CD11c+ and IRF8+ cell densities in rectal cancer biopsies predict outcomes of neoadjuvant chemoradiotherapy

Approximately 20% of locally advanced rectal cancer (LARC) patients treated preoperatively with chemoradiotherapy (CRT) achieve pathologically confirmed complete regression. However, there are no clinically implemented biomarkers measurable in biopsies that are predictive of tumor regression. Here, we conducted multiplexed immunophenotyping of rectal cancer diagnostic biopsies from 16 LARC patients treated preoperatively with CRT. We identified that patients with greater tumor regression had higher tumor infiltration of pan-T cells and IRF8+HLA-DR+ cells prior to CRT. High IRF8+HLA-DR+ cell density was further associated with prolonged disease-specific survival with 83% survival at 5 y compared to 28% in patients with low infiltration. Contrastingly, low CD11c+ myeloid cell infiltration prior to CRT was a putative biomarker associated with longer 3- and 5-y disease-free survival. The results demonstrate the potential use of rectal cancer diagnostic biopsies to measure IRF8+ HLA-DR+ cells as predictors of CRT-induced tumor regression and CD11c+ myeloid cells as predictors of LARC patient survival.

The Prognostic Value of FoxP3+ Tumour-Infiltrating Lymphocytes in Rectal Cancer Depends on Immune Phenotypes Defined by CD8+ Cytotoxic T Cell Density

Tumour-infiltrating FoxP3+ regulatory T cells have been identified as both positive and negative prognostic factors in colorectal cancer (CRC) and rectal cancer (RC). In this study we investigated whether immune phenotypes, defined by CD8+ cytotoxic T cell density, may influence the prognostic association of FoxP3+ T cell densities in RC. Tissue microarrays from 154 rectal cancer resections were immunohistochemically double stained for CD8 and FoxP3. CD8+ and FoxP3+ cell densities were measured in the stromal and intraepithelial compartment. Stromal FoxP3+ cell densities were not associated with 10-year overall survival (OS). In the “immune-desert” phenotype, defined by very low stromal CD8+ cell density, a high density of stromal FoxP3+ T cells displayed a tendency towards an association with decreased 10-year OS (p = 0.179). In “inflamed” tumours, defined by high intraepithelial CD8+ T cell infiltration, the opposite was the case and high stromal FoxP3+ T cell densities were a positive prognostic factor (p = 0.048). Additionally, patients with an increased FoxP3/CD8 cell density ratio demonstrated a strong trend towards decreased 10-year OS (p = 0.066). These contrasting findings suggest functional heterogeneity within the group of FoxP3+ T cells. They are consistent with experimental studies which reported suppressive and non-suppressive populations of FoxP3+ T cells in CRC. Furthermore, our study demonstrates that CD8 immunohistochemistry may act as an instrument to identify tumours infiltrated by possibly functionally differing FoxP3+ T cell subtypes.

Potential role of tumor-infiltrating T-, B-lymphocytes, tumor-associated macrophages and IgA-secreting plasma cells in long-term survival in the rectal adenocarcinoma patients

AIMS

Many studies investigated the associations between the role of immune cells of rectal cancer microenvironment and survival during the first 5 years post-surgery. This is problematic as this disease has the potential to progress even after 5 years after relapse and infiltrating immune cells could play key roles. Therefore, this retrospective study investigates expression and roles of tumor-infiltrating T-lymphocytes (TIL-T), tumor-infiltrating B-lymphocytes (TILB), IgA⁺ plasma cells (IgA⁺ PC) and tumor-associated macrophages (TAM) in patients with or without progression over 5 years survival with rectal adenocarcinoma.

MAIN METHODS

Here we used immunohistochemical staining of CD3, CD20, IgA, CD68 positive cells and its detection in rectal cancer stroma. Data was analyzed using Mann Whitney U test, ROC, survival and Cox's regression analysis.

KEY FINDINGS

The number of TIL-T (p = 0.0276), TIL-B (p < 0.0001) and IgA⁺ PC (p = 0.015) immune cells was significantly higher in rectal cancer stroma of patients with favorable outcome. Univariate Cox's regression analysis revealed a predictive role of TIL-T (HR = 0.482; 95% CI, 0.303 to 0.704; p < 0.0001), TIL-B (HR = 0.301; 95% CI, 0.198 to 0.481; p < 0.0001) and IgA⁺-PC (HR = 0.488; 95% CI, 0.322 to 0.741; p < 0.0001). Multivariate Cox's regression analysis showed prognostic role of TIL-B (HR = 0.940; 95% CI, 0.914 to 0.968; p < 0.0001) and IgA⁺-PC (HR = 0.985; 95% CI, 0.975 to 0.996; p = 0.006) play role in long time survival.

SIGNIFICANCE

CD20⁺ TIL-B and IgA⁺ cells have significant associations with long -term survival of patients with rectal cancer, with potential therapeutic intervention in cancer immunotherapy.

Peripheral blood CD45RO+T cells is a predictor of the effectiveness of neoadjuvant chemoradiotherapy in locally advanced rectal cancer

To investigate the relationship between the changes in circulating CD45RO+T lymphocyte subsets following neoadjuvant therapy for rectal cancer in patients with locally advanced rectal cancer.The clinicopathological data of 185 patients with rectal cancer who received neoadjuvant therapy in the General Surgery Department of Beijing Chaoyang Hospital affiliated to Capital Medical University from June 2015 to June 2017 were analyzed. Venous blood samples were collected 1 week before neoadjuvant therapy and 1 week before surgery, and the expression of CD45RO+T was detected by flow cytometry. The receiver operating characteristic curve analysis was used to determine the optimal cut-off point of CD45RO+ratio. Log-rank test and multivariate Cox regression were used to analyze the overall survival rate (OS) and disease-free survival rate (DFS) associated with CD45RO+ratio.Circulating CD45RO+ratio of 1.07 was determined as the optimal cut-off point and CD45RO+ratio-high was associated with lower tumor regression grade grading (P = .031), T stage (P = .001), and tumor node metastasis (TNM) stage (P = .012). The 3-year DFS and OS rate in the CD45RO+ratio-high group was significantly higher than that in the CD45RO+ratio-low group (89.2% vs 60.1%, P<.001; 94.4% vs 73.2%, P<.001). The multivariate Cox analysis revealed that elevated CD45RO+ratio was an independent factor for better DFS (OR, 0.339; 95% CI, 0.153-0.752; P = .008) and OS (OR, 0.244; 95% CI,0.082-0.726; P = .011).Circulating CD45RO+ratio could predict the tumor regression grade of neoadjuvant therapy for rectal cancer, as well as long-term prognosis. These findings could be used to stratify patients and develop alternative strategies for adjuvant therapy.

Tumor Microenvironment Mediators CD8+- and FOXP3+-Labeled T Lymphocytes Are Prospective Prognosticators in Curatively Treated Rectal Cancer Patients

PURPOSE

To explore the implication of CD8⁺- and FOXP3⁺-labeled T lymphocytes invading tumor microenvironment in prognosticating curatively treated rectal cancer with preoperative chemo-radiation.

METHODS

The diagnostic rectal biopsies from clinical T3-T4 and any nodal diseases or any T stage with nodal involvement were processed to quantify (CD8⁺and FOXP3⁺). The impact of tested indicators on the achieved pathologic response among other clinical-pathological variables was particularized. Additionally, the prognosticating eventuality of labeled T lymphocytes for survival was elaborated using Log-rank and Cox regression.

RESULTS

We selected fifty rectal patients who had negative surgical margins following preoperative chemo-radiation for clinical T3-T4 or any T stage with nodal involvement. The higher expressions of CD8⁺ and CD8⁺/FOXP3⁺, and the reduced FOXP3⁺incursion were interrelated with the lack of nodal and lympho-vascular invasion alongside accentuated pathologic response. Additionally, the augmented densities of FOXP3⁺ ≥ 120, the reduced CD8⁺/FOXP3⁺ ratio < 0.96, and the nodal incursion were considerably linked with the worsened OS [hazard ratio (HR) 2.37 (95% confidence interval (CI), 2.38-11.27), 2.41 (95% CI, 2.14-7.12), and 2.63 (95% CI, 2.81-5.32)], and dismal DFS [HR 2.61 (95% CI, 1.58-6.12), 3.12 (95% CI, 2.15-7.24), and 3.32 (95% CI, 2.47-9.24)], respectively.

CONCLUSION

The augmented expressions of CD8⁺ and C8⁺/FOXP3⁺ together with the reduced densities of FOXP3⁺ exhibited a substantial contribution to the attained pathological response and were linked to improved clinical-pathological characteristics of cancer rectum patients treated with chemo-radiation preceding mesorectal excision. Additionally, they can be authorized as reliable individual prognosticators of clinical outcomes.

Immunity, immunotherapy, and rectal cancer: A clinical and translational science review

Rectal cancer remains a challenging disease to treat. Therapy for locally advanced rectal cancer (LARC), the most frequent presentation, has evolved to include a multimodal approach of radiation, chemotherapy, and surgery. While this approach improves local disease control, the distant recurrence rate is nearly 30% and treatment-related morbidity is substantial, thus underscoring the need for new therapeutic approaches with better efficacy and lower side effects. Immunotherapy could potentially fill this need, but its promise is not yet realized in rectal cancer. In this translational science review, we address what is known about how cytotoxic therapies shape rectal cancer immunity and potentially prime the tumor microenvironment for response to immune checkpoint inhibitors and other immunotherapies. We also address the role of current immunotherapies in colorectal cancer and highlight where novel immunotherapy approaches are currently being evaluated in LARC. Finally, we address important future directions in LARC immunotherapy including the need to define optimal therapeutic sequencing, predictive biomarkers, strategies to limit treatment-related side effects and the potential of gut microbiome manipulation to improve outcomes. In summary, this review provides a framework to guide future research and inform immunotherapy trial design so as to advance rectal cancer care.

Differential and longitudinal immune gene patterns associated with reprogrammed microenvironment and viral mimicry in response to neoadjuvant radiotherapy in rectal cancer

BACKGROUND

Rectal cancers show a highly varied response to neoadjuvant radiotherapy/chemoradiation (RT/CRT) and the impact of the tumor immune microenvironment on this response is poorly understood. Current clinical tumor regression grading systems attempt to measure radiotherapy response but are subject to interobserver variation. An unbiased and unique histopathological quantification method (change in tumor cell density (ΔTCD)) may improve classification of RT/CRT response. Furthermore, immune gene expression profiling (GEP) may identify differences in expression levels of genes relevant to different radiotherapy responses: (1) at baseline between poor and good responders, and (2) longitudinally from preradiotherapy to postradiotherapy samples. Overall, this may inform novel therapeutic RT/CRT combination strategies in rectal cancer.

METHODS

We generated GEPs for 53 patients from biopsies taken prior to preoperative radiotherapy. TCD was used to assess rectal tumor response to neoadjuvant RT/CRT and ΔTCD was subjected to k-means clustering to classify patients into different response categories. Differential gene expression analysis was performed using statistical analysis of microarrays, pathway enrichment analysis and immune cell type analysis using single sample gene set enrichment analysis. Immunohistochemistry was performed to validate specific results. The results were validated using 220 pretreatment samples from publicly available datasets at metalevel of pathway and survival analyses.

RESULTS

ΔTCD scores ranged from 12.4% to -47.7% and stratified patients into three response categories. At baseline, 40 genes were significantly upregulated in poor (n=12) versus good responders (n=21), including myeloid and stromal cell genes. Of several pathways showing significant enrichment at baseline in poor responders, epithelial to mesenchymal transition, coagulation, complement activation and apical junction pathways were validated in external cohorts. Unlike poor responders, good responders showed longitudinal (preradiotherapy vs postradiotherapy samples) upregulation of 198 immune genes, reflecting an increased T-cell-inflamed GEP, type-I interferon and macrophage populations. Longitudinal pathway analysis suggested viral-like pathogen responses occurred in post-treatment resected samples compared with pretreatment biopsies in good responders.

CONCLUSION

This study suggests potentially druggable immune targets in poor responders at baseline and indicates that tumors with a good RT/CRT response reprogrammed from immune "cold" towards an immunologically "hot" phenotype on treatment with radiotherapy.

Effect of preoperative chemoradiotherapy on the immunological status of rectal cancer patients

The aim of the study was to investigate the effect of chemo-radiation on the genetic and immunological status of rectal cancer patients who were treated with preoperative chemoradiotherapy (CRT). The expression of immune response-associated genes was compared between rectal cancer patients treated (n = 9) and not-treated (n = 10) with preoperative CRT using volcano plot analysis. Apoptosis and epithelial-to-mesenchymal transition (EMT) marker genes were analysed by quantitative PCR (qPCR). Other markers associated with the tumor microenvironment (TME), such as tumor-infiltrating lymphocytes (TIL) and immune checkpoint molecules, were investigated using immunohistochemistry (IHC). The clinical responses of preoperative CRT for 9 rectal cancer patients were all rated as stable disease, while the pathological tumor regression score (TRG) revealed 6 cases of grade2 and 3 cases of grade1. According to the genetic signature of colon cancers, treated tumors belonged to consensus molecular subtype (CMS)4, while not-treated tumors had signatures of CMS2 or 3. CRT-treated tumors showed significant upregulation of EMT-associated genes, such as CDH2, TGF-beta and FGF, and cancer stem cell-associated genes. Additionally, qPCR and IHC demonstrated a suppressive immunological status derived from the upregulation of inflammatory cytokines (IL-6, IL-10 and TGF-beta) and immune checkpoint genes (B7-H3 and B7-H5) and from M2-type macrophage accumulation in the tumor. The induction of EMT and immune-suppressive status in the tumor after strong CRT treatment urges the development of a novel combined therapy that restores immune-suppression and inhibits EMT, ultimately leading to distant metastasis control.

The Immunoscore in the Clinical Practice of Patients with Colon and Rectal Cancers

In the fine balance between tumor invasion and our defensive systems, the role played by the adaptive immune response at the tumor site is critical. Beyond the fact that all the immune components of the innate and adaptive response can be observed to varying degrees in the tumor microenvironment, it appears that a high density of T cytotoxic and memory lymphocytes, in a context of Th1 immune orientation in the tumor and its invasion front, provides a prognostic marker of paramount importance for colorectal cancer and more generally all solid tumors. The understanding of the role of immunity in cancer, tailored during one century of intensive research, has led to a complete paradigm shift.based on a sharp dissection In order to show the major impact of this conceptual revolution, we herein retrace through the example of colorectal cancer, how an effective immune test, namely the "Immunoscore", has been developed. We also provide up to date data demonstrating the capacity of the Immunoscore to prognosticate with a better accuracy than the TME classification clinical outcomes and to guide therapeutic strategies.

Prognostic impact of persistent lower neutrophil-to-lymphocyte ratio during preoperative chemoradiotherapy in locally advanced rectal cancer patients: A propensity score matching analysis

Purpose

This study investigated the significance of change in neutrophil-to-lymphocyte ratio (NLR) during preoperative chemoradiotherapy (preop-CRT) in patients with non-metastatic rectal cancer using a propensity score matching method (PSM).

Methods

Patients who underwent surgery after completion of preop-CRT for non-metastatic rectal cancers from Jan 2004 to Dec 2013 were retrospectively enrolled. NLRs were obtained before commencement of CRT (pre-NLR) and between completion of CRT and surgery (post-NLR). Using Cox regression hazards models, the association of NLRs with survival after PSM was examined.

Results

A total of 131 patients were grouped as follows: group A, pre-NLR < 3 & post-NLR < 3 (n = 47); group B, pre-NLR < 3 & post-NLR ≥ 3 (n = 45); group C, pre-NLR ≥ 3 & post-NLR < 3 (n = 5); group D, pre-NLR ≥ 3 & post-NLR ≥ 3 (n = 34). There was no difference in disease-free survival (DFS) or overall survival (OS) rate according to group. When dichotomized into group A versus groups B-D, DFS was higher in group A (84.7%) than groups B-D (67.5%, p = 0.021). After PSM (n = 94), multivariable analysis identified persistent lower NLR as an independent favorable prognosticator of DFS (HR 0.37, 95% CI 0.15–0.92, p = 0.033).

Conclusions

Persistent non-inflammatory state measured by NLR may be an indicator of decreased risk of recurrence in patients with locally advanced rectal cancer treated with preop-CRT.

Lymphocyte nadir predicts tumor response and survival in locally advanced rectal cancer after neoadjuvant chemoradiotherapy: Immunologic relevance

BACKGROUND AND PURPOSE

Neoadjuvant chemoradiation (nCRT) could reduce tumor infiltrating lymphocytes. We examined absolute lymphocyte count (ALC) nadir during nCRT, pathologic response and prognosis for locally advanced rectal cancer (LARC).

MATERIALS AND METHODS

102 patients with LARC (cT3-4N0, or node-positive) treated between 2010 and 2015 with nCRT followed by complete resection were analyzed. The ALC value was obtained prior to, weekly during the treatment, and one month after nCRT. Associations of ALC nadir with immune cells' infiltrations, pathologic response and survival were analyzed.

RESULTS

Twenty-four (23.5%) and 60 (58.9%) patients achieved pathologic complete response and partial response respectively. Response rate was higher in high ALC nadir group than low nadir group (89.7% vs. 67.6%, p = 0.006). Compared to low ALC nadir group, increased tumor infiltrates of CD4+ (4% vs. 17.5%, p < 0.001), CD8+ (8% vs.30%, p < 0.001) T cells and CD68+ macrophages (6% vs. 25%, p < 0.001) were observed in high ALC nadir group. High ALC nadir [OR = 4.32 (95% CI, 1.22-15.26), p = 0.023] and well differentiation [OR = 10.53 (1.87-59.36), p = 0.008] were associated with pathologic response. Patients with high ALC nadir yielded better DFS [HR = 0.36 (0.16-0.81), p = 0.010] and OS [HR = 0.24 (0.08-0.69), p = 0.004].

CONCLUSIONS

Higher ALC nadir during nCRT is associated with a higher rate of pathologic response and better survival for LARC patients, suggesting that ALC may be a potential stratification strategy for LARC patients.

The prognostic value of combining the CD8 + lymphocyte density and the circulating lymphocyte ratio in circumferential resection margin biopsy in rectal cancer

BACKGROUND

A positive circumferential resection margin (CRM) may result in local recurrence (LR), but the significance remains controversial. We attempted to utilize the lymphocyte ratio (LYMR), neutrophil-lymphocyte ratio (NLR), tumor-infiltrating lymphocyte (TIL) count, and their combinations (TIL-LYMR/TIL-NLR) in predicting LR after rectal resection.

METHODS

Patients with rectal cancer who underwent curative resection between January 2016 and December 2018 were enrolled. Biopsy samples and data from the blood tests of 124 patients with rectal cancer who underwent curative resection were retrospectively obtained. Patients were divided into 2 groups: LR group and non-local recurrence (nLR) group. CD8 + TILs were immunostained using an antibody against CD8. The density of TILs was defined as the number of positive CD8 lymphocytes per square millimeter and was then graded as either high or low (cutoff = 80/mm). The count of LYMR and NLR was also graded as either high or low. The associations between TILs, LYMR, NLR, and their combinations (TIL-LYMR/TIL-NLR) were evaluated.

RESULTS

With a median follow-up of 24.4 months, TIL-LYMR showed a positive correlation with LR (P = .001), but not with the CD8 + TIL count (P = .215) or TIL-NLR count (P = .638). Among inflammatory and immune markers variables, univariate analysis revealed that gender, CD8 + TIL count, and TIL-NLR count were associated with anastomotic leakage (P = .001, P = .014, and P = .036, respectively). In multivariate analysis, TIL-LYMR remained an independent predictor of LR (OR = 8.918, CI = 1.124-70.747, P = .038). We also showed that gender associated with anastomotic leakage in rectal cancer (OR 5.429; 95% CI 1.885-15.637; P = .002).

CONCLUSION

In this study, our data indicate that absence of CD8 + T-cell infiltration in CRM may influence LR. These parameters may help identify LR provide additional information for therapeutic decision-making.

Delayed Cutaneous Hypersensitivity Reaction to Carcinoembryonic Antigen in Cancer Patients

The delayed cutaneous hypersensitivity reaction to carcinoembryonic antigen (CEA) was tested in 84 patients with different diseases including large bowel adenocarcinoma and breast carcinoma, with or without metastasis, liver cirrhosis and inflammatory or degenerative diseases. Positive skin test to CEA was observed in a small proportion (11 %) of the patients tested. No difference in positive skin test reactions was observed in the 6 different groups of patients. Similar delayed cutaneous hypersensitivity reactions were found to various amount of CEA ranging from 0.5 to 25 μg. No correlation was seen between the results of skin test and blood CEA levels.

Limitations of CEA Monitoring as a Guide to Second-Look Surgery in Colorectal Cancer Follow-Up

Forty-two patients with localized colorectal cancer (Dukes’ A, B, C stages) were treated with potentially curative surgery and controlled with a follow-up program, which included CEA monitoring, for a period ranging from 12 to 48 months (median 33 months). During this period, we observed recurrent neoplastic disease in 14 patients. A retrospective analysis of the results showed that: 1. patients with a preoperative CEA value > 20 ng/ml have a significantly higher risk of recurrence than the patients with CEA < 20 ng/ml; 2. sensitivity of the CEA test was good for metastatic recurrent disease, fairly good for residual neoplastic disease, but insufficient for local recurrence; 3. test-specificity was poor, as demonstrated by the negative results of four exploratory laparotomies performed exclusively on the basis of increased CEA levels. Since the principal aim of a second-look operation is the cure of local recurrence, this type of surgery cannot be proposed only on the basis of increased CEA levels.

The Clinical Value of the Tumor Markers Ca 19/9 and Carcinoembryonic Antigen (Cea) in Colorectal Carcinomas: A Critical Comparison

The monoclonal antibody serum test CA 19.9 after having been described as being colon tumor specific, was advertised as being more sensitive than CEA in the detection of both early and advanced colorectal carcinomas. Furthermore, the combined estimation of the two markers, CEA and CA 19.9 was said to improve the detection rate significantly. However, our own comparative studies as well as those of several other groups recently published have shown CA 19.9 measurements to be less valuable, because being less sensitive than those of CEA. This is especially true for the early stages of intestinal carcinomas.

The parallel determinations of CA 19.9 and CEA improved the positivity rate insignificantly, because in only 3.5% of all cases C 19.9 was elevated in CEA negative cancer sera. However, CA 19.9 was found to have a much lower rate of (false) positive results than CEA in benign intestinal diseases.

Effect of dexmedetomidine on stress reactions and cellular immune function of patients in perioperative period following radial resection for rectal carcinoma

The study aimed to assess the effects and the further mechanism of action of dexmedetomidine with regard to stress reactions and cellular immune function of patients during the perioperative period following radical resection for rectal carcinoma. A total of 36 patients with rectal carcinoma were selected for radical resection under general anesthesia. The patients were divided into two groups, namely an experimental and a control group. In the experimental group (dexmedetomidine group) 1 μg/ kg/bw dexmedetomidine was injected intravenously 10 min prior to the induction of general anesthesia, and then infusion was carried out at a rate of 0.2 μg·kg-1·h-1 for 30 min prior to the end of surgery. With regard to the control group, the same amount of normal saline (NS) was infused with the same method as the experimental group. Controlled intravenous analgesia was conducted following surgery to all of the patients. Regarding the effect of dexmedetomidine on the reaction of stress, a decrease of VAS scores was noted in the experimental group following extubation compared with the control group (P less than 0.05). Furthermore, a significant decrease in the consumption of morphine in the first 24 h was observed that was accompanied by a decrease of plasma cortisol levels at 6 and 24 h following surgery compared with the control group. The levels of IFN-γ/IL-10 in the experimental group were lower than those of the control group (P less than 0.05). The percentages of CD8+ and CD4+/CD8+ cells in the experimental group were increased compared with those of the control group (P less than 0.05). By infusing dexmedetomidine continuously, stress reactions during the perioperative period were significantly decreased, whereas the analgesic effects of opioid were increased.

Natural killer-like signature observed post therapy in locally advanced rectal cancer is a determinant of pathological response and improved survival

Around 12-15% of patients with locally advanced rectal cancer undergo a pathologically complete response (tumor regression grade 4) to long-course preoperative chemoradiotherapy; the remainder exhibit a spectrum of tumor regression (tumor regression grade 1-3). Understanding therapy-related transcriptional alterations may enable better prediction of response as measured by progression-free and overall survival, in addition to aiding the development of improved strategies based on the underlying biology of the disease. To this end, we performed high-throughput gene expression profiling in 40 pairs of formalin-fixed paraffin-embedded rectal cancer biopsies and matched resections following long-course preoperative chemoradiotherapy (discovery cohort). Differential gene expression analysis was performed contrasting tumor regression grades in resections. Enumeration of the tumor microenvironment cell population was undertaken using in silico analysis of the transcriptional data, and real-time PCR validation of NCR1 undertaken. Immunohistochemistry and survival analysis was used to measure CD56+ cell populations in an independent cohort (n=150). Gene expression traits observed following long-course preoperative chemoradiotherapy in the discovery cohort suggested an increased abundance of natural killer cells in tumors that displayed a clinical response to CRT in a tumor regression grade-dependent manner. CD56+ natural killer-cell populations were measured by immunohistochemistry and found to be significantly higher in tumor regression grade 3 patients compared with tumor regression grade 1-2 in the validation cohort. Furthermore, it was observed that patients positive for CD56 cells after therapy had a better overall survival (HR=0.282, 95% CI=0.109-0.729, χ2=7.854, P=0.005). In conclusion, we have identified a novel post-therapeutic natural killer-like transcription signature in patients responding to long-course preoperative chemoradiotherapy. Furthermore, patients with a higher abundance of CD56-positive natural killer cells post long-course preoperative chemoradiotherapy had better overall survival. Therefore, harnessing a natural killer-like response after therapy may improve outcomes for locally advanced rectal cancer patients. Finally, we hypothesize that future assessment of this natural killer-like response in on-treatment biopsy material may inform clinical decision-making for treatment duration.

Effects of oxycodone on immune function in patients undergoing radical resection of rectal cancer under general anesthesia

This study aims to explore the effect of oxycodone hydrochloride injection on the immune function of patients who underwent radical resection of rectal cancer under general anesthesia.Eighty patients were enrolled and randomly divided into group A and B (n = 40, each). All patients underwent general intravenous anesthesia. At the end of surgery, each patient in group A was injected with 5 mg (5 mL) of oxycodone hydrochloride, while 5 mg (5 mL) of morphine hydrochloride in group B. Venous blood was withdrawn in both groups at different time points. Changes in the numbers of T lymphocyte subsets and natural killer (NK) cells were determined by flow cytometry.First the numbers of T lymphocyte subsets and NK cells at T1, T2, T3, and T4 decreased in both groups, compared with those at T0, and the differences were statistically significant. Furthermore, the numbers reduced to a minimum at T2 and began to recover at T3. Second the differences between group A and B at T1, T2, T3, and T4 were statistically significant; and the numbers of T lymphocytes and NK cells were higher in group A than in group B at corresponding time points.Oxycodone hydrochloride and morphine hydrochloride both have inhibitory effects on immune function in patients undergoing radical resection of rectal cancer after surgery. However, oxycodone hydrochloride has a smaller effect compared to morphine hydrochloride.

[Detection and clinical significance of myeloid-derived suppressor cells in peripheral blood of patients with rectal carcinoma]

OBJECTIVE

To study the expression of myeloid-derived suppressor cells (MDSC) in peripheral blood of patients with rectal carcinoma and to preliminarily explore its clinical significance.

METHODS

Blood samples from 76 rectal carcinoma patients who underwent surgery in Department of General Surgery, The Affiliated Cancer Hospital, Zhengzhou University between June and October 2013 were collected before operation, postoperative day 10 and 2 years after operation respectively. Flow cytometry was used to detect MDSC percentage in peripheral blood of 76 rectal carcinoma patients and 40 healthy people. The change of MDSC percentage in peripheral blood of rectal carcinoma patients after treatment was investigated. Furthermore, the relationship of peripheral blood MDSC percentage with clinicopathological characteristics was examined.

RESULTS

Preoperative MDSC percentage in peripheral blood of 76 rectal carcinoma patients [(3.52±0.68)%] was higher than that of 40 healthy people[(0.92±0.21)%], with significant difference (t=3.026, P=0.005). Preoperative MDSC percentage in peripheral blood of rectal carcinoma patients was significantly related with histological classification (t=2.453, P=0.018), depth of tumor invasion (t=2.051, P=0.035), lymph node metastasis (t=2.328, P=0.022), TNM stage (t=2.529, P=0.016). Univariate analysis showed that TNM stage, histological classification, lymph node metastasis, preoperative MDSC percentage in peripheral blood were the prognostic factors in rectal carcinoma. Multivariate analysis showed that TNM stage (HR=2.535, 95%CI: 0.851 to 4.160, P=0.038) and preoperative MDSC percentage in peripheral blood (HR=3.651, 95%CI: 0.877 to 14.263, P=0.031) were independent prognostic factors of rectal carcinoma. MDSC percentage in peripheral blood of rectal carcinoma patients decreased significantly on the postoperative 10-day [(2.41±0.46)%] compared to that before operation [(3.52±0.68)%], whose difference was statistically significant (t=1.778, P=0.043). During follow-up, tumor recurrence or metastasis was found in 23 patients. MDSC percentage in peripheral blood of rectal carcinoma patients with recurrence or metastasis [(4.37±1.23)%] was higher than that of rectal carcinoma patients without recurrence or metastasis [(2.36±0.35)%] two years after operation, with statistically significant difference (t=1.982, P=0.039).

CONCLUSIONS

MDSC percentage in peripheral blood of rectal carcinoma patients is significantly elevated compared to that of healthy people. Increased MDSC percentage indicates poor prognosis and tumor progression in rectal carcinoma patients. Measurement of peripheral blood MDSC percentage may have a potential clinical value in prognosis prediction of rectal carcinoma.

[Clinical Significance of Serum p53 Antibody Measurement in Colorectal Cancer Patients]

We investigated the significance of serum p53 antibody in colorectal cancer. The subjects included 239 patients with colorectal cancerwithout any history of priortr eatment. Patients with multiple cancerordouble cancerwer e excluded. Serum p53 antibodies and relationships with clinicopathological factors and prognosis were examined. The preoperative positive rate of serum p53 antibody was 28.9%. There was no relationship between p53 antibody and clinicopathological factors or degree of progression. Examination of a possible relationship with prognosis revealed that p53 antibody was not related to whether recurrence occurred, and there was no difference observed for survival rate. Examination of the cases in which serum p53 antibody was measured continuously after curative resection revealed that there was a tendency to find a low incidence of cancer recurrence in cases in which serum p53 antibody became negative postoperatively. Furthermore, cancer recurred at a low incidence in the cases in which p53 antibody was on the decrease postoperatively(p=0.0008). Thus, ourr esults show that serum p53 antibody in colorectal cancer cases is not related to clinicopathological factors or prognosis. However, in cases positive for preoperative serum p53 antibody, changes in postoperative levels of the titer could be a marker for recurrence.

Analysis of tumor-infiltrating gamma delta T cells in rectal cancer

AIM: To investigate the regulatory effect of Vδ1 T cells and the antitumor activity of Vδ2 T cells in rectal cancer.

METHODS: Peripheral blood, tumor tissues and para-carcinoma tissues from 20 rectal cancer patients were collected. Naïve CD4 T cells from the peripheral blood of rectal cancer patients were purified by negative selection using a Naive CD4⁺ T Cell Isolation Kit II (Miltenyi Biotec). Tumor tissues and para-carcinoma tissues were minced into small pieces and digested in a triple enzyme mixture containing collagenase type IV, hyaluronidase, and deoxyribonuclease for 2 h at room temperature. After digestion, the cells were washed twice in RPMI1640 and cultured in RPMI1640 containing 10% human serum supplemented with L-glutamine and 2-mercaptoethanol and 1000 U/mL of IL-2 for the generation of T cells. Vδ1 T cells and Vδ2 T cells from tumor tissues and para-carcinoma tissues were expanded by anti-TCR γδ antibodies. The inhibitory effects of Vδ1 T cells on naïve CD4 T cells were analyzed using the CFSE method. The cytotoxicity of Vδ2 T cells on rectal cancer lines was determined by the LDH method.

RESULTS: The percentage of Vδ1 T cells in rectal tumor tissues from rectal cancer patients was significantly increased, and positively correlated with the T stage. The percentage of Vδ2 T cells in rectal tumor tissues from rectal cancer patients was significantly decreased, and negatively correlated with the T stage. After culture for 14 d with 1 μg/mL anti-TCR γδ antibodies, the percentage of Vδ1 T cells from para-carcinoma tissues was 21.45% ± 4.64%, and the percentage of Vδ2 T cells was 38.64% ± 8.05%. After culture for 14 d, the percentage of Vδ1 T cells from rectal cancer tissues was 67.45% ± 11.75% and the percentage of Vδ2 T cells was 8.94% ± 2.85%. Tumor-infiltrating Vδ1 T cells had strong inhibitory effects, and tumor-infiltrating Vδ2 T cells showed strong cytolytic activity. The inhibitory effects of Vδ1 T cells from para-carcinoma tissues and from rectal cancer tissue were not significantly different. In addition, the cytolytic activities of Vδ2 T cells from para-carcinoma tissues and from rectal cancer tissues were not significantly different.

CONCLUSION: A percentage imbalance in Vδ1 and Vδ2 T cells in rectal cancer patients may contribute to the development of rectal cancer.

[Relationship of preoperative and postoperative myeloid-derived suppressor cells percentage with the prognosis in rectal cancer patients]

OBJECTIVE

To observe the change of myeloid-derived suppressor cells (MDSCs) percentage in peripheral blood after operation in rectal cancer patients and to examine its association with the prognosis.

METHODS

Blood samples of pre-operation and postoperative 21-day from 64 stage I(-III( rectal cancer patients who underwent surgery in Department of General Surgery, The Affiliated Cancer Hospital, Zhengzhou University between January and December 2009 were collected. MDSCs percentage was detected by flow cytometry. Its association with the prognosis of patients was analyzed.

RESULTS

MDSCs percentage of postoperative 21-day decreased significantly compared with pre-operation (P<0.01). When local recurrence or distant metastasis presented, MDSCs percentage increased again (all P<0.01) and reached the preoperative level(P>0.05). All the patients were further divided into two groups based on median MDSCs percentage. Patients with higher MDSCs percentage before operation (>3.78%) and after operation (>2.11%) had significantly lower 5-year overall survival(OS) (58.1% and 62.1%) and 5-year disease-free survival (DFS)(54.8% and 58.6%) as compared to those with lower MDSCs percentage(5-year OS 87.9% and 84.8%; 5-year DFS 82.8% and 80.0%, all P<0.05). Multivariate analysis showed that preoperative MDSCs percentage was an independent prognostic factor of rectal cancer(HR:4.065, 95% CI:1.026 to 16.108, P=0.04).

CONCLUSIONS

Preoperative increased MDSCs percentage may be an important predictor of poor OS in rectal cancer patients. Dynamic change of MDSCs percentage can reflect the disease development.

[Immuno-Nutritional Factors Affecting the Incidence of Surgical Site Infection（SSI）after Rectal Cancer Surgery]

BACKGROUND

We analyzed immune nutritional factors that affected the incidence of SSI in rectal cancer surgery.

METHOD

A total of 103 patients who underwent rectal cancer resection were enrolled in this retrospective study. The risk factors (DM, BMI<18.5, ≥25.0, PNI≤40, G/L>2, CONUT≥2, mGPS D) for SSI (Grade≥Ⅱ) were analyzed.

RESULT

The factors that significantly affected SSI (in 13 cases) was PNI≤40 on univariate analysis. In the analysis adjusted by age and sex, mGPS D and PNI≤40 were significant factors. In the stepwise selection method, PNI≤40 was selected as an independent factor.

CONCLUSION

As a risk factor for SSI after rectal cancer surgery, PNI≤40 and mGPS were risk factors.

A prospective study of the immune system activation biomarker neopterin and colorectal cancer risk

BACKGROUND

Neopterin may be relevant for colorectal cancer (CRC) development, as a biomarker of cellular immune activity exerting pleiotropic effects on cellular ageing, oxidative stress, and inflammation. So far, the association between prediagnostic neopterin and colon and rectal cancer risk has not been evaluated in human populations.

METHODS

A nested case-control study was conducted within the European Prospective Investigation into Cancer and Nutrition cohort using data on plasma concentrations of total neopterin (T-N, sum of neopterin and 7,8-dihydroneopterin) in 830 incident CRC case patients (561 colon and 269 rectal) matched within risk sets to 830 control participants. A subsequent replication study used data from the Hordaland Health Study, where 173 CRC case patients have been diagnosed among 6594 healthy participants over 12 years of follow-up.

RESULTS

After multivariable adjustment for a priori chosen CRC risk factors, a "U-shaped" association of T-N with CRC was revealed. Compared with the second quintile of the T-N distribution, the relative risks for the first, third, fourth, and fifth quintiles were 2.37 (95% CI = 1.66 to 3.39), 1.24 (95% CI = 0.87 to 1.77), 1.55 (95% CI = 1.08 to 2.22), and 2.31 (95% CI = 1.63 to 3.27), respectively. Replication of these associations within the Hordaland Health Study yielded similar results. No differences have been observed when the associations were explored by colon and rectal cancer site (two-sided P difference = .87) and after excluding case patients diagnosed within the first four follow-up years.

CONCLUSIONS

These novel findings provide evidence of the role of both suppressed and activated cell-mediated immunity as reflected by prediagnostic T-N concentrations in the development of CRC.

Adverse reactions of biological therapy for psoriasis

AIM

To detect in patients with psoriasis the adverse effects during TNF-a inhibitor therapy.

MATERIAL AND METHODS

Fifty-seven patients with psoriasis, aged between 12 and 75 years were analyzed. They were treated with different TNF-α antagonists, the maximum treatment duration being 59 months. All patients were followed monthly after the initiation of therapy by clinical checkup, then every 3 months during the first 6 months of treatment by laboratory screening, and then every 6 month. Chest x-ray and tuberculin intradermal skin test were performed annually or as needed. All symptoms reported by patients were recorded, the treating doctor deciding the need for additional investigations or specialist consult.

RESULTS

Of the total of 57 patients with psoriasis on biological therapy, 9 patients developed diseases requiring temporary or permanent discontinuation of therapy. The recorded adverse reactions were: infectious (pulmonary tuberculosis, pulmonary empyema), oncologic (rectal cancer, renal cancer), dermatologic (vesiculobullous erythema multiforme major, nodular hypodermtis, secondary erythroderma, and hives) disorders.

CONCLUSIONS

Despite its adverse reactions, biological therapy is safe and is a necessary tool in the treatment of moderate and severe forms of psoriasis unresponsive to other treatments.

HLA class I expression and its alteration by preoperative hyperthermo-chemoradiotherapy in patients with rectal cancer

Objective

Enhancing immunologic responses, including human leukocyte antigen (HLA) class I expression on tumor cells and recognition and elimination of tumor cells by tumor-specific cytotoxic T lymphocyte (CTL), is considered a novel concept of radiotherapy. The present study examined patients who underwent preoperative hyperthermo-chemoradiotherapy (HCRT) for locally advanced rectal cancer to assess the correlation between HLA class I expression and clinical outcome.

Materials and Methods

Seventy-eight patients with locally advanced rectal adenocarcinoma who received preoperative HCRT were enrolled. The median age of the patients was 64 years (range, 33–85 years) and 4, 18, and 56 patients had clinical stage I, II and III disease, respectively. Formalin-fixed and paraffin-embedded tissues excised before and after HCRT were subjected to immunohistochemical analysis with an anti-HLA class I-A, B, C antibody. HLA class I expression was graded according to tumor cell positivity.

Results

In pre-HCRT, the number of specimens categorized as Grade 0 and 1 were 19 (24%) and 58 (74%), respectively. Only 1 patient (1%) showed Grade 2 expression. However, 6 (8%), 27 (35%), 7 (9%), and 12 (15%) post-HCRT specimens were graded as Grade 0, 1, 2, and 3, respectively. There was a significant increase in HLA class I expression in post-HCRT specimens (p<0.01). However, neither pre- nor post-HCRT HLA class I expression affected overall survival and distant metastasis-free survival in clinical stage III patients. Univariate analysis revealed that Post-HCRT HLA class I expression showed a significant negative relationship with LC (p<0.05). Nevertheless, multivariate analysis showed that there was no correlation between HLA class I expression and clinical outcome.

Conclusion

HCRT increased HLA class I expression in rectal cancer patients. However, multivariate analysis failed to show any correlation between the level of HLA class I expression and prognosis.

Drug allergy and the risk of lymph node metastasis in rectal cancer

Background

Previous epidemiologic studies have reported that a history of allergy is associated with reduced risk of colorectal cancer and other malignancies. However, no information is available for the association between allergy and the risk of lymph node metastasis. Our study was designed to determine this association in rectal cancer.

Methods

Patients who were treated at our hospital in the period from January 2003 to June 2011, and with a pathologically hospital discharge diagnosis of rectal adencarcinoma, were included. The clinical, laboratory, and pathologic parameters were analyzed. A multivariate logistic regression model was used to determine the association. Moreover, for type of allergic drug, sub-group analysis was performed.

Results

469 patients were included, including 231 with pathological lymph node metastasis (pLNM) (49.3%) and 238 without pLNM. Univariate analysis showed, compared with patients without pLNM, patients with pLNM had a younger age (60.6±12.8 yr vs. 63.6±12.2 yr, P = 0.012), a lower percentage of drug allergy (8.7% vs. 16.0%, P = 0.016), an increased CEA (median/interquartile-range 5.40/2.40–13.95 vs. 3.50/2.08–8.67, P = 0.009), and a lower serum sodium (141±3.1 mmol/L vs. 142±2.9 mmol/L, P = 0.028). Multivariate analysis showed that drug allergy was associated with a reduced risk of pLNM (OR = 0.553; 95% CI, 0.308–0.994; P = 0.048). In addition, our results showed that: (1) for tumor classification, patients with drug allergy had a higher percentage of group patients with pT1/pT2; and (2) for type of allergic drug, this inverse association was found for penicillins, not for other allergic drugs.

Conclusion

Drug allergy is associated with a reduced risk of pLNM in rectal cancer.

Prognostic value of HLA class I, HLA-E, HLA-G and Tregs in rectal cancer: a retrospective cohort study

BACKGROUND

Evasion of immune surveillance and suppression of the immune system are important hallmarks of tumorigenesis. The goal of this study was to establish distinct patterns that reflect a rectal tumors' immune-phenotype and to determine their relation to patient outcome.

METHODS

The study population consisted of 495 Stage I-IV non-preoperatively treated rectal cancer patients of which a tissue micro array (TMA) was available. Sections of this TMA were immunohistochemically stained and quantified for presence of Foxp3+ cells (Tregs) and tumor expression of HLA Class I and non-classical HLA-E and HLA-G. All markers were, separate and combined, analyzed for clinical prognostic value.

RESULTS

Expression of HLA class I (DFS HR 0.637 (0.458-0.886), p = 0.013), Foxp3+ infiltration above median (OS HR 0.637 (0.500-0.813), p < 0.001 and DFS HR 0.624 (0.491-0.793), p < 0.001) and expression of HLA-G (DFS HR 0.753 (0.574-0.989), p = 0.042) were related to a better clinical prognosis. When these markers were combined, patients with 2 or 3 markers associated with poor prognosis (loss of HLA Class I, Foxp3+ below median, and weak HLA-G expression), showed a significantly worse survival (OS and DFS p < 0.001). This immune-phenotype was an independent predictor for DFS (HR 1.56 (1.14-2.14), p = 0.019).

CONCLUSIONS

In conclusion, rectal tumors showing loss of HLA class I expression, Foxp3+ infiltration below median and weak HLA-G expression were related to a worse OS and DFS. Combining these immune markers lead to the creation of tumor immune-phenotypes , which related to patient outcome and were significant independent clinical prognostic markers in rectal cancer.

Advances in radiotherapy and targeted therapies for rectal cancer

The last decade witnessed a significant progress in understanding the biology and immunology of colorectal cancer alongside with the technical innovations in radiotherapy. The stepwise implementation of intensity-modulated and image-guided radiation therapy by means of megavolt computed tomography and helical tomotherapy enabled us to anatomically sculpt dose delivery, reducing treatment related toxicity. In addition, the administration of a simultaneous integrated boost offers excellent local control rates. The novel challenge is the development of treatment strategies for medically inoperable patient and organ preserving approaches. However, distant control remains unsatisfactory and indicates an urgent need for biomarkers that predict the risk of tumor spread. The expected benefit of targeted therapies that exploit the tumor genome alone is so far hindered by high cost techniques and pharmaceuticals, hence hardly justifying rather modest improvements in patient outcomes. On the other hand, the immune landscape of colorectal cancer is now better clarified with regard to the immunosuppressive network that promotes immune escape. Both N2 neutrophils and myeloid-derived suppressor cells (MDSC) emerge as useful clinical biomarkers of poor prognosis, while the growing list of anti-MDSC agents shows promising ability to boost antitumor T-cell immunity in preclinical settings. Therefore, integration of genetic and immune biomarkers is the next logical step towards effective targeted therapies in the context of personalized cancer treatment.

Long-term vaccine therapy with autologous whole tumor cell-pulsed dendritic cells for a patient with recurrent rectal carcinoma

We performed continuous dendritic cells (DCs) vaccination to treat a patient with chemotherapy-resistant recurrent rectal carcinoma and lung and bone metastases. A patient has received a total of 66 DC vaccinations at 14-day intervals for 3 years until his death. Necrotic whole tumor cells (WTC) were selected as the tumor-associated antigen source because they showed a greater capacity for DC maturation and interleukin-12 secretion than both necrotic tumor lysate alone and necrotic tumor cell fragment alone. After the sixth vaccination, both skin test and interferon-γ (IFN-γ) enzyme-linked immunospot (ELISPOT) response by peripheral blood T-cells to WTC-pulsed DCs were positive. Importantly, T-cell responses were positive towards DCs pulsed with several synthetic peptides including Carcinoembryonic antigen (CEA), Melanoma associated antigen (MAGE)1 and MAGE3. A biopsy specimen collected from the pelvic bone metastasis after the 6th vaccination showed marked necrotic change of the carcinoma cells, with many infiltrating mononuclear cells. The patient did not show any particular adverse reactions to vaccination such as autoimmune phenomena. Our experience of this case suggests that continuous long-term vaccination with autologous WTC-pulsed DCs can elicit in vivo T-cell response against multiple tumor-associated antigens and induce tumor regression in disease that has proven resistant to intensive chemo- or radiation therapy.

[Hepatic intra-arterial infusion of BAK immune cells to treat metastatic liver cancer]

Based on the "living with cancer" concept while maintaining a favorable QOL and avoiding side effects and drug resistance, we have developed a new immune cell treatment called BAK (BRM activated killer) therapy, primarily using CD56+ cells for a case of advanced progressive solid cancer. In the present case, we administered BAK cells by hepatic intra-arterial infusion to a patient who happened to be a surgeon and wished to undergo this therapy. The patient was a 52-year- old male surgeon who underwent surgery for rectal cancer in April 2007. Heavy particle radiotherapy was administered when liver metastases were identified in July 2008. Starting in December 2008, 10 billion BAK cells were administered each month by hepatic intra-arterial infusion via a catheter on a total of six different occasions. The 10 billion autologous lymphocytes were suspended in 200 mL of Ringer's solution and returned to the patient by hepatic intra-arterial infusion over a period of one hour. Interactions between the activated lymphocytes and liver cancer cells increased levels of serum α1AG, an inflammation marker, but these levels normalized following the sixth and final administration. Conventional drip-infusion BAK therapy was administered thereafter. Diagnostic imaging, including PET-CT and PET, confirmed a complete disappearance of liver metastases. This case suggests the effectiveness of hepatic intra-arterial infusion BAK cell therapy in treating liver cancer.

Expression of cancer stem cell markers CD133 and CD44 in locoregional recurrence of rectal cancer

BACKGROUND

Recent findings suggest that cells with surface CD markers include cancer stem cells (CSCs) which can produce a cancer cluster, and that the presence of CSCs may be linked with prognosis. CD133 and CD44 are among the most useful markers for identification of colorectal CSCs.

MATERIALS AND METHODS

An immunohistological analysis of CD133 and CD44 was performed using tissue from cases shown to be locoregionally recurrent or non-recurrent clinico-pathologically.

RESULTS

The CD133-positive rates were 38.7% and 59.23% in non-recurrent and recurrent cases, respectively, and the CD44-positive rates were 35.5% and 44.4%, respectively. Expression of the CD markers had no correlation with other clinicopathological factors. The prognosis of patients who were positive for both markers was significantly worse than that of other patients.

CONCLUSION

These results suggest that detection of CD133 and CD44 can provide useful information for selection of treatment and performance of intensive follow-up of colorectal cancer.

The surgical stress response and postoperative immune function after laparoscopic or conventional total mesorectal excision in rectal cancer: a randomized trial

PURPOSE

This study evaluated differences in stress response and immunological function following laparoscopic and conventional total mesorectal excision (TME) for rectal cancer.

METHODS

Patients with non-metastasized rectal cancer were prospectively randomized to open (n = 18) or laparoscopic (n = 22) TME. Blood samples were taken preoperatively (baseline), 2, 24, and 72 h following surgery. Systemic white blood cell and monocyte count, C-reactive protein, interleukin-6 (IL-6), interleukin-8 (IL-8), HLA-DR expression on monocytes, growth hormone, prolactin, and cortisol were measured.

RESULTS

Forty patients with a median age of 66 years (interquartile range, 60-74 years) were included. Eighteen patients (45%) were randomized to open surgery and 22 patients (55%) to laparoscopic surgery. Patient demographics in terms of gender, age, BMI, ASA classification, localization of the tumor, and type of neoadjuvant therapy were comparable for both groups. Laparoscopic surgery resulted in a significantly better short-term preservation of postoperative immune function. HLA-DR expression on monocytes was significantly higher (64% vs 50%, P = 0.014) and IL-6 level increase was significantly lower (4.6 vs 10.8, P = 0.003) 2 h after laparoscopic surgery. No differences between the open and laparoscopic technique were observed in postoperative white blood cell count, monocyte count, C-reactive protein, IL-8, growth hormone, prolactin, and cortisol levels.

CONCLUSION

Short-term postoperative immune and inflammatory functions tended to be better after laparoscopic rectal surgery. However, the differences were not consistent at all time intervals, making a definitive conclusion difficult. Better preserved inflammatory function 2 h after surgery may reflect a reduction in operative trauma when the laparoscopic technique is compared with open rectal procedures.

Survival in rectal cancer is predicted by T cell infiltration of tumour-associated lymphoid nodules

Lymphoid nodules are a normal component of the mucosa of the rectum, but little is known about their function and whether they contribute to the host immune response in malignancy. In rectal cancer specimens from patients with local (n=18), regional (n=12) and distant (n=10) disease, we quantified T cell (CD3, CD25) and dendritic cell (CD1a, CD83) levels at the tumour margin as well as within tumour-associated lymphoid nodules. In normal tissue CD3+, but not CD25+, T cells are concentrated at high levels within lymphoid nodules, with significantly fewer cells found in surrounding normal mucosa (P=0.001). Mature (CD83), but not immature (CD1a), dendritic cells in normal tissue are also found clustered almost exclusively within lymphoid nodules (P=<0.0001). In rectal tumours, both CD3+ T cells (P=0.004) and CD83+ dendritic cells (P=0.0001) are also localized preferentially within tumour-associated lymphoid nodules. However, when comparing tumour specimens to normal rectal tissue, the average density of CD3+ T cells (P=0.0005) and CD83+ dendritic cells (P=0.0006) in tumour-associated lymphoid nodules was significantly less than that seen in lymphoid nodules in normal mucosa. Interestingly, regardless of where quantified, T cell and dendritic cell levels did not depend upon the stage of disease. Increased CD3+ T cell infiltration of tumour-associated lymphoid nodules predicted improved survival, independent of stage (P=0.05). Other T cell (CD25) markers and different levels of CD1a+ or CD83+ dendritic cells did not predict survival. Tumour-associated lymphoid nodules, enriched in dendritic cells and T cells, may be an important site for antigen presentation and increased T cell infiltration may be a marker for improved survival.

Effects of preoperative immunochemoradiotherapy and chemoradiotherapy on immune responses in patients with rectal adenocarcinoma

BACKGROUND

We previously reported that preoperative chemoradiotherapy (CRT) combined with intraoperative electron irradiation for cT3/T4 adenocarcinoma of the rectum reduced the local recurrence, with significant improvement of survival. Radiotherapy has been reported to reduce immune function. We examined the effects of PSK, a protein-bound polysaccharide, concomitant with preoperative CRT on immune responses.

PATIENTS AND METHODS

Thirty patients with cT3/T4 adenocarcinoma of the rectum were randomly assigned to 2 weeks' irradiation and 4 weeks' S-1 administration before surgery (control group), or the same CRT with simultaneous 4 weeks' PSK administration (PSK group). Both systemic and local immune responses were evaluated.

RESULTS

Significant increase of natural killer cell count in the peripheral blood and cytotoxic T-cell counts in the peri-tumoral and normal mucosa, and a significant decrease of serum immunosuppressive acidic protein level were observed in the PSK group.

CONCLUSION

Combined use of PSK with preoperative CRT may improve immune function.

[Immunochemical assay of MIC A production by tumor cells in vitro and in vivo as a component of antitumor vaccine development]

Due to immunological monitoring, most of aggressive tumor cells are selected capable of producing soluble factors of immunosuppression in their microenvironment. A ligand for NK- and T-cells receptor (MICA/B) activation is one of them. We investigated MICA concentrations in serum of 10 healthy volunteers and 114 patients with solid tumors (breast cancer - 24, gastrointestinal tumors - 27, renal cell carcinoma - 15, lung cancer - 9, ovarian carcinoma - 13, cutaneous melanoma - 18, primary multiple tumors - 2, prostate cancer - 6). The lowest level of MICA was reported in ovarian carcinoma (91.19 +/- 29.42 pg/ml), the highest - in rectal cancer (311.13 +/- 50.11 pg/ml) while mean concentration in healthy volunteers was (19.38 +/- 5.91 pg/ml). Cells of melanoma, renal cell carcinoma and prostate cancer became capable of producing MICA during cultivation and antitumor vaccine preparation. It is suggested that culture supernatants be tested for MICA contents as well as patients screened for vaccination. Selection of patients should be carried out on the basis of MICA molecules detection in blood flow.

[A case of liver metastasis of rectal cancer, refractory to previous chemotherapy(5-FU/LV, irinotecan, oxaliplatin) responding to bevacizumab combined with FOLFIRI chemotherapy]

The case was a 69-year-old man with liver metastasis who had relapsed after the resection of rectal cancer. We treated the patient with FOLFIRI+bevacizumab(BV)after the failure of S-1+CPT-11, radiation, UFT/LV, FOLFOX and FOLFIRI regimen. The tumor marker level and accumulation of FDG-PET were rapidly decreased after initiating FOLFIRI+BV. There was no serious adverse event, and a remarkable improvement of QOL was observed. This case suggests that the BV combination regimen is useful even after the failure of FOLFOX and FOLFIRI regimen.

[Effect of laparoscopic-assisted resection of rectal carcinoma on C-reactive protein and humoral immunity]

OBJECTIVE

To investigate the effect of laparoscopic-assisted resection of rectal carcinoma on perioperative levels of C-reactive protein (CRP), immunoglobulins(Ig) and complements.

METHODS

Fifty-four patients with rectal carcinoma were divided into laparoscopic group (n=26) and open operation group(n=28) according to the patients' will. C-reactive protein (CRP), IgG, IgA, IgM, C(3), C(4) and CH(50) of peripheral blood were assayed preoperatively and on the 1st, 2nd, 3rd and 7th day postoperatively.

RESULTS

Compared with the preoperative period, the CRP levels in both groups were significantly increased on the 1st, 2nd, and 3rd day(P<0.01) and peaked on the 2nd day postoperatively. The postoperative CRP levels were significantly lower in the laparoscopic group than those in the open operation group(P<0.01). After operation, the immunoglobulin levels were significantly decreased in both groups(P<0.01), and there were no significant differences in IgG and IgM. The levels of C(3), C(4) and CH(50) were significantly decreased after operation in both groups(P<0.05) and returned to the preoperative levels during postoperative 48-72 hours in laparoscopic group.

CONCLUSION

Laparoscopic-assisted resection of rectal carcinoma results in less wound, lower levels of stress response, and less effect on immune function compared to open surgery, which recovers the immune function of patients more rapidly after operation.

Targeting of CD4+CD25high cells while preserving CD4+CD25low cells with low-dose chimeric anti-CD25 antibody in adoptive immunotherapy of cancer

The CD4+CD25high regulatory T (Treg) cells have been demonstrated to negatively modulate anti-tumor immune responses in cancer patients. In this study, effects of low dose anti-CD25 antibody (Ab) to attenuate Treg cells were investigated in cancer patients in vitro and in vivo. Peripheral blood mononuclear cells (PBMCs) from cancer patients were cultivated in vitro in the presence of a high-affinity chimeric anti-CD25 Ab (basiliximab). The CD4+CD25high population, interferon-gamma (IFN-gamma) production and FOXP3 expression were analyzed using flow cytometry (FCM), enzyme-linked immunosorbent assay and reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, respectively. During in vivo studies, basiliximab was administered intravenously on day 1, followed by AIT using autologous activated lymphocytes on day 8, and the treatment cycle was repeated. Subjective and objective effects were observed, and patients' PBMCs were subjected to FCM and RT-PCR analysis. In vitro analysis revealed that a low concentration of 0.01 microg/ml basiliximab reduced almost all of CD4+CD25high cells, but less of the CD4+ CD25low cells, and augmented IFN-gamma production of activated PBMCs. FOXP3 mRNA expression of PBMCs was not affected with or without basiliximab. An in vivo study of 9 metastatic cancer patients (7 colorectal and 2 esophageal) demonstrated no subjective or objective adverse effects, even under repeated administration of basiliximab. The results suggested that low-dose basiliximab can safely be administered repeatedly, and can target CD4+CD25high Treg cells whilst relatively preserving CD4+CD25low activated T cells. The host conditioning with low-dose basiliximab may augment the efficacy of AIT for cancer using activated autologous lymphocytes.

[Influence of preoperative chemoradiotherapy, preoperative chemotherapy, and operation on immunity function in middle or lower rectal cancer patients]

OBJECTIVE

To study the influence of preoperative chemoradiotherapy, preoperative chemotherapy, and operation alone on the cellular immunity in patients with middle or lower rectal cancer.

METHODS

Ninety middle or lower rectal cancer patients were non-randomly divided into 3 equal groups: preoperative radiotherapy group, receiving conventional radiotherapy with a total dose of 30 Gy in 10 fractions completed within 2 weeks; preoperative chemoradiotherapy group, receiving 2 cycles of single-oral drug regimen (capecitabine 1000 mg/m(2) for 2 weeks as a cycle with an interval of 1 week) and then, i.e., 2 days later, receiving conventional radiotherapy as prescribed for the patients in the preoperative radiotherapy group; and operation alone group. Operation was performed on the patients of the former 2 groups 3 weeks after the completion of the relevant treatment. Blood samples were collected on the admission day, 1 day before operation, and 7 day and 1 month after operation. Flow cytometry was used to detect the levels of CD(3)(+), CD(4)(+), CD(8)(+), CD(4)(+)/CD(8)(+), and NK cells.

RESULTS

There were no significant differences in the levels of CD(3)(+), CD(4)(+), CD(8)(+), CD(4)(+)/CD(8)(+), and NK cells before and after radiotherapy between the preoperative chemoradiotherapy group and preoperative chemotherapy group (all P > 0.05). 7 days after operation, the levels of CD(3)(+), CD(4)(+), CD(4)(+)/CD(8)(+), and NK cells were degraded and the CD(8)(+) level was increased significantly (all P < 0.05) in all 3 groups. One month after operation, the levels of CD(3)(+), CD(4)(+), CD(4)(+)/CD(8)(+), and NK cells were all significantly higher and the CD(8)(+) level was significantly lower than those before operation and 7 days after operation (all P < 0.05)in all 3 groups. There were no significant differences in the T cell number and the proportions of different categories of cells at different time points in these 3 group (all P < 0.05).

CONCLUSION

Preoperative chemoradiotherapy and preoperative chemotherapy have no significant impact on the cellular immune function in the patients with rectal cancer.

[A case with liver resection of metastasis from rectal cancer after FOLFOX4+bevacizumab treatment]

We report a 59-year-old woman with rectal cancer who underwent low anterior resection in March 2007. After curative operation at Stage IIIb(pT3N2M0), multiple liver metastasis was diagnosed in May 2007. Chemotherapy with FOLFOX4+bevacizumab was performed from June to August in 2007, and liver resection(left lobectomy and partial resection)was performed in September 2007. Bevacizumab was newly available from June 2007 in Japan, and liver resection after bevacizumab administration was safely performed.

A study of immunoendocrine strategies with pineal indoles and interleukin-2 to prevent radiotherapy-induced lymphocytopenia in cancer patients

BACKGROUND

Lymphocytopenia represents one of the most evident side-effects of radiotherapy (RT), particularly in the case of irradiation of pelvis, since it is the main location of bone-marrow proliferating cells in adults. Because of the fundamental role of lymphocytes in suppressing anticancer immunity, RT-induced lymphocytopenia could negatively influence the prognosis of cancer patients and the therapeutic efficacy of RT itself. In experimental conditions, the biological toxicity of irradiation appeared to be reduced by antioxidant agents, such as pineal hormones melatonin. A preliminary study was conducted to evaluate the influence of different immunobiological strategies with pineal indoles melatonin (MLT), 5 methoxytriptamine (5-MTT) or low-dose IL-2, the lymphocyte growth factor, on pelvic irradiation-induced lymphocytopenia in cancer patients suffering from rectal cancer or uterine cervix carcinoma.

PATIENTS AND METHODS

The study included 20 consecutive patients, who underwent pelvic irradiation for a total dose of 50.4 Gy. The patients were randomized to be concomitantly treated with MLT alone, with MLT plus 5-MTT or with s.c. low-dose IL-2 .

RESULTS

RT induced a significant decline in the mean number of lymphocytes while neither MLT alone, nor MLT plus 5-MTT were able to significantly reduce this decline. Conversely, IL-2 caused a statistically significant reduction of the RT-induced effect, so that the mean number of lymphocytes was significantly higher in patients concomitantly treated by IL-2 than in the other groups.

CONCLUSION

This preliminary study showed that low-dose IL-2 was sufficient to reduce, even though not to completely abrogate, RT-induced lymphocytopenia. Further studies with different schedules and doses of IL-2 will be required to optimize the protective effect of IL-2 on irradiation-induced lymphocytopenia in humans.

Immunoscintigraphy of local recurrent rectal cancer with 99mTc-labeled anti-CEA monoclonal antibody CL58

AIM: To explore a specific diagnostic method for local recurrent rectal cancer.

METHODS: Immunoscintigraphy with ^99mTc-labeled anti-CEA monoclonal antibody (MoAb) CL-58 was performed for patients suspected of having a postoperative local recurrent rectal cancer and the findings were compared with the results of conventional imaging and pathology.

RESULTS: A total of 36 patients with a suspected local recurrent rectal cancer underwent immunoscintigraphy with ^99mTc-conjugated CL58. Local recurrence of rectal cancer was identified in 31 patients and established in 30 during operation, endoscopy and pathological examination. No local recurrence was found in 5 patients without specific accumulation of ^99mTc during the follow-up. Immunoscintigraphy had a positive rate of 86.11%, a specificity of 83.33%, and a sensitivity of 100%.

CONCLUSION: Immunoscintigraphy has a highly specific and predictive value for detecting local recurrent rectal cancer, especially after abdominal perineal resection (APR).

Predictors of recurrence in patients with T2 and early T3, N0 adenocarcinoma of the rectum treated by surgery alone

PURPOSE

Treatment of rectal cancer with neoadjuvant radiotherapy has been shown to reduce local recurrence and improve overall survival. The role of chemoradiotherapy in patients with T2, N0 and early T3, N0 rectal cancer, treated by radical surgery with total mesorectal excision, remains controversial. The aim of this study was to identify predictors of recurrence in this group of patients to enhance treatment selection.

PATIENTS AND METHODS

One hundred patients with primary T2-3, N0 adenocarcinoma of the rectum, uniformly treated by surgery alone, were studied. The pathology slides available for 97 patients were rereviewed. Three patients with incomplete data sets were excluded. Clinical and survival data were obtained from a prospective computerized database and updated from hospital and office charts. The study end points were disease-free survival, disease-specific survival (DSS), time to pelvic recurrence (PR), and distant recurrence.

RESULTS

Complete follow-up was available for all study patients. Median follow-up was 79.5 months (range, 57.7 to 105.9 months). During this time period 30 patients (31.9%) died as a result of disease and 64 patients (68.1%) remained alive and disease free. Five-year DSS was 73%. The cumulative risk for PR was 8% at 5 years and 10% at 8 years. Lymphovascular invasion, preoperative serum carcinoembryonic antigen (CEA > 5 ng/mL) level, and age older than 70 years were all associated with adverse outcome. CONCLUSION Patients with T2-3, N0 rectal cancers and either lymphovascular invasion or elevated CEA levels have reduced survival and a higher incidence of PR, and should be considered for future randomized trials.

[The prospective study on application of parenteral nutrition with alanyl-glutamine dipeptide in chemotherapy of gastrointestinal neoplasms patients]

BACKGROUND & OBJECTIVE

There is an argument on whether or not glutamine-supplemented parenteral nutrition is beneficial to chemotherapy in gastrointestinal neoplasm patients. The aim of this study was to prospectively evaluate the effect of parenteral nutrition with alanyl-glutamine dipeptide on gastrointestinal neoplasm patients receiving chemotherapy.

METHODS

This study was a prospective, randomized double-blind clinical trial. Seventy-two patients were randomly divided into study group and control group (each group had 36 patients). The side effects during chemotherapy were observed. Serum albumin, serum pre-albumin, IgG, IgA, IgM, C3, C4 level were measured before chemotherapy and on day 4 and day 8 after chemotherapy. Nitrogen balance was also calculated simultaneously.

RESULTS

(1) Less side effects during chemotherapy in study group were revealed compared to those in control group (P<0.05). (2) Serum albumin and pre-albumin levels were both decreased in the two groups on day 4 after chemotherapy, and were markedly decreased in control group on day 8 after chemotherapy (P<0.05). (3) IgG, IgM, IgA levels were all decreased compared with the test results before chemotherapy on day 4 after chemotherapy in two groups, and were significantly decreased in control group on day 8 after chemotherapy (P<0.05). C3 and C4 levels were higher in study group compared with control group on day 8 after chemotherapy (P<0.05). (4) Nitrogen balance in study group was better than that in control group (P<0.05) on day 8 after chemotherapy.

CONCLUSIONS

Alanyl-glutamine dipeptide is beneficial to chemotherapy in gastrointestinal neoplasm patients. It could reduce the side effects of chemotherapy, which helps to improve the nutritional status, the immune function and the survival quality of patients during chemotherapy.