUSION

This study identified eight metabolites as dynamic differential biomarkers to discriminate NCRT-sensitive and resistant patients. The changes of metabolite level during NCRT show better performance in predicting NCRT sensitivity. These findings highlight the clinical significance of metabolites variabilities in metabolomics analysis.

Pathologic stage of ypT0N+ rectal cancers following neo-adjuvant treatment: clinical interpretation of an orphan status

Approximately 20% of locally advanced rectal cancers treated with neoadjuvant therapy achieve a pathologic complete response, but approximately 10% of them present residual nodal metastases (ypT0N+). We aimed this research to compare the survival rates of ypT0/ypTisN+ and stage 3a rectal cancer patients. A large multicenter study recently investigated ypT0/ypTis rectal cancers treated between 2005 and 2015 in Italy and Spain. ypT0/ypTisN+ were selected and compared with stage 3a rectal cancers treated at the same institutions with upfront surgery (ySICO group). Additionally, the SEER database was searched for patients with stage 3a rectal cancers treated with surgery in the same years. Overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) were analyzed using Kaplan-Meier curves and random survival forest analysis (RSF). The ySICO study population consisted of 19 ypT0/2ypTisN+ (mean follow-up 41.8 months) and 72 Stage 3a patients (mean follow-up 56.9 months). These subgroups were comparable, but stage 3a patients were treated more frequently with adjuvant therapy (90.5% vs 61.9%, p 0.0001). No significant differences were reported between the ySICO subgroups for the OS, DFS, and DSS curves. When the 1213 SEER patients were added to Stage 3a, the RFS model failed to differentiate OS between groups that presented identical survival. Root analysis showed that adjuvant therapy was the only variable differentiating OS and DSS in the ySICO population. These findings suggest that ypT0/ypTisN+ and stage 3a rectal cancers could be ranked together based on their similar outcomes and pathologic assessment, and they stress the importance of adjuvant therapy in patients presenting with residual nodal metastases.

Construction of a new clinical staging system for colorectal cancer based on the lymph node ratio: A validation study

Aim

This study aims to construct a new staging system for colorectal cancer (CRC) based on the lymph node ratio (LNR) as a supplement to the American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) staging system for predicting the prognosis of CRC patients with <12 lymph nodes.

Methods

The data of 26,695 CRC patients with <12 lymph nodes were extracted from the Surveillance, Epidemiology, and End Results (SEER) database as a training set. A total of 635 CRC patients were also enrolled from Northern Jiangsu People's Hospital affiliated with Yangzhou University as an independent validation set. Classification and regression tree analysis was used to obtain the LNR cutoff value. Survival curves were estimated using the Kaplan–Meier method, and the log-rank test was used for comparisons of differences among the survival curves. The monotonic decreasing trend of the overall survival curve in the staging system was expressed by the linear correlation degree R.

Results

The 5-year survival rates of patients in the training set based on the AJCC staging system from stage I to stage IV were 75.6% (95%CI: 74.4–76.8), 59.8% (95%CI: 58.6–61.0), 42.1% (95%CI: 34.5–49.7), 33.2% (95%CI: 24.6–41.8), 72.0% (95%CI: 69.1–74.9), 48.8% (95%CI: 47.4–50.2), 26.5% (95%CI: 23.0–30.0), and 11.3% (95%CI: 10.3–12.3). The 5-year survival rates of patients in the training set from stage I to stage IIIC were 80.4%, 72.9%, 59.8%, 48.4%, 32.5%, and 15.0%, according to the TNM + LNR (TNRM) staging system. According to the AJCC staging system, the 5-year survival rates of patients in the validation set from stage I to stage IIIC were 91.3%, 90.8%, 72.6%, 61.3%, 72.4%, 58.1%, and 32.8%. Based on the TNRM staging system, the 5-year survival rates of patients in the validation set from stage I to stage IIIC were 99.2%, 90.5%, 81.4%, 78.6%, 60.2%, and 35.8%.

Conclusion

The TNRM staging system successfully eliminated “survival paradox” in the AJCC staging system, which might be superior to the AJCC staging system.

Current status of neoadjuvant therapy for locally advanced rectal cancer in Wuhan Union Hospital Cancer Center

BACKGROUND

To analyze and explore the evolution and short-term efficacy of neoadjuvant therapy for patients with mid and low LARC in Wuhan Union Hospital Cancer Center.

METHODS

Patients diagnosed with rectal cancer from January 2015 to December 2021 were collected. The treatment patterns, short-term efficacy and treatment-related adverse events (AEs) of mid and low LARC patients who received neoadjuvant therapy were analyzed. The Chi-square test was used to compare the differences between groups.

RESULTS

A total of 980 patients with mid and low LARC were enrolled, over time, the proportion of patients receiving neoadjuvant therapy gradually increased, and the treatment mode of direct surgery after diagnosis was gradually watered down. More than 80% of the patients implemented radiotherapy-based neoadjuvant therapy, and the proportion of patients receiving SCRT sequential systemic therapy gradually exceeded that of LCRT combined chemotherapy after 2020. Of all patients who completed radiotherapy and underwent surgery, 170 patients received long-course chemoradiotherapy (LCRT) combined with chemotherapy (Group C) and 98 patients received short-course radiotherapy (SCRT) combined with systemic therapy (chemotherapy with or without immunotherapy) (Group D). The pathological complete response (pCR) rate in Group D was significantly higher than that in Group C (38.8% vs. 19.4%, P = 0.001). The pCR rate in the SCRT plus immunotherapy group was better than that in the group without immunotherapy (49.2% vs. 21.6%, P = 0.007). 82.3% of the patients receiving immunotherapy were treated with SCRT sequential 2-cycle CapOX plus Camrelizumab treatment, and the pCR was as high as 52.9%. Immunotherapy did not increase the incidence of Grade 3-4 AEs.

CONCLUSIONS

Neoadjuvant therapy based on radiotherapy is becoming used in patients with mid and low LARC. SCRT sequential systemic therapy is increasingly widely used in LARC patients in our center. Compared with the traditional LCRT or SCRT sequential chemotherapy, SCRT sequential chemotherapy plus immunotherapy has a remarkable pCR rate and manageable toxicity. Looking forward this new treatment mode will bring lasting survival benefits to patients.

Occurrence of peritoneal carcinomatosis in patients with rectal cancer undergoing staging pelvic MRI: clinical observations

OBJECTIVES

Describe the cumulative incidence (CUIN) of peritoneal carcinomatosis (PC) and survival in patients presenting with advanced rectal cancer at staging pelvic MRI.

METHODS

From 2013 to 2018, clinicopathologic records of patients with pretreatment rectal MRI clinical (c)T3c, cT3d, cT4a, and cT4b primary rectal adenocarcinoma were retrospectively reviewed by two radiologists. Standard MRI descriptors and pathologic stages were recorded. Recurrence-free (RFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Development of PC was explored using competing risk analysis. Differences in survival were compared using the log-rank test. Gray's test was used to test for differences in CUIN of PC.

RESULTS

Three hundred forty-three patients (147 women; median age, 56 years) had MRI stages cT3cd, n = 170; cT4a, n = 40; and cT4b, n = 133. Median follow-up among survivors was 27 months (0.36-70 months). For M1 patients, OS differed only by cT stage (2-year OS: cT3 88.1%, cT4a 79.1%, cT4b 64.7%, p = 0.045). For M0 patients, OS and RFS differed only by pathological (p)T stage. We observed a statistically significant difference in the cumulative incidence of PC by cT stage (2-year CUIN: cT3 3.2%, cT4a 8.5%, cT4b 1.6%, p = 0.01), but not by pT stage. Seventy-nine patients (23%) presented with metastatic disease (M1), eight with PC (2.3%). Overall, eight patients presented with PC (cT4a: n = 4, other stages: n = 4) and 22 developed PC (cT4a: n = 5, other stages: n = 17).

CONCLUSIONS

PC is uncommon in rectal cancer. MRI-based T stage exhibited an overall association with the cumulative incidence of PC, and descriptively, cT4a stage appears to have the highest CUIN.

KEY POINTS

• In a retrospective study of 343 patients with rectal cancer undergoing baseline MRI and clinical follow-up, we found that peritoneal carcinomatosis was rare. • We observed a significant overall association between PC at presentation and cT stage that appeared to be driven by the higher proportion of cT4a patients presenting with PC. • Among patients that did not present with PC, we observed a significant overall association between time to PC and cT stage that may be driven by the higher cumulative incidence of PC in cT4a patients.

Radiomic analysis for predicting prognosis of colorectal cancer from preoperative 18F-FDG PET/CT

Background

To develop and validate a survival model with clinico-biological features and ¹⁸F- FDG PET/CT radiomic features via machine learning, and for predicting the prognosis from the primary tumor of colorectal cancer.

Methods

A total of 196 pathologically confirmed patients with colorectal cancer (stage I to stage IV) were included. Preoperative clinical factors, serum tumor markers, and PET/CT radiomic features were included for the recurrence-free survival analysis. For the modeling and validation, patients were randomly divided into the training (n = 137) and validation (n = 59) set, while the 78 stage III patients [training (n = 55), and validation (n = 23)] was divided for the further experiment. After selecting features by the log-rank test and variable-hunting methods, random survival forest (RSF) models were built on the training set to analyze the prognostic value of selected features. The performance of models was measured by C-index and was tested on the validation set with bootstrapping. Feature importance and the Pearson correlation were also analyzed.

Results

Radiomics signature (containing four PET/CT features and four clinical factors) achieved the best result for prognostic prediction of 196 patients (C-index 0.780, 95% CI 0.634–0.877). Moreover, four features (including two clinical features and two radiomics features) were selected for prognostic prediction of the 78 stage III patients (C-index was 0.820, 95% CI 0.676–0.900). K–M curves of both models significantly stratified low-risk and high-risk groups (P < 0.0001). Pearson correlation analysis demonstrated that selected radiomics features were correlated with tumor metabolic factors, such as SUVmean, SUVmax.

Conclusion

This study presents integrated clinico-biological-radiological models that can accurately predict the prognosis in colorectal cancer using the preoperative ¹⁸F-FDG PET/CT radiomics in colorectal cancer. It is of potential value in assisting the management and decision making for precision treatment in colorectal cancer.

Trial registration The retrospectively registered study was approved by the Ethics Committee of Fudan University Shanghai Cancer Center (No. 1909207-14-1910) and the data were analyzed anonymously.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03262-5.

Comparison of Long-Term Survival Outcomes of T4a and T4b Colorectal Cancer

Background

Although T4b is known to have worse oncologic outcomes, it is unclear whether it truly shows a worse prognosis. This study aims to compare the survival differences between T4a and T4b.

Methods

Patients who were pathologically diagnosed with T3 and T4 colorectal adenocarcinoma from 2010 to 2014 were included (T3, n = 1822; T4a, n = 424; T4b, n = 67). Overall survival (OS) and cancer-specific survival (CSS) were compared between T4a and T4b using the Kaplan-Meier method and log-rank test.

Results

In stage II, T4a had better OS and CSS than T4b (5-year OS, 89.5% vs. 72.6%; 5-year CSS, 94.4% vs. 81.7%, all p < 0.05), however, in stage III, there were no significant differences in survivals between groups (all p > 0.05). In multivariable analysis, T classification was not an independent risk factor for OS (p > 0.05). However, for CSS, when respectively compared to T3, T4b (HR 3.53, p < 0.001) showed a relatively higher hazard ratio than T4a (HR 2.27, p < 0.001).

Conclusions

T4a showed more favorable OS and CSS than T4b, especially in stage II. Our findings support the current AJCC guidelines, in which T4b is presented as a more advanced stage than T4a.

A Postsurgical Prognostic Nomogram for Locally Advanced Rectosigmoid Cancer to Assist in Patient Selection for Adjuvant Chemotherapy

Background

The perioperative treatment model for locally advanced rectosigmoid junction cancer (LARSC) has not been finalized; whether this model should refer to the treatment model for rectal cancer remains controversial.

Methods

We screened 10,188 patients with stage II/III rectosigmoid junction adenocarcinoma who underwent surgery between 2004 and 2016 from the National Cancer Institute Surveillance, Epidemiology, and End Results database. Among them, 4,960 did not receive adjuvant chemotherapy, while 5,228 did receive adjuvant chemotherapy. Propensity score matching was used to balance the two groups for confounding factors, and the Kaplan-Meier method and log-rank test were used for survival analysis. Cox proportional hazards regression analysis was used to identify independent prognostic factors and build a predictive nomogram of survival for LARSC. X-tile software was used to divide the patients into three groups (low, medium, and high) according to their risk scores. 726 patients in our hospital were included for external validation.

Results

LARSC patients did not show a benefit from neoadjuvant radiotherapy (P>0.05). After further excluding patients who received neoadjuvant radiotherapy, multivariate analysis found that age, grade, tumor size, T stage, and log odds of positive lymph nodes were independent prognostic factors for patients without adjuvant chemotherapy and were included in the nomogram. The C-index of the model was 0.690 (95% confidence interval: 0.668–0.712). We divided the patients into low, moderate, and high risk subgroups based on prediction scores of the nomogram. We found that adjuvant chemotherapy did not improve the prognosis of low risk patients, while moderate and high risk patients benefited from adjuvant therapy. External validation data found that moderate, and high risk patients also benefited from AT.

Conclusion

Direct surgery plus adjuvant chemotherapy may be the best perioperative treatment for LARSC. Moreover, adjuvant chemotherapy is only recommended for moderate and high risk patients as it did not benefit low risk patients.

Scatter patterns in lymph node metastases as a novel prognostic indicator in patients with stage III/N2 colorectal cancer

To classify patients with stage III/N2 colorectal cancer into high- and low-risk groups for recurrence, the present study compared clinicopathological features by immunohistochemical staining. The single-center analysis included 53/668 patients (7.9%) with stage III/N2 colorectal cancer who underwent radical resection between January 2006 and December 2014. The present study examined cancer cell distribution in metastatic lymph nodes and classified patients into a group with circumferential localization patterns like a cystic mass (CLP) and a group with scatter patterns like fireworks (SPF). Subsequently, 5-year relapse-free survival (5Y-RFS) and 5-year overall survival (5Y-OS) rates were compared and the histological type (differentiation degree) of the primary adenocarcinoma was included. The CLP group included 16 patients (30.2%) and the SPF group included 37 patients (69.8%). The 5Y-RFS rates in these groups were 75.0 vs. 37.8%, respectively (P=0.021), and the 5Y-OS rates were 81.3 vs. 48.6% (P=0.033). Patient clinicopathological characteristics exhibited no significant differences between groups. The adenocarcinoma was well differentiated in 14 patients (Well; 26.4%) and moderately (Mod; n=37) or poorly (Por; n=2) differentiated in 39 patients (Mod+Por; 73.6%). Patients were further classified into four groups: Well/CLP (n=6), Well/SPF (n=8), Mod+Por/CLP (n=10) and Mod+Por/SPF (n=29). For Well/CLP vs. Well/SPF, the 5Y-RFS rates were 66.7 vs. 25.0%, respectively (P=0.293), and for Mod+Por/CLP vs. Mod+Por/SPF (80.0 vs. 41.4%; P=0.052), the respective values for 5Y-OS were 66.7 vs. 50.0% (P=0.552) and 90.0 vs. 48.3% (P=0.059). Based on the aforementioned results, the CLP group was considered a low-risk group for recurrence with a relatively good prognosis; however, the SPF group was considered a high-risk group for recurrence with a poor prognosis, suggesting a need for more potent multi-combination chemotherapy in these patients from the early postoperative period.

Systemic Inflammation Status Relates to Anti-Inflammatory Drug Benefit and Survival in Rectal Cancer

BACKGROUND

Systemic inflammation status has been recognized as a sensitive marker associated with survival in cancers and anti-inflammatory treatment outcomes in inflammation-derived diseases. This study aimed to investigate the role of systemic inflammation status as a predictive marker for survival and anti-inflammatory treatment benefit in rectal cancer patients.

METHODS

A total of 475 patients with stage I-III rectal cancer receiving curative resection were prospectively enrolled. The platelet-neutrophils to lymphocytes ratio (PNLR) that integrates neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios was applied to enable a comprehensive evaluation of systemic inflammation status and investigate its association with survival and nonsteroidal anti-inflammatory drugs (NSAIDs) benefit. Patients were grouped according to baseline PNLR and perioperative use of NSAIDs.

RESULTS

The high-PNLR group had worse 5-y disease-free survival (DFS) compared with the low-PNLR group (61.2% versus 70.9%, P = 0.014). Multivariate analyses confirmed that PNLR was an independent predictor for DFS (hazard ratio [HR] 1.42, 95% CI: 1.03-1.97, P = 0.031). A nomogram including PNLR and other independent prognostic factors was developed and validated to predict DFS. In the high-PNLR subset, NSAIDs group had a 21.3% lower risk of recurrence than non-NSAIDs group (P = 0.009), and multivariate analysis confirmed the independently significant association of perioperative NSAIDs use with better DFS (hazard ratio 0.36, 95% CI 0.16-0.78, P = 0.010). However, this association was not significant in the low-PLR subset.

CONCLUSIONS

Baseline PNLR could be used to predict DFS and NSAIDs benefit in rectal cancer patients. This study highlights the potential survival benefit from the anti-inflammatory treatment in the patients with elevated systemic inflammation status in cancer patients.

The Stage Migration Should be Reconsidered in Stage IIIA Rectal Cancer: Based on Propensity Score Analysis

BACKGROUND

Few studies have compared the survival outcomes of stages II and IIIA rectal cancer patients who did not receive neoadjuvant treatment. This study aimed to compare oncologic outcomes between 2 groups.

PATIENTS AND METHODS

This study analyzed stage II or IIIA rectal cancer patients who underwent radical operation without neoadjuvant treatment between 1996 and 2013. The 3:1 propensity score analysis was used to adjust for several variables. After propensity score matching, 364 stage II rectal cancer, and 172 stage IIIA rectal cancer patients were analyzed.

RESULTS

There were no significant differences in 5-year overall survival or disease-free survival rates between the 2 groups. When stage II rectal cancer was subdivided into stages IIA, IIB, and IIC, the 5-year DFS and OS rates of stage IIIA rectal cancer patients were similar to those of stage IIA cancer patients. Moreover, stage IIIA rectal cancer patients showed a statistically significantly better survival rates than stage IIC rectal cancer patients.

CONCLUSION

Stage IIIA group showed similar survival outcomes compared to stage IIA and IIB group and significantly better outcomes than stage IIC group. Thus, it should be considered to classify stage IIIA as a subgroup of stage II rather than as a subgroup of stage III rectal cancer. It should be also be considered to change to determine whether to do adjuvant treatment according to stage II rectal cancer.

Prognostic Factors Affecting Disease-Free Survival and Overall Survival in T4 Colon Cancer

PURPOSE

It is known that as the T stage of a carcinoma progresses, the prognosis becomes poorer. However, there are few studies about factors that affect the prognosis of T4 advanced colon cancer. This study aimed to identify the prognostic factors associated with disease-free survival (DFS) and overall survival (OS) in T4 colon cancer.

METHODS

Patients diagnosed with stage T4 on histopathology after undergoing curative surgery for colon cancer between March 2009 and March 2018 were retrospectively analyzed for factors related to postoperative survival. Primary outcomes were DFS and OS.

RESULTS

Eighty-two patients were included in the study. DFS and OS of the pathologic (p) T4b group were not inferior to that of the pT4a group. Multivariate analysis showed that differentiation (hazard ratio [HR], 4.994; P = 0.005), and laparoscopic surgery (HR, 0.323; P = 0.008) were significant prognostic factors for DFS, while differentiation (HR, 7.904; P ≤ 0.001) and chemotherapy (HR, 0.344; P = 0.038) were significant prognostic factors for OS.

CONCLUSION

Tumor differentiation, laparoscopic surgery, and adjuvant chemotherapy were found to be significant prognostic factors in patients with T4 colon cancer. Adjuvant chemotherapy and curative resections by laparoscopy might improve the prognosis in these patients.

LAG-3 Expression Predicts Outcome in Stage II Colon Cancer

INTRODUCTION

LAG-3 is an inhibitory immune checkpoint molecule that suppresses T cell activation and inflammatory cytokine secretion. T cell density in the tumor microenvironment of colon cancer plays an important role in the host's immunosurveillance. We therefore hypothesized that LAG-3 expression on tumor-infiltrating lymphocytes (TILs) predicts outcome in patients with stage II colon cancer.

PATIENTS AND METHODS

Immunohistochemical staining for LAG-3 was performed on tissue microarrays (TMAs) of formalin-fixed paraffin-embedded tissue from 142 stage II colon cancer patients. LAG-3 expression was assessed in TILs within both the tumor front and tumor center and scored as either positive or negative. The primary endpoint was disease-free survival (DFS).

RESULTS

In patients diagnosed with stage II colon cancer, the presence of LAG-3 expression on TILs was significantly associated with better 5-year DFS (HR 0.34, 95% CI 0.14-0.80, p = 0.009). The effect on DFS was mainly due to LAG-3-positive TILs in the tumor front (HR 0.33, 95% CI 0.13-0.82, p = 0.012).

CONCLUSION

Assessment of LAG-3 might help to predict outcomes in patients with stage II colon cancer and potentially identify those patients who might benefit from adjuvant chemotherapy. Therefore, LAG-3 may serve as a prognostic biomarker in stage II colon cancer.

Heterogeneity of Colorectal Cancer Progression: Molecular Gas and Brakes

The review begins with molecular genetics, which hit the field unveiling the involvement of oncogenes and tumor suppressor genes in the pathogenesis of colorectal cancer (CRC) and uncovering genetic predispositions. Then the notion of molecular phenotypes with different clinical behaviors was introduced and translated in the clinical arena, paving the way to next-generation sequencing that captured previously unrecognized heterogeneity. Among other molecular regulators of CRC progression, the extent of host immune response within the tumor micro-environment has a critical position. Translational sciences deeply investigated the field, accelerating the pace toward clinical transition, due to its strong association with outcomes. While the perturbation of gut homeostasis occurring in inflammatory bowel diseases can fuel carcinogenesis, micronutrients like vitamin D and calcium can act as brakes, and we discuss underlying molecular mechanisms. Among the components of gut microbiota, Fusobacterium nucleatum is over-represented in CRC, and may worsen patient outcome. However, any translational knowledge tracing the multifaceted evolution of CRC should be interpreted according to the prognostic and predictive frame of the TNM-staging system in a perspective of clinical actionability. Eventually, we examine challenges and promises of pharmacological interventions aimed to restrain disease progression at different disease stages.

Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level

BACKGROUND

A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response.

OBJECTIVE

Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level.

DESIGN

This is a population-based study.

SETTINGS

Data were retrieved from the Dutch Colorectal Audit.

PATIENTS

A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected.

MAIN OUTCOME MEASURES

Main outcomes were resection margins, postoperative complications, and mortality.

RESULTS

Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001).

LIMITATIONS

Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available.

CONCLUSIONS

This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457.

ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL

ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.

Identifying Stage II Colorectal Cancer Recurrence Associated Genes by Microarray Meta-Analysis and Building Predictive Models with Machine Learning Algorithms

BACKGROUND

Stage II colorectal cancer patients had heterogeneous prognosis, and patients with recurrent events had poor survival. In this study, we aimed to identify stage II colorectal cancer recurrence associated genes by microarray meta-analysis and build predictive models to stratify patients' recurrence-free survival.

METHODS

We searched the GEO database to retrieve eligible microarray datasets. The microarray meta-analysis was used to identify universal recurrence associated genes. Total samples were randomly divided into the training set and the test set. Two survival models (lasso Cox model and random survival forest model) were trained in the training set, and AUC values of the time-dependent receiver operating characteristic (ROC) curves were calculated. Survival analysis was performed to determine whether there was significant difference between the predicted high and low risk groups in the test set.

RESULTS

Six datasets containing 651 stage II colorectal cancer patients were included in this study. The microarray meta-analysis identified 479 recurrence associated genes. KEGG and GO enrichment analysis showed that G protein-coupled glutamate receptor binding and Hedgehog signaling were significantly enriched. AUC values of the lasso Cox model and the random survival forest model were 0.815 and 0.993 at 60 months, respectively. In addition, the random survival forest model demonstrated that the effects of gene expression on the recurrence-free survival probability were nonlinear. According to the risk scores computed by the random survival forest model, the high risk group had significantly higher recurrence risk than the low risk group (HR = 1.824, 95% CI: 1.079-3.084, p = 0.025).

CONCLUSIONS

We identified 479 stage II colorectal cancer recurrence associated genes by microarray meta-analysis. The random survival forest model which was based on the recurrence associated gene signature could strongly predict the recurrence risk of stage II colorectal cancer patients.

Accurate nomograms with excellent clinical value for locally advanced rectal cancer

Background

Rectal cancer accounts for approximately 30–50% of colorectal cancer. Despite its widespread use and convenience, the American Joint Committee on Cancer (AJCC) staging system for predicting survival is prone to inaccuracy, even including a survival paradox for locally advanced rectal cancer (LARC). An accurate risk stratification of LARC is essential for proper treatment selection and prognostic evaluation. Therefore, we aimed to create prognostic nomograms for LARC capable of assessing overall survival (OS) and cancer-specific survival (CSS) precisely and intuitively.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was accessed. All of the significant variables in the multivariate analysis were integrated to build the nomograms.

Results

Data for a total of 23,055 patients with LARC were collected from the SEER database in this study. Based on the multivariate Cox regression analysis, both OS and CSS were significantly associated with 13 variables: age, marital status, race, pathological grade, histological type, T stage, N stage, surgery, radiotherapy, chemotherapy, regional nodes examined (RNE), tumor size, and carcinoembryonic antigen (CEA). These were included in the construction of nomograms for OS and CSS. Time-dependent receiver operating characteristic (ROC) curves, decision curve analysis (DCA), concordance index, and calibration curves demonstrated the discriminative superiority of the nomograms.

Conclusions

The nomograms, which effectively solve the issue of the survival paradox in the AJCC staging system regarding LARC, may act as excellent tools for integrating clinical characteristics and to guiding therapeutic choices for LARC patients.

A retrospective study on the impact of the number of resected lymph nodes on the survival outcome of stage IV rectal cancer patients after preoperative therapy

Background

There is no consensus on the optimal number of examined LNs for stage IV rectal cancer patients after preoperative therapy. We aimed to explore the impact of the number of resected lymph nodes (LNs) on the survival outcomes of stage IV rectal cancer patients after preoperative therapy.

Methods

Clinicopathologic data of 556 patients diagnosed with stage IV rectal cancer between 1st January, 2010 and 31st December, 2015 from the Surveillance, Epidemiology, and End Results (SEER) database after preoperative therapy were reviewed. The patients were further divided into two groups: the ≥15 resected LNs group and <15 resected LNs group based on the X-tile software analysis results of the number of resected LNs.

Results

Both univariate and multivariate regression analyses revealed that the number of resected LNs and N status were significantly positively correlated with the survival outcome of the patients. Patients in the ≥15 resected LNs group had a significant better cancer-specific survival (CSS) (P=0.003) than those in the <15 resected LNs group. The 3-year CSS rate was 63.2% for patients with ≥15 resected LNs compared with 55.7% for those with <15 resected LNs. The 5-year CSS rate was 50.2% and 30.5% for patients in the ≥15 resected LNs group and those in the <15 resected LNs group, respectively.

Conclusions

The number of resected LNs is an important independent prognostic factor that influences the survival outcome of stage IV rectal cancer patients after receiving preoperative therapy.

Association of Bevacizumab Plus Oxaliplatin-Based Chemotherapy With Disease-Free Survival and Overall Survival in Patients With Stage II Colon Cancer: A Secondary Analysis of the AVANT Trial

IMPORTANCE

In the pivotal Bevacizumab-Avastin Adjuvant (AVANT) trial, patients with high-risk stage II colon cancer (CC) had 5-year and 10-year overall survival (OS) rates of 88% and 75%, respectively, with adjuvant fluorouracil and oxaliplatin-based chemotherapy; however, the trial did not demonstrate a disease-free survival (DFS) benefit of adding bevacizumab to oxaliplatin-based chemotherapy in stage III CC and suggested a detrimental effect on OS. The Long-term Survival AVANT (S-AVANT) study was designed to collect extended follow-up for patients in the AVANT trial.

OBJECTIVE

To explore the efficacy of adjuvant bevacizumab combined with oxaliplatin-based chemotherapy in patients with high-risk, stage II CC.

DESIGN, SETTING, AND PARTICIPANTS

This prespecified secondary end point analysis of the AVANT and S-AVANT studies included 573 patients with curatively resected high-risk stage II CC and at least 1 of the following criteria: stage T4, bowel obstruction or perforation, blood and/or lymphatic vascular invasion and/or perineural invasion, age younger than 50 years, or fewer than 12 nodes analyzed. The AVANT study was a multicenter randomized stage 3 clinical trial. Data were collected from December 2004 to February 2019, and data for this study were analyzed from March to September 2019.

INTERVENTION

Patients were randomly assigned to receive 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX4), FOLFOX4 with bevacizumab, or capecitabine and oxaliplatin (XELOX) with bevacizumab.

MAIN OUTCOMES AND MEASURES

The primary end points of this secondary analysis were DFS and OS in patients with high-risk stage II CC.

RESULTS

The AVANT study included 3451 patients, of whom 573 (16.6%) had high-risk stage II CC (192 [33.5%] randomized to FOLFOX4 group; 194 [33.9%] randomized to FOLFOX4 with bevacizumab group; 187 [32.6%] randomized to XELOX with bevacizumab group). With a median (interquartile range) age of 57.0 (47.2-65.7) years, the study population comprised 325 men (56.7%) and 248 women (43.3%). After a median (interquartile range) follow-up of 6.9 (6.1-11.3) years, the 3-year DFS and 5-year OS rates were 88.2% (95% CI, 83.7%-93.0%) and 89.7% (95% CI, 85.4%-94.2%) in the FOLFOX4 group, 86.6% (95% CI, 81.8%-91.6%) and 89.7% (95% CI, 85.4%-94.2%) in the FOLFOX4 with bevacizumab group, and 86.7% (95% CI, 81.8%-91.8%) and 93.2% (95% CI, 89.6%-97.0%) in the XELOX with bevacizumab group, respectively. The DFS hazard ratio was 0.94 (95% CI, 0.59-1.48; P = .78) for FOLFOX4 with bevacizumab vs FOLFOX4 and 1.07 (95% CI, 0.69-1.67; P = .76) for XELOX with bevacizumab vs FOLFOX4. The OS hazard ratio was 0.92 (95% CI, 0.55-1.55; P = .76) for FOLFOX4 with bevacizumab vs FOLFOX4 and 0.85 (95% CI, 0.50-1.44; P = .55) for XELOX with bevacizumab vs FOLFOX4.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of data from the AVANT trial, adding bevacizumab to oxaliplatin-based chemotherapy was not associated with longer DFS or OS in patients with high-risk stage II CC. The findings suggest that the definition of high-risk stage II CC needs to be revisited.

TRIAL REGISTRATION

ClinicalTrial.gov Identifiers: AVANT (NCT00112918); S-AVANT (NCT02228668).

MYL6B drives the capabilities of proliferation, invasion, and migration in rectal adenocarcinoma through the EMT process

Objective

This study was designed to explore the biological significance of myosin light chain 6B (MYL6B) in rectal adenocarcinoma.

Methods

Profiles on the Oncomine dataset, GEPIA website, and UALCAN-TCGA database were searched to assess the MYL6B expression level in rectal adenocarcinoma tissues and normal tissues. After MYL6B knockdown using siRNA strategy, cell counting kit-8 (CCK-8) and transwell assays were conducted to measure cell proliferation, migration and invasion, respectively. Flow cytometry analysis was conducted to assess cell apoptosis. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and western blot were performed to detect the expression level of mRNAs and proteins.

Results

The data showed that overexpression of MYL6B was observed in rectal adenocarcinoma tissues and correlated with a poor prognosis of patients. Functional in vitro experiments revealed that MYL6B knockdown could inhibit proliferation, migration, and invasion of rectal adenocarcinoma cells, while promote cell apoptosis. Moreover, western blot analysis suggested that increased expression of E-cadherin and decreased expression of N-cadherin and Vimentin were induced by si-MYL6B.

Conclusion

In summary, this study elaborated on the promoting effect of MYL6B in rectal adenocarcinoma progression, thus providing novel insight for strategies of clinical diagnosis and drug application in the future clinical study.

Clinical efficacy of adjuvant chemotherapy in the treatment of pT4 stage II colorectal cancer with defective mismatch repair status: A protocol for systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis is to assess the efficacy of adjuvant chemotherapy in patients with stage IIB/C CRC and defective mismatch repair (dMMr) status, and to evaluate what is the determinant risk factor for adjuvant chemotherapy in those patients.

METHOD

A systematic search of PubMed, EMBASE, Web of science, Cochrane Library databases will be performed. All RCTs published in electronic databases from inception to March 19, 2020, with language restricted in English will be included in this review study. Two reviewers will independently perform the Study selection, data extraction, quality assessment, and assessment of risk bias and will be supervised by third party. Outcomes consisted of overall survival, progression-free survival and sufficient information to extract hazard ratios and their 95% confidence intervals and it will be calculated to present the prognostic role of adjuvant chemotherapy in patients with stage IIB/C CRC and dMMR status using Review Manager version 5.3 when there is sufficient available data.

RESULTS

The results of this systematic review and meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will summarize up-to-date evidence to assess the efficacy of adjuvant chemotherapy in patients with stage IIB/C CRC and dMMR status and provide a scientific and practical suggestions for treatment decision-making.

REGISTRATION

This protocol has been registered on the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) with a registration number of INPLASY202050019.

Verification of the Japanese staging system for rectal cancer, focusing on differences with the TNM classification

PURPOSE

The 9th Japanese Classification of Colorectal Cancer (9th JSCCR) has two main differences from the TNM classification (8th AJCC): first, main or lateral lymph node metastasis is classified as jN3; second, tumor nodules (ND) are treated as lymph node metastasis. In this study, we verified the 9th JSCCR for rectal cancer, focusing on the differences with the 8th AJCC.

METHODS

This retrospective analysis involved 212 patients with stage I-III rectal cancer. ND was evaluated using whole-mount sections. We evaluated the relapse-free survival of each staging system, and compared the prognostic significance of the different staging systems using the Akaike information criterion (AIC) and Harrell's concordance index (c-index).

RESULTS

Main or lateral lymph node metastasis was detected in nine of 212 (4%) patients. ND was detected in 79 of 212 (37%) patients. The best risk stratification power was observed in the 9th JSCCR (AIC, 759; c-index, 0.708) compared with the 7th JSCCR (AIC, 771; c-index, 0.681), 8th JSCCR (AIC, 768; c-index, 0.696), and the 8th AJCC (AIC, 766; c-index, 0.691).

CONCLUSIONS

The 9th JSCCR, which includes the concepts of jN3 and ND, is useful for the risk stratification of rectal cancer, and the contributes to precise decision-making for follow-up management and adjuvant therapy.

A lower cut-off for lymph node harvest predicts for poorer overall survival after rectal surgery post neoadjuvant chemoradiotherapy

Background

A lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. However, neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; hence, a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients.

Methods

A retrospective review of patients who underwent elective surgery for rectal cancer from 2006 to 2013 was performed. All patients with R1/2 resections and presence of metastases and those operated on for recurrence were excluded. Patient demographics, clinical features, operative details, LNH, 30-day mortality and disease-free and overall survival were recorded. P values of < 0.05 were considered significant.

Results

A total of 257 patients were studied, with 174 (68%) males and a median age of 66 years. Ninety-four (37%) patients received long-course NACRT, and 122 (48%) patients were stage 2 and below. Median LNH was 17, which was reduced in the NACRT group (14 versus 23, P < 0.01). Average length of stay was 9 ± 8 days, with a major post-operative complication rate of 4%. Using hazard ratio plots for the NACRT subgroup, LNH cut-offs of 16.5 and 8.5 were obtained for disease-free survival (DFS) and overall survival (OS) respectively. Survival analysis showed that a LNH cut-off of 8.5 was a significant predictor of OS (P < 0.001).

Conclusion

LNH is reduced in patients receiving NACRT before rectal cancer surgery. A LNH of 9 and above is associated with improved overall survival. We propose that this can be used as a tool for prognosis.

Gene Copy Number and Post-Transductional Mechanisms Regulate TRAP1 Expression in Human Colorectal Carcinomas

Tumor Necrosis Factor Receptor-Associated Protein 1 (TRAP1) is a heat shock protein 90 (HSP90) molecular chaperone overexpressed in 60-70% human colorectal carcinomas (CRCs) and the co-upregulation of TRAP1 and associated 6-related proteins identifies metastatic CRCs with poor prognosis. Since the molecular mechanisms responsible for TRAP1 regulation are still unknown, the significance of TRAP1 gene copy number (CN) and the role of post-transductional protein modifications were addressed. TRAP1 gene aneuploidy accounted for 34.5% of cases in a cohort of 58 human CRCs and TRAP1 CN correlated with its mRNA and protein expression, suggesting that transcriptional mechanisms are responsible for TRAP1 upregulation. Furthermore, the analysis of the National Cancer Institute's Clinical Proteomic Tumor Analysis Consortium/The Cancer Genome Atlas (CPTAC/TCGA) CRC database showed that TRAP1 polysomy significantly correlates with lymph node involvement. However, a subgroup of tumors showed TRAP1 protein levels independent from its CN. Of note, a direct correlation was observed between TRAP1 protein levels and the expression of S-nitrosoglutathione reductase (GSNOR), a denitrosylase involved in the regulation of protein S-nitrosylation. Furthermore, CRC cell lines exposed to hypoxia or dichloroacetate treatment showed the downregulation of TRAP1 upon GSNOR silencing and this resulted in increased TRAP1 mono/polyubiquitination. These data suggest that transcriptional and post-transductional mechanisms account for TRAP1 expression in human CRCs and GSNOR protects TRAP1 from S-nitrosylation and consequent proteasome degradation mostly in conditions of stress.

ACRNaCT trial protocol: efficacy of adjuvant chemotherapy in patients with clinical T3b/T4, N+ rectal Cancer undergoing Neoadjuvant Chemoradiotherapy: a pathology-oriented, prospective, multicenter, randomized, open-label, parallel group clinical trial

BACKGROUND

The CAO/ARO/AIO-94 demonstrated that neoadjuvant chemoradiotherapy (CRT) could decrease the rate of local recurrence rather than distal metastases in advanced rectal cancer. Adjuvant chemotherapy (ACT) can eliminate micrometastasis, and render a better prognosis to rectal cancer. However, adoption of ACT mainly depends on the evidence from colon cancer. Neoadjuvant CRT can lead to tumor shrinkage in a number of patients with advanced rectal cancer. The administration of adjuvant therapy depending on pretreatment clinical stage or postoperative yield pathological (yp) stage remains controversial. At present, the clinical guidelines recommend ACT for patients with stage II/III (ypT3-4 N0 or ypTanyN1-2) rectal cancer following neoadjuvant CRT and surgery. However, the yp stage may influence the guidance of ACT.

METHODS

According to the postoperative pathological stage, the present study was divided into two parts with different study design procedures. Patients will undergo different therapeutic strategies after collecting data related to postoperative pathological stage. For patients with pathologic complete response or yp stage I, the study was designed as a non-inferiority trial to compare the patients' long-term outcomes in observational group and those in treatment group with 5-fluorouracil. For patients at yp stage II or III, the study was designed as a superiority trial to compare the oncological effect of oxaliplatin combined with 5-fluorouracil, in addition to 5-fluorouracil alone in ACT. The primary endpoint is 3-year disease-free survival (DFS). Secondary endpoints are 3-year, 5-year overall survival, 5-year DFS, and the rate of local recurrence and adverse events resulted from chemotherapy and the patients' quality of life postoperatively.

DISCUSSION

The ACRNaCT trial aims to investigate whether observation is not inferior than 5-fluorouracil for pathologic complete response or yp stage I, and indicate whether combined chemotherapy contains superior outcomes than 5-fluorouracil alone for yp stage II or III in patients receiving neoadjuvant CRT and surgery for locally advanced rectal cancer (LARC). This trial is expected to provide individualized adjuvant treatment strategies for LARC patients following neoadjuvant CRT and surgery.

TRIAL REGISTRATION

The trial has been registered in ClinicalTrials.gov on January 30, 2018 (Registration No. NCT03415763), and also, that was registered in Chinese Clinical Trial Registry on November 12, 2018 (Registration No. ChiCTR1800019445).

Fat clearance and conventional fixation identified ypN0 rectal cancers following intermediate neoadjuvant radiotherapy have similar long-term outcomes

BACKGROUND

As a prognostic factor for colorectal cancer, lymph node (LN) status, particularly the number of LN harvested, has been demonstrated to be essential in the evaluation of quality control in terms of surgical specimen. Neoadjuvant chemoradiation, however, decreases the LN harvest. Therefore, certain approaches (such as fat clearance or methylene blue) has drawn significant attention in order to raise LN yield.

AIM

To compare the long-term oncologic outcome of ypN0 rectal cancer identified using fat clearance (FC) or conventional fixation (CF) following 30 Gy in 10 fractions (30 Gy/10f) of neoadjuvant radiotherapy (nRT).

METHODS

Three hundred and eighty-two patients with resectable and locally advanced rectal cancer were treated by 30 Gy/10f intermediate nRT (biologically equivalent dose of 36 Gy) plus total mesorectal excision. Two specimen fixation methods (FC or CF) were non-randomly used. The ypN0 status was identified in 124 and 101 patients in the FL and CF groups, respectively. Primary endpoints were local recurrence-free survival (LRFS) and cancer-specific survival (CSS).

RESULTS

The median follow-up of patients was 5.1 years. The median numbers of retrieved LNs in the FC and CF groups were 19.5 (range, 4-47) and 12 (range, 0-44), respectively, with a significant difference (P = 0.000). The percentages of patients with 12 or more retrieved nodes were 82.3% and 50.5% (101/159) in the FC and CF groups, respectively, with a significant difference (P = 0.000). The LRFS at 5 years were 95.7% and 94.6% in the FC and CF groups, respectively, without statistical difference (P = 0.819). The CSS at 5 years were 92.0% and 87.2% in the FC and CF groups, respectively, without statistical difference (P = 0.482).

CONCLUSION

For patients with ypN0 rectal cancer who underwent 30 Gy/10f preoperative radiotherapy, the increased retrieval of LNs using fat clearance is not associated with survival benefit. This time-consuming fixation method has a low efficacy as a routine practice.

Esthesioneuroblastoma: A Patterns-of-Care and Outcomes Analysis of the National Cancer Database

BACKGROUND

The available literature to guide treatment decision making in esthesioneuroblastoma (ENB) is limited.

OBJECTIVE

To define treatment patterns and outcomes in ENB according to treatment modality using a large national cancer registry.

METHODS

This study is a retrospective cohort analysis of 931 patients with a diagnosis of ENB who were treated with surgery, radiation therapy, and/or chemotherapy in the United States between the years of 2004 and 2012. Log-rank statistics were used to compare overall survival by primary treatment modality. Logistic regression modeling was used to identify predictors of receipt of postoperative radiotherapy (PORT). Cox proportional hazards modeling was used to determine the survival benefit of PORT. Subgroup analyses identified subgroups that derived the greatest benefit of PORT.

RESULTS

Primary surgery was the most common treatment modality (90%) and resulted in superior survival compared to radiation (P < .01) or chemotherapy (P < .01). On multivariate analysis, PORT was associated with decreased risk of death (hazard ratio [HR] 0.53, P < .01). PORT showed a survival benefit in Kadish stage C (HR 0.42, P < .01) and D (HR 0.09, P = .01), but not Kadish A (HR 1.17, P = .74) and B (HR 1.37, P = .80). Patients who received chemotherapy derived greater benefit from PORT (HR 0.22, P < .01) compared with those who did not (HR 0.68, P = .13). Predictors of PORT included stage, grade, extent of resection, and chemotherapy use.

CONCLUSION

Best outcomes were obtained in patients undergoing primary surgery. The benefit of PORT was driven by patients with stages C and D disease, and by those also receiving chemotherapy.

Assessment of peritoneal elastic laminal invasion improves survival stratification of pT3 and pT4a colorectal cancer: a meta-analysis

Evaluating peritoneal elastic laminal invasion (ELI) has been proposed as an additional assessment for pT3 colorectal cancers (CRC). Its clinical significance has not yet been established. We performed a meta-analysis to investigate the prognostic impact of ELI assessment for subcategorisation of pT3 CRC. We performed a search in three electronic databases. HR and its 95% CI for overall survival (OS) and disease-free survival (DFS) were calculated using the random effects model weighted by the inverse variance method. We identified six studies that met inclusion criteria out of an original 703 studies found with our database search terms. Our meta-analysis included 1925 patients with pT3 and pT4a CRCs. The presence of ELI in pT3 CRC was associated with shortened OS compared with ELI negative pT3 CRC (HR=1.76; 95% CI 1.21 to 2.55); whereas the DFS was not statistically significant (HR=1.79; 95% CI 0.91 to 3.52). Furthermore, pT4a patients’ OS (HR=1.84; 95% CI 1.41 to 2.40) and DFS (HR=1.88; 95% CI 1.17 to 3.04) were even worse than the OS and DFS of pT3 ELI (+) patients. ELI is a useful marker for stratifying patients with pT3 or pT4a CRCs into three prognostically distinct groups. We recommend the subcategorisation of pT3 CRC by ELI for better prognostic assessment and treatment strategy of patients with CRC.

Apical Lymph Nodes in the Distant Metastases and Prognosis of Patients with Stage III Colorectal Cancer with Adequate Lymph Node Retrieval Following FOLFOX Adjuvant Chemotherapy

The aim of the study was to assess apical lymph nodes (APNs) for predicting distant metastases in patients with stage III colorectal cancer (CRC) curatively treated with FOLFOX adjuvant chemotherapy and adequate lymph node retrieval. We investigated the correlation between APN metastasis and clinical outcomes. This retrospective study examined 97 patients. All patients were followed until death, loss to follow-up, or May 2017. Clinicopathological variables, including the APN status, were assessed. Multivariate logistic regression model was used to identify the independent risk factors for APN and distant metastases, and Cox proportional regression model was used to evaluate the association between APN metastasis and oncologic outcomes. Multivariate analyses revealed the N2 stage as an independent predictor of APN metastasis [P = 0.036; odds ratio (OR): 3.016; 95% confidence interval (CI): 1.076-8.499], while APN metastasis was an independent risk factor for distant metastases (P < 0.001; OR: 13.876; 95% CI: 3.815-50.475). Furthermore, APN metastasis was an independent risk factor for poorer disease-free survival (DFS) and overall survival (OS) (P < 0.001 and P = 0.005, respectively). The liver (31.6%) was the most common site of distant metastases in patients with APN metastases. APN metastasis is an important prognostic factor for node-positive CRC; it enhanced the distant metastases in patients with stage III CRC curatively treated with adequate lymph node retrieval following FOLFOX adjuvant chemotherapy. Therefore, for patients with stage III CRC involving APN metastasis, prospectively randomized trials are mandatory to investigate different therapeutic strategies in addition to conventional FOLFOX adjuvant chemotherapy.