Palliative primary tumor resection provides survival benefits for the patients with metastatic colorectal cancer and low circulating levels of dehydrogenase and carcinoembryonic antigen

Primary Tumor Resection for Metastatic Colorectal, Gastric and Pancreatic Cancer Patients: In Search of Scientific Evidence to Inform Clinical Practice

The management of the primary tumor in metastatic colorectal, gastric and pancreatic cancer patients may be challenging. Indeed, primary tumor progression could be associated with severe symptoms, compromising the quality of life and the feasibility of effective systemic therapy, and might result in life-threatening complications. While retrospective series have suggested that surgery on the primary tumor may confer a survival advantage even in asymptomatic patients, randomized trials seem not to definitively support this hypothesis. We discuss the evidence for and against primary tumor resection for patients with metastatic gastrointestinal (colorectal, gastric and pancreatic) cancers treated with systemic therapies and put in context the pros and cons of the onco-surgical approach in the time of precision oncology. We also evaluate current ongoing trials on this topic, anticipating how these will influence both research and everyday practice.

Metastatic lymph node ratio as a prognostic indicator in patients with stage IV colon cancer undergoing resection

Background: It has been shown that the metastatic lymph node ratio (LNR, metastatic LNs divided by the total number of retrieved LNs) significantly affects the prognosis of patients with non-stage IV and some curative stage IV colon cancer undergoing curative resection. In this study, we aimed to evaluate the role of the LNR as a predictor of prognosis in patients with stage IV colon cancer undergoing curative or palliative resection. Patients and Methods: We conducted a retrospective study of 424 patients who were initially diagnosed with stage IV colon cancer at the Sun Yat-Sen University Cancer Center from 2003 to 2014. The patients were divided into the curative and palliative primary tumor resection groups with regional lymph nodes harvest. The median value was used as the cutoff for the LNR. Overall survival (OS) was assessed with the Kaplan-Meier method and log-rank test. Multivariate analysis was performed to identify the prognostic factors for OS. Results: The cutoff value for the LNR was 0.2. A total of 71 and 353 patients were classified as being in the curative and palliative resection groups, respectively. Patients in the palliative resection group showed higher pretreatment levels of carbohydrate antigen 19-9 (CA199; P = 0.014), a deeper infiltration of the primary tumor (P = 0.049), a lower regional lymph node harvest (i.e., total lymph node yield [TLN] ≤ 11; P = 0.001), and more extensive metastasis (P = 0.006). Among all patients, initial elevated CA199 levels, a TLN≤11, a negative lymph nodes (NLN) ≤7, and a LNR ≤0.2 were significantly associated with an unfavorable prognosis. OS was significantly longer in patients with a low LNR in both groups (P = 0.008 and P = 0.001, respectively). The LNR was an independent prognostic indicator in patients with stage IV colon cancer, with a hazard ratio (HR) of 1.47 (95% confidence interval [CI] 1.14-1.91; P = 0.003) in total population, and an HR of 1.43 (95% CI 1.09-1.86; P = 0.009) in patients with palliative resection. Conclusion: The LNR can be used as an independent prognostic factor in patients with stage IV colon cancer patients undergoing resection.

The systemic immune-inflammation index is an independent predictor of survival for metastatic colorectal cancer and its association with the lymphocytic response to the tumor

BACKGROUND

Systemic inflammation and immune dysfunction has been proved to be significantly associated with cancer progression and metastasis in many cancer types, including colorectal cancer. We examined the prognostic significance of the systemic immune-inflammation index (SII) in patients with metastatic colorectal cancer (mCRC) and the relationship between the lymphocytic response to the tumor and this index.

METHODS

This retrospective study evaluated 240 consecutive patients with newly diagnosed stage IV mCRC who underwent surgical resection. The SII values were calculated based on preoperative laboratory data regarding platelet, neutrophil, and lymphocyte counts. Tumor-infiltrating lymphocytes were evaluated using the surgical specimens. The overall survival and their 95% confidence interval (95% CI) were estimated by regression analyses and the Kaplan-Meier method.

RESULTS

After a mean follow-up of 26.7 (1.1-92.4) months, 146 patients (60.8%) died. In the univariate analysis, a high SII was significantly associated with poor overall survival (P = 0.009). The multivariable analysis also confirmed that a high SII was independently associated with poor overall survival (hazard ratio: 1.462, 95% confidence interval 1.049-2.038, P = 0.025). The SII value was significantly correlated with the TILs value at the tumor's center (P = 0.04), but not at the invasive margin (P = 0.39). When we evaluated overall survival for groupings of the tumor-infiltrating lymphocytes and SII values, we identified three distinct prognostic groups. The group with low tumor-infiltrating lymphocyte values and high SII values had the worst prognosis.

CONCLUSIONS

A high SII value independently predicts poor clinical outcomes among patients with mCRC. In addition, combining the lymphocytic response to the tumor and SII could further enhance prognostication for mCRC.

Predictors of Survival after Yttrium-90 Radioembolization for Colorectal Cancer Liver Metastases

PURPOSE

To identify clinical parameters that are prognostic for improved overall survival (OS) after yttrium-90 radioembolization (RE) in patients with liver metastases from colorectal cancer (CRC).

MATERIALS AND METHODS

A total of 131 patients who underwent RE for liver metastases from CRC, treated at 2 academic centers, were reviewed. Twenty-one baseline pretreatment clinical factors were analyzed in relation to OS by the Kaplan-Meier method along with log-rank tests and univariate and multivariate Cox regression analyses.

RESULTS

The median OS from first RE procedure was 10.7 months (95% confidence interval [CI], 9.4-12.7 months). Several pretreatment factors, including lower carcinoembryonic antigen (CEA; ≤20 ng/mL), lower aspartate transaminase (AST; ≤40 IU/L), neutrophil-lymphocyte ratio (NLR) <5, and absence of extrahepatic disease at baseline were associated with significantly improved OS after RE, compared with high CEA (>20 ng/mL), high AST (>40 IU/L), NLR ≥5, and extrahepatic metastases (P values of <.001, <.001, .0001, and .04, respectively). On multivariate analysis, higher CEA, higher AST, NLR ≥5, extrahepatic disease, and larger volume of liver metastases remained independently associated with risk of death (hazard ratios of 1.63, 2.06, 2.22, 1.48, and 1.02, respectively).

CONCLUSIONS

The prognosis of patients with metastases from CRC is impacted by a complex set of clinical parameters. This analysis of pretreatment factors identified lower AST, lower CEA, lower NLR, and lower tumor burden (intra- or extrahepatic) to be independently associated with higher survival after hepatic RE. Optimal selection of patients with CRC liver metastases may improve survival rates after administration of yttrium-90.

Tumor-infiltrating lymphocyte as a prognostic biomarker in stage IV colorectal cancer should take into account the metastatic status and operation modality

BACKGROUND

Although tumor-infiltrating lymphocytes (TILs) have been understood for years as a favorable prognostic factor for colorectal cancers (CRCs) after complete surgical resection, its prognostic role in metastatic CRC (mCRC) remains poorly defined, and it is largely unknown how this prognostic benefit relates to the metastatic status and operation modality.

MATERIALS AND METHODS

After reviewing 2215 consecutive cases of surgically resected CRC, 332 patients newly diagnosed with stage IV CRC and treated at the Sun Yat-Sen University Cancer Center between 2009 and 2014 were included. H&E-stained (HES) slides from surgical specimens were evaluated for the extent of TILs. The primary end point was overall survival (OS). Cox proportional hazards regression was conducted to determine the prognostic significance of TILs. All statistical tests were 2-sided.

RESULTS

HES slides from primary tumor samples were evaluable for 302 of the 332 included cases. Among the 302 patients, 105 patients (34.8%) were classified as high TIL, the remaining 197 (65.2%) were defined as low TIL. In the univariate analysis, TILs were significantly associated with better OS (P=0.015). Multivariable analysis confirmed that high TIL strongly predicted better survival (hazard ratio =0.62, 95% CI: 0.44-0.89, P=0.008), independent of other patients' clinicopathological characteristics. Stratified analysis revealed a prognostic benefit of high TIL for patients in the subgroup with non-oligometastatic disease (P=0.002), ≥2 metastatic organs (P=0.006), and non-metastasectomy (P=0.005). By contrast, oligometastatic disease, 1 metastatic organ, or metastasectomy fully abrogated the prognostic effect of TIL.

CONCLUSION

Our findings indicate that the level of TILs can be used to predict the outcome for patients with mCRC; however, the operation modality and the metastatic status of patients should also be taken into account.