Recent advances in understanding colorectal cancer

Chitosan oligosaccharide enhances the anti-cancer effects of 5-fluorouracil on SNU-C5 colorectal cancer cells by activating ERK

Background

Chitosan oligosaccharide (COS) is the major degradation product of chitosan by enzymatic processes. COS, with complete water solubility, exerts significant biological effects, including anti-cancer activity. We investigated the anti-tumor effects of COS on colorectal cancer as effective therapeutic methods with low side effects are lacking.

Methods

COS was obtained from low molecular weight chitosan by an enzymatic method and the anti-cancer effects were measured by cell viability assay, flow cytometry analysis, Western blotting, and xenograft.

Results

COS suppressed the proliferation of SNU-C5 cells compared to other colorectal cancer cells, but higher concentrations were required in the xenograft model. Co-treatment with 5-fluorouracil (5-FU) and COS enhanced the anti-cancer effects of 5-FU in SNU-C5 cells in vitro and in vivo. Flow cytometry revealed that COS induced cell cycle arrest at the G0/G1 phase without 5-FU or at the S and G2/M phases with 5-FU but did not affect cell death pathways. COS increased extracellular signal-regulated protein kinase (ERK) activation with or without 5-FU, whereas 5-FU treatment increased p53 activation. A low-dose of an ERK inhibitor suppressed COS-induced ERK activation and resulted in higher proliferation compared with COS.

Conclusions

These results suggest that COS might enhance the anti-cancer effects of 5-FU in SNU-C5 colorectal cancer cells by activating ERK.

Global, regional and national burden and trends of larynx cancer among adults aged 55 and older from 1990 to 2021: results from the global burden of disease study 2021

BACKGROUND

Laryngeal cancer (LC), as a common head and neck tumor, significantly impacts the quality of life. Utilizing data from the 2021 Global Burden of Disease (GBD) study, we sought to delve deeply into the global LC burden experienced by individuals aged 55 and older from 1990 to 2021 at the global, regional, and national levels. This research encompassed three key indicators: incidence rate, mortality, and disability-adjusted life years (DALYs).

METHODS

Based on the GBD 2021 database, we selected data from 204 countries and regions covering the period from 1990 to 2021 for individuals aged 55 and above. We analyzed LC's performance in terms of incidence, mortality, and DALYs, calculating the age-standardized rates and the mean average annual percent change (AAPC) at global, regional, and national levels. In our analysis of global trends, we carefully considered multiple variables including age, sex, and the socio-demographic index (SDI). Furthermore, we assessed potential risk factors for LC-associated DALYs and made prospective predictions for the possible scenario by 2035.

RESULTS

Globally, the age-standardized DALY rate of LC among adults aged 55 years and older has undergone significant changes. Specifically, this rate dropped sharply from 245.89 cases per 100,000 people in 1990 to 153.76 cases per 100,000 people in 2021, with an AAPC showing a decreasing trend of -2.916. Simultaneously, the age-standardized incidence rate and mortality rate also exhibited a similar downward trend. From a regional perspective, South Asia ranked highest in relevant indicators in 2021, reporting a death toll of 29,258.96, confirmed cases of 34,234.23, and DALYs related to LC reaching 709,622.00. In contrast, the figures in Oceania were the lowest, with only 26.23 deaths, 29.53 incident cases, and 609.09 DALYs. When divided according to the quintiles of the SDI, in 2021, the medium-high SDI led in incidence rates, while the low SDI ranked last. However, in terms of mortality and DALY rates, medium-low SDI topped the list, with high SDI being the lowest. In terms of gender differences, in 2021, the age-standardized DALY rate of LC in males was approximately 7.13 times that of females, with the former reaching 282.12 cases per 100,000 people and the latter only 39.59 cases per 100,000 people. Among all age groups, a notable decrease was observed in the age-specific incidence rate and DALY for adults aged 60-64 years, with AAPC values of -0.123 (95% CI: -0.130 to -0.116) and - 3.553 (95% CI: -3.620 to -3.486), respectively. Similarly, the mortality rate for adults aged 65-69 years also showed a significant decline, with an AAPC of -0.123 (95% CI: -0.127 to -0.118). Additionally, tobacco has been revealed as the most important risk factor affecting the mortality and DALY of LC in adults aged 55 years and older. Looking ahead, it is predicted that by 2035, the incidence rate, mortality rate, and DALY rate of LC among people over 55 years old will continue to decline.

CONCLUSIONS

Despite the current data and future predictions indicating a decline in the global age-standardized incidence rate, the absolute number of estimates continues to increase. Therefore, we advocate that cancer prevention strategies should place greater emphasis on vigorously addressing modifiable risk factors, particularly for the male population, which requires special attention and scientific intervention.

Early-Onset Colorectal Cancer Incidence, Staging, and Mortality in Canada: Implications for Population-Based Screening

INTRODUCTION

The incidence of early-onset colorectal cancer (eoCRC) has been increasing in North America. Debate remains as to whether the trends by topography, histology, stage, or mortality in this population are amenable to intervention from screening.

METHODS

CRC incidence (2000-2017) and mortality (2000-2018) data were obtained from the Canadian Cancer Registry and Vital Statistics. Annual percentage changes (APC) in the incidence (topography and histology) and mortality of eoCRC were estimated using joinpoint regression. Incidence of late-stage CRC (III or IV) versus early-stage CRC (I or II) was compared between the eoCRC (age 20-49 years) and eligible screening (age 50-74 years) groups with Poisson regression.

RESULTS

Among women aged 20-49 years, the incidence of CRC significantly increased from 2000 to 2017 in both the distal colon (APC = 1.40) and rectum (APC = 3.00), whereas for men aged 20-49 years, the CRC incidence increased in the proximal colon (APC = 1.10), distal colon (APC = 3.00), and rectum (APC = 3.70). Among both men and women aged 20-49 years, the incidence of nonmucinous adenocarcinomas significantly increased (APC: 1.90 and 2.30, respectively), whereas mucinous adenocarcinomas decreased for women (APC = -1.60) and remained stable for men. Adults aged 30 to 49 years, when diagnosed with CRC, had a significantly higher risk of being diagnosed with a late-stage CRC compared with those in the age group of 50-74 years. Rectal cancer mortality increased from 2000 to 2018 in the eoCRC group (APC for women and men 3.80 and 3.40, respectively).

DISCUSSION

Emerging data support future modifications to guidelines on screening for eoCRC in Canada. Further research is required on the effect, cost-effectiveness, and risk prediction for targeted screening within this group.

MODUL cohort 2: an adaptable, randomized, signal-seeking trial of fluoropyrimidine plus bevacizumab with or without atezolizumab maintenance therapy for BRAFwt metastatic colorectal cancer

Background

MODUL is an adaptable, signal-seeking trial designed to test novel agents in predefined patient subgroups in first-line metastatic colorectal cancer (mCRC).

Patients and methods

Patients with measurable, unresectable, previously untreated mCRC received induction with ≤8 cycles of FOLFOX + bevacizumab followed by randomization to maintenance treatment comprising control [fluoropyrimidine (FP)/bevacizumab: 5-fluorouracil 1600-2400 mg/m² 46-h intravenous (i.v.) infusion day 1 q2 weeks plus leucovorin 400 mg/m² 2-h infusion i.v. day 1 q2 weeks or capecitabine 1000 mg/m² b.i.d. orally days 1-14 every 21 days; bevacizumab 5 mg/kg 15-30-min i.v. infusion q2 weeks] or experimental treatment in one of four biomarker-driven cohorts. In patients with BRAF wild-type (BRAF^wt) tumors (cohort 2), experimental treatment was FP/bevacizumab + atezolizumab (800 mg 60-min i.v. infusion q2 weeks). Primary efficacy endpoint was progression-free survival (PFS; intent-to-treat population). Enrollment is complete; efficacy and safety findings from cohort 2 are presented.

Results

Four hundred and forty-five patients with BRAF^wt mCRC were randomized (2 : 1) to maintenance in cohort 2. At a median follow-up of 10.5 months, PFS outcome hypothesis was not met [hazard ratio (HR) 0.92; 95% confidence interval (CI) 0.72-1.17; P = 0.48]; overall survival (OS) was immature. At a median follow-up of 20.3 months (2-year survival follow-up), PFS benefit was also not met (HR 0.95; 95% CI 0.77-1.18; P = 0.666); OS HR with nearly two-thirds of patients with events was 0.83 (95% CI 0.65-1.05; P = 0.117). No new safety signals were identified. The most common grade ≥3 treatment-emergent adverse events (TEAEs) for experimental versus control arms were hypertension (6.1% versus 4.2%), diarrhea (3.1% versus 2.1%), and palmar-plantar erythrodysesthesia syndrome (1.0% versus 2.5%). Four patients experienced TEAEs with fatal outcome, two were study treatment-related: hepatic failure (experimental arm) and large intestine perforation (control arm; bevacizumab-related).

Conclusions

Adding atezolizumab to FP/bevacizumab as first-line maintenance treatment after FOLFOX + bevacizumab induction for BRAF^wt mCRC did not improve efficacy outcomes.

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MODUL is an adaptable, signal-seeking trial of novel combinations in predefined subgroups of patients with mCRC.

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In cohort 2 (BRAF^wt mCRC), adding atezolizumab to FP/bevacizumab (bev) first-line maintenance therapy did not improve PFS or OS versus FP/bev.

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ORR and DCR were numerically but not statistically significantly higher with atezolizumab + FP/bev versus FP/bev.

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The safety profile of atezolizumab + FP/bev was consistent with previous findings with no new safety signals identified.

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Findings from MODUL cohort 2 indicate that immunotherapy has limited efficacy in patients with microsatellite stable mCRC.

Head and Neck Cancer Primary Tumor Auto Segmentation Using Model Ensembling of Deep Learning in PET/CT Images

Auto-segmentation of primary tumors in oropharyngeal cancer using PET/CT images is an unmet need that has the potential to improve radiation oncology workflows. In this study, we develop a series of deep learning models based on a 3D Residual Unet (ResUnet) architecture that can segment oropharyngeal tumors with high performance as demonstrated through internal and external validation of large-scale datasets (training size = 224 patients, testing size = 101 patients) as part of the 2021 HECKTOR Challenge. Specifically, we leverage ResUNet models with either 256 or 512 bottleneck layer channels that demonstrate internal validation (10-fold cross-validation) mean Dice similarity coefficient (DSC) up to 0.771 and median 95% Hausdorff distance (95% HD) as low as 2.919 mm. We employ label fusion ensemble approaches, including Simultaneous Truth and Performance Level Estimation (STAPLE) and a voxel-level threshold approach based on majority voting (AVERAGE), to generate consensus segmentations on the test data by combining the segmentations produced through different trained cross-validation models. We demonstrate that our best performing ensembling approach (256 channels AVERAGE) achieves a mean DSC of 0.770 and median 95% HD of 3.143 mm through independent external validation on the test set. Our DSC and 95% HD test results are within 0.01 and 0.06 mm of the top ranked model in the competition, respectively. Concordance of internal and external validation results suggests our models are robust and can generalize well to unseen PET/CT data. We advocate that ResUNet models coupled to label fusion ensembling approaches are promising candidates for PET/CT oropharyngeal primary tumors auto-segmentation. Future investigations should target the ideal combination of channel combinations and label fusion strategies to maximize segmentation performance.

Identification of colon tumor marker NKD1 via integrated bioinformatics analysis and experimental validation

Background

Colorectal cancer is an important death‐related disease in the worldwide. However, specific colon cancer tumor markers currently used for diagnosis and treatment are few. The purpose of this study is to screen the potential colon cancer markers by bioinformatics and verify the results with experiments.

Methods

Gene expression data were downloaded from two different databases: TCGA database and GEO datasets, which were then analyzed by two different methods (difference analysis and WGCNA method). Venn and PPI analysis obtained the potential core genes, which were then performed the GO enrichment and KEGG pathway analysis. Expressions levels of NKD1 in colon carcinoma tissues were further confirmed by immunohistochemical staining and western blot assays. Moreover, the function was measured by MTT, clone formation, and tumor transplantation experiments. Importantly, co‐immunoprecipitation, immunofluorescence, and protein stability assays were further performed to explore the underlying mechanism of NKD1 promoting cell proliferation.

Results

Nine potential core genes highly expressed in colon cancer samples were screened out by bioinformatics analysis. NKD1, one of the hub genes, highly expressed in the colon carcinoma tissues could enhance the proliferation of colon cancer cells. Mechanism research demonstrated that NKD1 was essential for the combination between Wnt signalosome (DVL) and β‐catenin, and that NKD1 knockout remarkably decreased the β‐catenin expression. Immunofluorescence assays further implied that NKD1 knockout significantly inhibited β‐catenin nuclear accumulation. Importantly, the stability of β‐catenin proteins was maintained by NKD1 in the colon cancer cells.

Conclusion

We believe that NKD1 well expressed in the colorectal carcinoma tissues can enhance the proliferation of colon cancer cells. Furthermore, the functions that NKD1 may have in colon cancer cells should be different from that NKD1 has played in the zebrafish. Thus, NKD1 could be a specific colorectal cancer marker.

High-Grade Inflammation Attenuates Chemosensitivity and Confers to Poor Survival of Surgical Stage III CRC Patients

Background: Heterogeneous clinical and molecular characteristics are reported in colorectal cancer (CRC) with different tumor laterality. However, the outcome of left- and right-sided patients with stage I-III CRC and the role of chronic inflammation in survival differences between them remain unclear. Method: A prospective study including 1,181 surgical patients with stage I-III CRC was carried out to investigate the involvement of circulating fibrinogen-to-pre-albumin (Alb) ratio (FPR) and primary tumor sidedness in the clinical outcome of those patients. We further investigated the effect of FPR on adjuvant chemotherapy response and recurrence in stage III patients. Results: Our study showed that the right tumor location was significantly associated with poor recurrence-free survival (RFS) (p = 0.04, adjusted HR = 1.41, 95% CI = 1.02-1.94) and overall survival (OS) (p = 0.04, adjusted HR = 1.55, 95% CI = 1.01-2.38) only in the stage III disease. In these patients, T4 stage distribution (83.39 vs. 70.94%, p < 0.01) within right-sided cases was significantly higher than left-sided patients. Moreover, preoperative FPR within right-sidedness (p < 0.01), T4 stage (p < 0.05), and large cancer bulk (≥5 cm) (p < 0.05) subgroups was significantly elevated compared to their counterparts, and it was gradually rising following the increased cancer bulk (p trend < 0.01). High-FPR distribution (52.30 vs. 27.00%, p < 0.01) within right-sided patients with the stage III disease was significantly higher than that in the left-sided cases. RFS (p log-rank < 0.01) and OS (p log-rank < 0.01) of the high-FPR patients were extremely inferior to the low-FPR cases, and the significant associations were observed when they were adjusted by other confounders including primary tumor location (p < 0.01, adjusted HR = 1.96, 95% CI = 1.42-2.70 for RFS; p < 0.01, adjusted HR = 2.44, 95% CI = 1.59-3.75 for OS). Additionally, RFS of adjuvant chemotherapy-treated high-FPR patients was superior to the patients without chemotherapy (p log-rank = 0.01) but was inferior to the low-FPR patients undergoing the treatment, especially in the 5-FU- and XELOX-treated subgroup. Conclusion: These findings indicate that chronic high-grade inflammation weakens chemotherapy efficacy and contributes to the poor prognosis of stage III surgical CRC patients.

Copanlisib promotes growth inhibition and apoptosis by modulating the AKT/FoxO3a/PUMA axis in colorectal cancer

Colorectal cancer (CRC) is the type of cancer with the third highest incidence and is associated with high mortality and low 5-year survival rates. We observed that copanlisib, an inhibitor of PI3K (pan-class I phosphoinositide 3-kinase) that preferentially inhibits PI3Kδ and PI3Kα, impedes the growth of CRC cells by inducing apoptosis via PUMA. There was a marked increase in the expression of PUMA independent of p53 after treatment with copanlisib. The response of CRC cells to copanlisib could be predicted by PUMA expression. Copanlisib was found to induce PUMA expression through FoxO3a by directly binding to the PUMA promoter after inhibiting AKT signaling. PUMA deficiency mitigated the apoptosis induced by copanlisib. Caspase activation and mitochondrial dysfunction led to copanlisib resistance, as observed through a clonogenic assay, whereas enhanced expression of PUMA increased the copanlisib-induced susceptibility to apoptosis. Moreover, the antitumor effects of copanlisib were suppressed by a deficiency of PUMA in a xenograft model, and caspase activation and reduced apoptosis were also observed in vivo. Copanlisib-mediated chemosensitization seemed to involve the concurrent induction of PUMA expression via mechanisms that were both dependent and independent of p53. These observations indicate that apoptosis mediated by PUMA is crucial for the anticancer effects of copanlisib and that manipulation of PUMA may aid in enhancing anticancer activities.

Increased Temperature Facilitates Adeno-Associated Virus Vector Transduction of Colorectal Cancer Cell Lines in a Manner Dependent on Heat Shock Protein Signature

Colorectal cancer (CRC) is one of the most common cancers in human population. A great achievement in the treatment of CRC was the introduction of targeted biological drugs and solutions of chemotherapy, combined with hyperthermia. Cytoreductive surgery and HIPEC (hyperthermic intraperitoneal chemotherapy) extends the patients' survival with CRC. Recently, gene therapy approaches are also postulated. The studies indicate the possibility of enhancing the gene transfer to cells by recombinant adeno-associated vectors (rAAV) at hyperthermia. The rAAV vectors arouse a lot of attention in the field of cancer treatment due to many advantages. In this study, the effect of elevated temperature on the transduction efficiency of rAAV vectors on CRC cells with different origin and gene profile was examined. The effect of heat shock on the penetration of rAAV vectors into CRC cells in relation with the expression of HSP and AAV receptor genes was tested. It was found that the examined cells under hyperthermia (43°C, 1 h) are transduced at a higher level than in normal conditions (37°C). The results also indicate that studied RKO, HT-29, and LS411N cell lines express HSP genes at different levels under both 37°C and 43°C. Moreover, the results showed that the expression of AAV receptors increases in response to elevated temperature. The study suggests that increased rAAV transfer to CRC can be achieved under elevated temperature conditions. The obtained results provide information relevant to the design of new solutions in CRC therapy based on the combination of hyperthermia, chemotherapy, and gene therapy.

Identification of gene modules and hub genes in colon adenocarcinoma associated with pathological stage based on WGCNA analysis

Colorectal cancer (CRC) is one of the leading causes of cancer-related mortality in the world, in which colon adenocarcinoma (COAD) is the most common histological subtype of CRC. In this study, our aim is to identify gene modules and representative candidate biomarkers for clinical prognosis of patients with COAD, and help to predict prognosis and reveal the mechanisms of cancer progression. Weighted gene co-expression network analysis (WGCNA) was performed to construct a co-expression network and identify gene modules correlated with TNM clinical staging of COAD patients. The Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were performed with the module gene. Protein-protein interaction (PPI) network and hub gene identification were explored with Cytoscape software. Finally, the hub gene mRNA level was validated in Oncomine database. Five gene modules, related with the pathological TNM stage, were constructed, and the gene module was enriched in cell proliferation, invasion and migration related GO terms and metabolic related KEGG pathways. A total of top 10 hub genes was identified, and in which six of the hub genes show a significant up-regulation in COAD as compared to normal tissue, including IVL, KRT16, KRT6C, KRT6A, KRT78 and SBSN. In conclusion, we identified five gene modules and six candidate biomarkers correlated with the TNM staging of COAD patients. These findings may help us to understand the tumor progression of COAD and provide prognostic biomarkers as well as therapeutic targets.

Robotic surgery of head and neck cancers, a narrative review

Head and neck cancers are the most common cancers in the body. Treatments are determined on the basis of the location and stage of the primary tumor. The goal of treatment is to eliminate the tumor, prevent recurrence or metastasis, and maintain the quality of life. There are several treatments available for the management of head and neck cancers, including surgery, radiation therapy, chemotherapy, new molecular agents, and a combination of them. Transoral robotic technique is a short-time operation using a type of robotic machine in which the patient undergoes anesthesia for a shorter time and the side effects of this operation and the time of hospitalization are less than open surgery. Due to the importance of speed and accuracy in head and neck cancer surgery and the importance of application of robotics in surgery, the present study was designed and implemented to review the application of robotics in the management of head and neck cancers. In this review study, the keywords: application, robotic, surgical, head cancer, transoral robotic surgery (TORS), and neck cancer, were searched in ISI, PubMed, Scopus, Google scholar databases. Related articles written domestically or abroad that have covered areas such as the background of transoral robotic surgery, maintaining organ function and approaches, the advantages and disadvantages of TORS, the affordability of TORS, the combination of TORS with other therapeutic approaches published from 2003 to 2019 were reviewed. The use of robotic surgery for precise operations such as head and neck cancers seems to be essential. More advanced robotic devices are expected to expand the surgery treatment for head and neck cancers as well as the results of using TORS for oncologic optimization and acceptability of results while maintaining organ function and patient's quality of life.

The emerging use of immune checkpoint blockade in the adjuvant setting for solid tumors: a review

The use of immune checkpoint inhibitors has been approved in the advanced and metastatic setting for many types of solid tumors. Nonetheless, their role in the adjuvant setting is limited to the treatment of surgically resected melanoma. Ipilimumab was the first immune checkpoint inhibitor approved for this indication, followed by nivolumab and pembrolizumab. Many ongoing trials are evaluating these molecules in the postoperative setting, alone or in combination with other therapies. Preliminary results are promising regarding the treatment of other cutaneous tumors, lung cancers, head and neck squamous cell carcinomas, bladder cancer and renal cell carcinomas. Some data assessing their use for the adjuvant treatment of esophageal, colorectal, ovarian cancer and other solid tumors are similarly emerging.

Mps1 is associated with the BRAFV600E mutation and predicts poor outcome in patients with colorectal cancer

Colorectal cancer (CRC) with the V600E mutation of B-Raf proto-oncogene serine/threonine kinase (BRAFV600E) mutation is insensitive to chemotherapy and is indicative of a poor patient prognosis. Although BRAF inhibitors have a marked effect on malignant melanoma harboring the BRAFV600E mutation, they have a limited effect on patients with CRC with the same BRAF mutation. A previous study identified a novel gene, monopolar spindle protein kinase 1 (Mps1), a downstream target of BRAFV600E only, rather than of wild-type BRAF as well, which contributes to tumorigenesis in melanoma. In the present study, the incidence of BRAFV600E in patients with CRC was identified and the correlation of Mps1, phospho-extracellular-signal-regulated kinase (p-ERK) and BRAFV600E was investigated. The results indicated that the mutation rate of BRAFV600E was 5.2% in CRC. Poorly differentiated tumors and mucinous tumors have a significantly higher incidence of BRAFV600E compared with well-differentiated tumors and non-mucinous tumors (P<0.05). Kaplan-Meier survival analysis indicated that the survival rate was markedly lower in patients with BRAFV600E compared with in patients with wild-type BRAF (BRAFWT). The expression of p-ERK and Mps1 in CRC with BRAFV600E was significantly higher compared with in CRC with BRAFWT (P<0.05), and their expression is associated with cancer classification, degree of differentiation and lymph node transfusion (P<0.05). In addition p-ERK expression was positively correlated with Mps1 expression, with a contingency coefficient of 0.679 (P=0.002). In conclusion, the results of the present study indicated that Mps1 was significantly associated with BRAFV600E/p-ERK and may serve a crucial function in the development of CRC. The results of the present study raise the possibility that targeting the oncogenic BRAF and Mps1, particularly when in conjunction, could provide promising therapeutic opportunities for the treatment of CRC.