Prognostic value of tumor budding in patients with stage II and III colon cancer: A single-institution experience

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Background: Tumor budding has recently been recognized as one important prognostic factor for recurrence in patients with localized colon cancer. Nevertheless, not all guidelines consider tumor budding in the decision-making process for selecting patients for adjuvant chemotherapy. We aim to assess the prognostic value of tumor budding in a cohort of patients with stage II and III colon cancer. Methods: We included patients with pathologically confirmed diagnosis of stage II and III colon cancer at Hospital Universitario La Paz and tumor budding assessment available, from October 2016 to August 2021. Tumor budding was reported following the recommendations from the 2016 International Tumour Budding Consensus Conference. Results: A total of 390 patients were included. Patients were predominantly men (55%) and had a median age of 75 (35-95). Fifty percent of the patients were stage II and 50% were localized in the right colon. Tumor budding was reported as low, intermediate, and high in 186 (48%), 110 (28%), and 94 (24%) patients, respectively. After a median follow up of 18 months, 63 recurrences and 73 deaths were observed. Time to recurrence was significantly worse for patients with high tumor budding. At 24 months, 91%, 79%, and 67% of patients with low, intermediate and high budding were recurrence-free. Median TTR was not reached in any of the three cohort (P <0.001). Comparing high vs low or intermediate budding, the hazard ratio (HR) for recurrence was 0.13 [confidence interval (CI)95%: 0.05 to 0.32; P < 0.001]. We performed a univariate analysis with the most relevant clinic-pathological features. T4, N2, R1, bowel obstruction or perforation, positive resection margins (R1), lymphovascular or perineural invasion, and mismatch repair protein status were found to be statistically associated with TTR and entered the multivariate analysis. T4, N2, R1 and high tumor budding (HR: 0.48 [CI95%: 0.28 to 0.84], P = 0.011) were independent prognostic factors for recurrence at the multivariate analysis. Conclusions: High tumor budding is an adverse independent prognostic factor for recurrence in patients with stage II and III colon cancer and should be acknowledge when considering adjuvant chemotherapy.

Predicting recurrence in patients with stage II and III colon cancer: Validation cohort and long-term follow-up of the experimental cohort

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Background: The prognosis of stage II and III colon cancer is heterogeneous and current staging system do not accurately predict recurrence. We previously reported a score that was able to select a subgroup of patient with excellent prognosis ( https://doi.org/10.1016/j.annonc.2022.04.177 ). Here we present long-term follow up of the experimental cohort and the results of the validation cohort. Methods: We included patients with pathologically confirmed diagnosis of stage II and III colon cancer at Hospital Universitario La Paz. The experimental cohort included patients from October 2016 to September 2020. The validation cohort included patients from October 2020 to August 2021. Our prognostic score assigns 1 point for each of the following features: T4, N2, R1 and high tumor budding. Patients with a score of 0 as compared to those with ≥1 had an excellent prognosis regardless AJCC TNM staging. We assess the time to recurrence (TTR) between both groups in the experimental and validation cohort. Results: Baseline characteristics of the experimental cohort (n = 304) were reported previously. 135 (44%) and 169 (56%) patients had a score of 0 and ≥1, respectively. After a median follow up of 45 months, 81 recurrences and 96 deaths were observed. Median TTR was not reached in either cohort (score 0 vs ≥1; P < 0.001), with a hazard ratio (HR) for recurrence of 0.13 [confidence interval (CI)95%: 0.05 to 0.32; P < 0.001]. At 24 months, 95% and 73% of the patients were recurrence free in the score 0 and ≥1 groups, respectively. Within the validation cohort (n = 86), thirty-eight (44%) patients had a score of 0 and 48 (56%) of ≥1. After a median follow up of 19 months, 14 recurrences were observed, all of them in patients with score ≥1. Mediant TTR was not reached in either cohort (P < 0.001), with a HR for recurrence of 0.14 (IC95%: 0.00 – 1.07, P = 0.05). At 12 months, 100% and 78% of the patients were recurrence-free in the score 0 and ≥1 groups, respectively. When assessing TTR according to AJCC TNM stage, we found similar TTR between patients with stage II (n = 45) and III (n = 41) (not reached in either cohort; P = 0.16), with a HR for recurrence of 0.47 (CI95%: 0.15 to 1.40; P = 0.17). At 12 months, 90% and 86% of the patients with stage II and III were recurrence-free. Conclusions: In this study, we validate a prognostic score that identifies a subgroup of patients with localized colon cancer with an excellent prognosis regardless of their TNM stage.

Clinicopathological characteristics and outcomes of patients with deficient mismatch repair colorectal cancer

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Background: Patients with microsatellite-instability–high (MSI-H) or deficient mismatch repair (dMMR) colorectal cancer (CRC) represent a unique subgroup of patients with evolving treatment opportunities. Methods: We included all of the patients with pathologically confirmed diagnosis of CRC at Hospital Universitario La Paz from October 2016 to September 2020. Results: A total of 1,152 patients were diagnosed with CRC. IHC for MMR was available in 1,014 patients. Of those, 100 (9,8%) patients were deficient for MLH1 and PSM2 (n = 78), MSH2 and MSH6 (n = 12), PMS2 (n =5), MSH6 (n = 4), or MSH2 (n = 1). Baseline characteristics are depicted in the table. Female sex (55% vs. 38%; p = 0,001), right primary tumor location (75% vs. 29%; p = 0,001), histological grade 3 (20% vs. 8%; p <0,001), and mucinous component (39% vs. 10%; p < 0,001), and localized disease at diagnosis (97% vs. 79% p < 0,001), were more frequent in dMMR group. Among patients with dMMR CRC, 53% were ≥75 years old. The prevalence of BRAF V600E mutation was 56%. More female sex (67% vs. 40%; p = 0,006) and BRAFV600E mutation (66% vs. 48%; p = 0,06) were found in older vs. younger dMMR patients. Six patients were diagnosed with Lynch syndrome. After a median follow-up of 24 months, 279 patients have died. Median overall survival (OS) was not reached in either group (p = 0,327). Three-year OS was 75% (95% CI: 70-80) and 69 (95% CI: 67-71) in the dMMR and pMMR, respectively. In patients with localized disease that underwent antineoplastic treatment (n = 856), median disease-free survival (DFS) and OS were not reached in either group (p =0,403 and p = 0,232). Three-year DFS in patients with stage I (n = 216) was 64% (95% CI: 46-82) and 85% (95%CI: 80-90), p = 0,055; in patients with stage II (n = 274) was 84% (95% CI: 77-91) and 70% (95% CI: 66-74), p = 0,588; and in patients with stage III (n = 366) was 79 (95% CI: 71-87) and 66% (95% CI: 62-70%), p = 0,322; in dMMR and pMMR, respectively. No baseline characteristics were associated with recurrence in patients with localized dMMR CRC. Conclusions: Patients with MSI-High/dMMR CRC display distinctive clinical and pathological features. Overall prognosis does not differ in our series, but older age of dMMR patients may have influenced the outcomes.[Table: see text]

Efficacy and safety of the combination of aflibercept with fluorouracil, leucovorin, and irinotecan in patients aged 70 years and older with metastatic colorectal cancer previously treated with an oxaliplatin-based regimen in Spain: A retrospective multicenter cohort study

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Background: Colorectal cancer is currently the third most common cancer worldwide. The results of the VELOUR study showed that the addition of aflibercept to Fluorouracil, Leucovorin, and Irinotecan (FOLFIRI) produced an advantage in both progression-free and overall survival (PFS and OS) in patients with metastatic colorectal cancer (mCRC) previously treated with an oxaliplatin-based regimen. The purpose of this study was to evaluate the efficacy and safety of the combination of aflibercept with FOLFIRI in patients aged 70 years and older with mCRC. Methods: We conducted a retrospective multicenter study, which included all patients aged 70 years and older with mCRC treated with Aflibercept plus FOLFIRI between May 2013 and March 2019 in 5 centers in Spain. Data regarding clinical and pathological characteristics, treatment response and survival were collected. Results: We selected 69 patients, of whom the majority (n = 48, 69.6%) were males with a median age of 75 years (range 70 to 84 years). Patients received an average of nine courses of aflibercept with FOLFIRI overall. Regarding response rates, 17 patients (24.6%) achieved a partial response, 37 (53.6%) had stable disease and 15 (21.7%) experienced disease progression. The median PFS was 6.1 months (CI 95%: 4.4–7.8), and the median OS was 13.9 months (CI 95%: 11.1–16.7). Treatment adverse events grade 3 and 4 were reported in 42 patients (60.9%). The most frequently reported treatment adverse events grade 3 and 4 were asthenia (24.6%), diarrhea (18.8%), stomatitis and ulceration (18.8%) and neutropenia (14.5%). Adverse events grade 3 and 4 typically associated with anti-VEGF therapy were infrequent. Adverse events led to permanent discontinuation of treatment in 26.1% of patients. Conclusions: In our sample the combination of aflibercept with FOLFIRI in patients aged 70 years and older with mCRC was effective and safe. Aflibercept plus FOLFIRI is a good therapeutic option for the treatment of mCRC in patients aged 70 years and older previously treated with oxaliplatin.