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Lloyd JM, McIver CM, Stephenson S-A, Hewett PJ, Rieger N, Hardingham JEIdentification of early-stage colorectal cancer patients at risk of relapse post-resection by immunobead reverse transcription-PCR analysis of peritoneal lavage fluid for malignant cells. Clin Cancer Res 12: 417-423
Abstract
Colorectal cancer patients diagnosed with stage I or II disease are not routinely offered adjuvant chemotherapy following resection of the primary tumor. However, up to 10% of stage I and 30% of stage II patients relapse within 5 years of surgery from recurrent or metastatic disease. The aim of this study was to determine if tumor-associated markers could detect disseminated malignant cells and so identify a subgroup of patients with early-stage colorectal cancer that were at risk of relapse.
We recruited consecutive patients undergoing curative resection for early-stage colorectal cancer. Immunobead reverse transcription-PCR of five tumor-associated markers (carcinoembryonic antigen, laminin gamma2, ephrin B4, matrilysin, and cytokeratin 20) was used to detect the presence of colon tumor cells in peripheral blood and within the peritoneal cavity of colon cancer patients perioperatively. Clinicopathologic variables were tested for their effect on survival outcomes in univariate analyses using the Kaplan-Meier method. A multivariate Cox proportional hazards regression analysis was done to determine whether detection of tumor cells was an independent prognostic marker for disease relapse.
Overall, 41 of 125 (32.8%) early-stage patients were positive for disseminated tumor cells. Patients who were marker positive for disseminated cells in post-resection lavage samples showed a significantly poorer prognosis (hazard ratio, 6.2; 95% confidence interval, 1.9-19.6; P = 0.002), and this was independent of other risk factors.
The markers used in this study identified a subgroup of early-stage patients at increased risk of relapse post-resection for primary colorectal cancer. This method may be considered as a new diagnostic tool to improve the staging and management of colorectal cancer.
... Surgical resection is the most effective method to remove primary tumors and metastatic lymph nodes. However, some cancer cells may remain after surgery, and micro-metastases or tumor dislodged during surgical manipulation may spread via lymphovascular vessels [1]. During the perioperative period, surgery induced stress responses and anesthetic-induced immunosuppression may play a critical role in establishment and growth of metastatic lesions [2][3][4][5]. ...
... Although surgical resection is a major component of cancer treatment, surgery itself suppresses immunity; thus, metastasis is promoted through growth facilitation of pre-existing micro-metastases and dissemination of cancer cells during resection of the primary lesion [20]. Detection of tumor cells in peritoneal blood and fluid after surgery has been associated with significantly shorter disease-free survival in patients with colorectal cancer [1,21]. Given that surgery modifies neural, endocrine, metabolic, inflammatory, and immunologic microenvironments [22], surgery-induced stress responses may activate angiogenesis and increase vascularization to promote tumor growth [2][3][4][5]. ...
... Increased vascularization [3] Augmentation of angiogenesis [2] Inadvertent dispersal of tumor cells [20] Modification of neural, endocrine, metabolic, inflammatory, and immunologic microenvironments [1] Detectable tumor cells in blood and peritoneal fluid after surgery associated with shorter disease-free survival in colorectal cancer [1] Surgery causes neoplastic cells to be dislodged from primary tumor [1,21] Induction of angiogenesis and proliferation of distant, dormant micrometastases in breast cancer surgery [4] Surgery-induced angiogenesis in breast cancer [5] Acceleration of metastasis by surgical resection of primary breast cancer [25] Surgical manipulation NK cell activity Suppression of NK cell activity, dependent on extent of surgical trauma and intensity of stress response [29] Stimulation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system ...
Background:
The relationship between surgery and anesthetic-induced immunosuppression and cancer recurrence remains unresolved. Surgery and anesthesia stimulate the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) to cause immunosuppression through several tumor-derived soluble factors. The potential impact of surgery and anesthesia on cancer recurrence was reviewed to provide guidance for cancer surgical treatment.
Methods:
PubMed was searched up to December 31, 2016 using search terms such as, "anesthetic technique and cancer recurrence," "regional anesthesia and cancer recurrence," "local anesthesia and cancer recurrence," "anesthetic technique and immunosuppression," and "anesthetic technique and oncologic surgery."
Results:
Surgery-induced stress responses and surgical manipulation enhance tumor metastasis via release of angiogenic factors and suppression of natural killer (NK) cells and cell-mediated immunity. Intravenous agents such as ketamine and thiopental suppress NK cell activity, whereas propofol does not. Ketamine induces T-lymphocyte apoptosis but midazolam does not affect cytotoxic T-lymphocytes. Volatile anesthetics suppress NK cell activity, induce T-lymphocyte apoptosis, and enhance angiogenesis through hypoxia inducible factor-1α (HIF-1α) activity. Opioids suppress NK cell activity and increase regulatory T cells.
Conclusion:
Local anesthetics such as lidocaine increase NK cell activity. Anesthetics such as propofol and locoregional anesthesia, which decrease surgery-induced neuroendocrine responses through HPA-axis and SNS suppression, may cause less immunosuppression and recurrence of certain types of cancer compared to volatile anesthetics and opioids.
... A wide range of 2.1% to 52% positive peritoneal cytology is reported across several studies, which reflects the heterogeneity of the techniques and the timing to detect malignant cells in peritoneal washes (Table 2) [45,76,78] . Lloyd et al [75] and Altomare et al [79] performed both pre and post resection peritoneal lavage cytology analysis using polymerase chain reaction. They both report a similar preresection rate of positive cytology, 12% to 14%, but differ in the post resection detection rate, 3% [79] and 20% [75] . ...
... Lloyd et al [75] and Altomare et al [79] performed both pre and post resection peritoneal lavage cytology analysis using polymerase chain reaction. They both report a similar preresection rate of positive cytology, 12% to 14%, but differ in the post resection detection rate, 3% [79] and 20% [75] . Recently, Bae et al [76] performed peritoneal lavage cytology in patients with CRC without distant metastasis who underwent curative resection, immediately after making a midline abdominal incision and just before manipulation of the tumor. ...
... Kirstensen et al [73] 237 PCR 200-600 mL 0.9% NaCl After 8.01% Nishikawa et al [74] 410 Cytology 200 mL 0.9% NaCl Before 7.60% Lloyd et al [75] 125 Immunobead RT-PCR 100 mL 0.9% NaCl Before 12.80% After 29.60% Bae et al [76] 145 Cytology 100 mL 0.9% NaCl Before 4.10% Noura et al [77] 697 Cytology 100 mL 0.9% NaCl Before 2.20% Altomare et al [79] 29 glycoprotein, which is widely expressed in several non neoplastic cells as well as neoplastic cells and is involved in migration of cells, homotypic and heterotypic cell cell adhesion. ...
Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death worldwide. Besides the lymphatic and haematogenous routes of dissemination, CRC frequently gives rise to transcoelomic spread of tumor cells in the peritoneal cavity, which ultimately leads to peritoneal carcinomatosis (PC). PC is associated with a poor prognosis and bad quality of life for these patients in their terminal stages of disease. A loco-regional treatment modality for PC combining cytoreductive surgery and hyperthermic intraperitoneal peroperative chemotherapy has resulted in promising clinical results. However, this novel approach is associated with significant morbidity and mortality. A comprehensive understanding of the molecular events involved in peritoneal disease spread is paramount in avoiding unnecessary toxicity. The emergence of PC is the result of a molecular crosstalk between cancer cells and host elements, involving several well-defined steps, together known as the peritoneal metastatic cascade. Individual or clumps of tumor cells detach from the primary tumor, gain access to the peritoneal cavity and become susceptible to the regular peritoneal transport. They attach to the distant peritoneum, subsequently invade the subperitoneal space, where angiogenesis sustains proliferation and enables further metastatic growth. These molecular events are not isolated events but rather a continuous and interdependent process. In this manuscript, we review current data regarding the molecular mechanisms underlying the development of colorectal PC, with a special focus on the peritoneum and the role of the surgeon in peritoneal disease spread.
... Surgical resection is still the most valuable procedure to eliminate primary tumors and involved lymph nodes. However, residual cancerous cells may remain after surgery, and the tumor dislodged during excision may spread via lymphovascular vessels [132,133]. For instance, identification of tumor cells in the blood and peritoneal lavage fluid after surgery has been linked with significantly shorter disease-free survival in patients with colorectal cancer [132]. ...
... However, residual cancerous cells may remain after surgery, and the tumor dislodged during excision may spread via lymphovascular vessels [132,133]. For instance, identification of tumor cells in the blood and peritoneal lavage fluid after surgery has been linked with significantly shorter disease-free survival in patients with colorectal cancer [132]. Similarly, circulating tumor cell numbers expand following surgery for gastric, lung, breast, and hepatocellular cancers and are associated with poor survival [55,57,58,134]. ...
Surgery remains an essential therapeutic approach for most solid malignancies. Although for more than a century accumulating clinical and experimental data have indicated that surgical procedures themselves may promote the appearance and progression of recurrent and metastatic lesions, only in recent years has renewed interest been taken in the mechanism by which metastasizing of cancer occurs following operative procedures. It is well proven now that surgery constitutes a risk factor for the promotion of pre-existing, possibly dormant micrometastases and the acceleration of new metastases through several mechanisms, including the release of neuroendocrine and stress hormones and wound healing pathway-associated immunosuppression, neovascularization, and tissue remodeling. These postoperative consequences synergistically facilitate the establishment of new metastases and the development of pre-existing micrometastases. While only in recent years the role of the peripheral nervous system has been recognized as another contributor to cancer development and metastasis, little is known about the contribution of tumor-associated neuronal and neuroglial elements in the metastatic disease related to surgical trauma and wound healing. Specifically, although numerous clinical and experimental data suggest that biopsy- and surgery-induced wound healing can promote survival and metastatic spread of residual and dormant malignant cells, the involvement of the tumor-associated neuroglial cells in the formation of metastases following tissue injury has not been well understood. Understanding the clinical significance and underlying mechanisms of neuroimmune regulation of surgery-associated metastasis will not only advance the field of neuro–immuno–oncology and contribute to basic science and translational oncology research but will also produce a strong foundation for developing novel mechanism-based therapeutic approaches that may protect patients against the oncologically adverse effects of primary tumor biopsy and excision.
... The spread of tumor cells in the peritoneal cavity during surgery in cases of gastric carcinoma [10,36] , colorectal cancer [9,15,27] and pancreatic resection [7] as well as other surgical trauma [37] is associated with a poor prognosis. ...
... Icodextrin, as a glucose polymer, is not metabolized significantly in the peritoneum. Instead, it is slowly absorbed into the blood by the lymphatic vessels [44]and is used as a primary osmotic agent at a concentration of 4% in peritoneal dialysis solution [5,22,[10][11][12][13][14][15][16][17][18][19][20]. Consequently, icodextrin may be a candidate for use during surgery to inhibit potential cancer cell expansion [11]. ...
Aim
Evaluation of fibrin role on cancer cells implantation in injured tissues and studying the molecular mechanism of cancer cell interaction with the peritoneal damage.
Material and methods
Mouse colon cancer (CT26) and human mesothelial cells (HMCs) were used. CT26 cells were implanted on injured peritoneal zones. Icodextrin was used as a lubricant. For in vitro studies, fibrin clots from human plasma were used. The cell-fibrin interaction was observed by optical, electronic, and confocal microscopies. Aprotinin was used as a plasmin inhibitor. Hemostasis impact quantified by (1) the fibrin degradation product D-Dimer and PAR expression in HMCs; (2) the expression of plasminogen activator (PA) and its inhibitor (PAI-1) in cancer cells by qPCR and in supernatants through ELISA after in vitro HMC incubation with 2U of thrombin for 24 h.
Results
(i) Cancer cell lines were adhered and implanted into the wound area in vivo in both the incision and peeling zones of the peritoneum and on the fibrin network in vitro. (ii) Icodextrin significantly inhibited cancer nodule formation in the scar and the incision or peritoneal damaged zones after surgery. (iii) In in vitro studies, cancer cell interaction with the fibrin clot generated a lysed area, causing an increase in plasmin-dependent fibrinolysis measured by D-dimer levels in the supernatants that was inhibited by aprotinin. (iv) Aprotinin inhibited cell-fibrin interaction and invasion. (v) Thrombin upregulates PAI-1 and downregulates PA expression in HMC.
Conclusion
Injured tissues favor cancer cell implantation through generated fibrin. Fibrin-cancer cells adhesion can be inhibited by icodextrin.
... In group NOSES, the tumor relapsed in five patients at 30, 28, 25, 24, and 19 months after operation, and the recurrence rate was 5.2% (5/96). In group CL, the tumor relapsed in seven patients at 16,19,23,24,28,30, and 32 months after operation, and the recurrence rate was 7.9% (7/89). The recurrence rate of tumor had no significant difference between the two groups (p = 0.56). ...
... This showed that the positive rate of cancer cells in the postoperative peritoneal lavage fluid was related to the stage of the tumor itself. Although we used sterile specimen bag during specimen extraction to avoid tumor implantation and peritoneal (17)(18)(19)(20), the worse the tumor stage, the higher positive rate of tumor cells in peritoneal lavage fluid. The low rate of positive samples in our study may be due to our having only included early stage patients undergoing scheduled curative surgery. ...
Background: Colorectal natural orifice specimen extraction surgery (NOSES) is considered to be a scarless operation that avoids the laparotomy of extraction specimen, but bacteriological and oncological concerns are raised with this technique.
Objective: The purpose of this study was to compare the oncological and bacteriological outcomes of NOSES and conventional laparoscopic (CL) procedures.
Methods: This is a retrospective study of prospectively collected outcomes data. Patients operated with colorectal cancer from January 2016 to December 2019 in Xiangya Hospital were assigned to the group NOSES and the group CL according to the size of the tumor. Prior to dissection, peritoneal lavage fluid was collected for cytological assessment. At the end of the procedure, peritoneal lavage fluid was collected for aerobic culture and cytological assessment. Baseline characteristics and short-term and long-term outcomes for NOSES and CL were compared.
Results: Between January 2016 and December 2019, 212 patients were enrolled from our center and 185 patients were analyzed (96 and 89 in NOSES and CL groups, respectively). The bacterial positive rate of peritoneal lavage fluid was 34.4 vs. 32.6% in NOSES and CL groups, respectively (P = 0.80). The positive rate of tumor cells in peritoneal lavage fluid was 7.3 vs. 9.0% in NOSES and CL groups, respectively (P = 0.67). Univariate analysis showed that the positive rate of tumor cells in peritoneal lavage fluid was significantly associated with tumor invasion depth and lymph node metastasis (P < 0.05). T4 (OR = 20.47, 95%CI = 1.241–337.661; P = 0.04), N1 (OR = 5.445, 95%CI = 1.412–20.991; P = 0.01), and N2 (OR = 6.315, 95%CI = 1.458–27.348; P = 0.01) served as independent predictors of peritoneal lavage fluid positive oncology patients. Local recurrence-free survival was not significantly different between two groups (HR = 0.909, 95%CI = 0.291–2.840; P = 0.87).
Conclusions: Compared with conventional laparoscopic procedure, NOSES is in conformity with the principle of asepsis and tumor-free technique and can be worthy of clinical application and promotion.
... The lncRNAs participate in gene regulation (23,24). Numerous lncRNAs have been shown to promote cell invasion and metastasis (25,26). HOTAIR is an lncRNA located in the HOXC locus, and it can interact with PRC2. ...
... Therefore, it is well-known to check the association with clinical parameters, and it is necessary to perform disease management based on this. In addition, due to the development of many studies and techniques, the pathogenesis and diagnosis methods of CRC are developing, and the rate of CRC treatment by early diagnosis is increasing (25,26,48,49). However, despite advances in technology, people in blind spots, those with the burden of medical expenses and the difficulties of living conditions do not receive these benefits (50)(51)(52). ...
In colorectal carcinogenesis, the unique molecular and genetic changes that occur within cells result in specific CRC phenotypes. The involvement of the long non-coding RNA, HOTAIR, in cancer development, progression, and metastasis is well-established. Various studies have reported on the contribution of HOTAIR to cancer pathogenesis. Therefore, we selected four HOTAIR polymorphisms (rs7958904G>C, rs1899663G>T, rs4759314A>G, and rs920778T>C) to evaluate the association of each variant with CRC prevalence and prognosis. We conducted a case–control study of 850 individuals to identify the genotype frequencies of each polymorphism. The study population included 450 CRC patients and 400 control individuals that were randomly selected following a health screening. Notably, rs7958904 and rs1899663, their hetero genotype, and the dominant model were significantly different when compared to the healthy control group (rs7958904; AOR = 1.392, 95% CI = 1.052–1.843, P = 0.021). To evaluate the effect of HOTAIR polymorphisms on the survival rate, we analyzed patient mortality and relapse occurrence within 3 and 5 years with Cox-regression analysis. The rs7958904 CC polymorphism mortality rate was significantly higher than the GG polymorphism mortality rate (adjusted HR = 2.995, 95% CI = 1.189–7.542, P = 0.021). In addition, the rs920778 CC genotype was significantly different than the TT genotype (adjusted HR = 3.639, 95% CI = 1.435–9.230, P = 0.007). In addition, this study confirmed that genetic variants of HOTAIR alter the mRNA expression level (P < 0.01). We suggest that HOTAIR rs7958904G>C which is associated with CRC prevalence and mortality is a potential biomarker for CRC. The association between HOTAIR gene polymorphisms and CRC prevalence were reported for the first time.
... As mentioned previously, the clinico-pathological characteristics also differ between the various studies on the detection of CTC in early-stage CRC. Most prominent are the differences in TNM stage varying from studies including only stage I or II patients to studies including patients with stages I to IV CRC [41][42][43] limiting a correct interpretation and comparison between the available data. The PePITA sub-study only included 2 stage II and 30 stage III patients. ...
... In this study, peripheral blood samples were collected pre-operatively both before and after one cycle of FOLFOX therapy. Different time points were evaluated in other studies, CTCs were detected peri-operatively, 24 h after tumor resection and even later than 48 h after resection [30,41,44]. Out of 53 eligible patients enrolled in the PePiTA trial, blood samples for CTC analysis were collected for 36 patients (68%) indicating low participation rate in translational research especially when the collection of biological material is optional, highlighting the difficulty to rely on optional sub-studies and questioning the need for minimizing the options in both ICFs and studies. ...
Background
Adjuvant therapy improves the prognosis of stage II & III colon cancer patients. Unfortunately, most patients do not benefit from this treatment. PePITA (NCT00994864) is a prospective, multicenter, non-randomized study whose primary objective is to predict the outcome of adjuvant therapy in colon cancer.
Methods
The primary objective was to determine the prognostic and predictive value of circulating tumor cell (CTC) detection before therapy and after one course of preoperative FOLFOX.
Results
Out of the 58 first patients accrued in PePiTA trial, 36 patients participated in the CTC companion study, of whom 32 had at least one evaluable sample. Only 5 patients (14, 95% CI = 5–30%) had ≥1 CTC/22.5 ml blood in at least one of the two timepoints with 2 patients having ≥1 CTC/22.5 ml at baseline (6, 95% CI: 1–19%). The detection rate of patients with CTCs at baseline being lower than expected, the inclusion of patients in the PePiTA CTC substudy was stopped. The limited sample size did not allow us to investigate the prognostic and predictive value of CTCs in locally advanced colon cancer.
Conclusions
Our data illustrate the need for further standardized studies in order to find the most reliable prognostic/predictive biomarker in early-stage colon cancer.
Trial registration
This trial was prospectively registered at Jules Bordet institute (NCT00994864) on the October 14, 2009.
... 35 Patients with stage II or stage III disease and elevated preoperative serum CEA levels may have occult systemic disease at the time of curative surgery. Lloyd et al. 38 proved that 32.8% of patients with stage I and II disease test positive for disseminated tumor cells after surgery. Therefore, even after curative resection, residual malignant cells can remain in situ. ...
... Therefore, even after curative resection, residual malignant cells can remain in situ. 38 Several authors have attempted to determine the correlation between histological characteristics and vascular or perineural invasion. 35,36 However, no convincingly significant differences have been found in these retrospective Asian studies. ...
Introduction::
Serum carcinoembryonic (CEA) antigen is used as a diagnostic screening tool during follow-up in colorectal cancer patients. However, it remains unclear whether preoperative serum CEA is a reliable marker in the follow-up to predict recurrence. The aim of the study is to determine the value of elevated pre- and postoperative serum carcinoembryonic antigen levels (CEA > 5 µg/L) as an independent prognostic factor for locoregional and distant recurrence in patients who underwent curative surgery for colorectal cancer.
Methods::
This single center retrospective observational cohort study includes patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and had pre- and postoperative serum CEA measurements. Five-year disease-free survival and multivariate Cox regression analyses were performed to adjust for confounding factors.
Results::
Preoperative serum CEA level was measured in 2093 patients with colorectal cancer. No significant association was found between an elevated preoperative serum CEA and locoregional recurrence (adjusted hazard ratio (HR) 1.29 (95% confidence interval (CI) 0.91, 1.84; P=0.26)). However, a significant association was found between an elevated preoperative serum CEA and systemic recurrence (adjusted HR 1.58 (95% CI 1.25, 2.00; P<0.01)]. The five-year disease-free survival was lower in patients with elevated preoperative serum CEA levels ( P<0.01). Postoperative serum CEA level was the most sensitive for hepatic metastases during follow-up (73.3%).
Conclusions::
The preoperative serum CEA level is an independent prognostic factor for systemic metastasis after curative surgery for colorectal cancer in patients with stage I-III disease. The level is the most sensitive for hepatic metastasis compared to metastasis to other anatomic sites.
... Of these, two studies [38,41] were excluded from pooled analysis because they included cases recruited at the same center and within the same period of time, and already reported elsewhere [39,40]. The remaining 5 studies (Table 3) involved 117 patients (male: 54.7%; median age 60.7 years [range: [55][56][57][58][59][60][61][62][63][64][65][66][67]). In 88 cases primary tumour was located in the colon and in the remaining 29 in the rectum. ...
... This was the only high-risk factor in the Noura et al. study [33] and the most common one in the studies by Shumizu et al. [40] and Virzi et al. [43]. The incidence of detection of disseminated tumor cells in the peritoneal fluid at primary surgery was 3-28% by plain cytology [54,55] and as high as 12-47% by immunocytochemistry or reverse transcriptase-polymerase chain reaction [56][57][58]. However, as aforementioned, the rate of metachronous PC is only 4.2% [3], and if prophylactic HIPEC is offered to all patients with positive peritoneal cytology, the intervention will not be of any additional benefit in the majority of them. ...
Purpose:
Τo evaluate all available data on the effect of preemptive intervention in patients who have curative surgery for colorectal cancer (CRC) and are at high risk to develop peritoneal carcinomatosis (PC).
Methods:
The authors conducted a systematic review of all published studies from January 2000 to July 2016. Twelve studies were eventually considered for analysis, and were divided in four categories, according to different approaches for adjuvant intra-peritoneal chemotherapy: a) hyperthermic intraperitoneal chemotherapy (HIPEC), during primary surgery for CRC; b) early postoperative intraperitoneal chemotherapy (EPIC), after primary surgery for CRC; c) early re-intervention (laparotomy or laparoscopy) and HIPEC; and d) as second look laparotomy and HIPEC + cytoreductive surgery (CRS), several months after primary surgery.
Results:
Considering prophylactic HIPEC during primary surgery, the studies that were analysed showed a peritoneal recurrence rate of 0-12.9%, a 3- and 5-year disease free survival (DFS) of 67-97.5% and 54.8-84% respectively, and a 3- and 5-year overall survival (OS) of 67-100% and 84%, respectively. These oncological results are probably better than what is expected in patients at high risk to develop PC and have only adjuvant systemic chemotherapy. Because of the great heterogeneity in inclusion criteria (risk factors for PC) and methodology of intra-peritoneal chemotherapy (different timing, different techniques, different agents), a meta-analysis was not performed.
Conclusions:
At present and because of the insufficient available evidence, preemptive intervention at the immediate postoperative adjuvant setting is recommended only in the setting of a registered clinical trial.
... Blood-borne cancer micrometastases usually happened before clinical metastasis, which can be detect by laboratory test, such as microscopic and submicroscopic residual tumor cells in various body tissues, body fluids, and cell grafts before any clinical manifestations. [7][8][9] As the micro-metastases have no significant clinical signs, it very hard detect by current imaging technologies, such as computed tomography (CT), magnetic resonance imaging (MRI), and pathological examination. [7][8][9] The presence of micrometastases directly affects tumor prognosis, and the early detection of micrometastases holds great values for tumor diagnosis, staging, recurrence, prognosis, and the choice of comprehensive postoperative treatment. ...
... [7][8][9] As the micro-metastases have no significant clinical signs, it very hard detect by current imaging technologies, such as computed tomography (CT), magnetic resonance imaging (MRI), and pathological examination. [7][8][9] The presence of micrometastases directly affects tumor prognosis, and the early detection of micrometastases holds great values for tumor diagnosis, staging, recurrence, prognosis, and the choice of comprehensive postoperative treatment. [10,11] Therefore, the detection of micrometastasis has become another hot spot in the field of clinical medicine in recent years. ...
The aim of this study was to evaluate the effect of laparoscopic radical hysterectomy on expressions of circulating tumor cells (CTCs) of cytokeratin 19 (CK19), cytokeratin 20 (CK20), and squamous cell carcinoma antigen (SCC-Ag) mRNA.
We collect 78 patients with stage IA2-IIA1 cervical cancer who underwent radical hysterectomy by laparotomy or laparoscopy in our study, and 34 uterine fibroids patients and 32 healthy subjects were recruited as the positive control group and negative control group, respectively. Blood samples were taken from early-stage primary cervical squamous cell carcinoma patients. Real-time reverse transcription polymerase chain reaction (RT-PCR) was used to amplify peripheral blood CK19, CK20 and SCC-Ag from total RNA. We measured the expression of CK19, CK20, and SCC-Ag before laparoscopic radical hysterectomy, 24 hours and 30 days after surgery. Meanwhile, the expression of these markers was compared between laparoscopic and laparotomy groups.
The expressions of CK19, CK20, and SCC-Ag in the experimental group before surgery were (0.0035 ± 0.0018), (1.06 ± 0.49), and (1.48 ± 0.46), respectively, and the positive rates were 32.1%, 33.3%, and 35.9%, respectively. The expression levels of CK19, CK20, and SCC-Ag in the experimental group before surgery was significantly higher than the positive and negative control groups, and there were no significant differences between the positive and negative control groups. The expressions and positive rates of CK19, CK20, and SCC-Ag before laparoscopic radical hysterectomy were significantly lower than the stage at 24 hours after surgery (P < .05), but higher than the stage at 30 days after surgery (P > .05). There were no significant differences in CK19, CK20, and SCC-Ag expressions before surgery, 24 hours and 30 days after surgery between laparoscopic group and laparotomy group (P > .05).
Both laparotomy and laparoscopic radical mastectomy tend to increase the expression of CTCs in peripheral blood, and the expressions have no differences between these 2 groups. So, the use of CK19, CK20, and SCC-Ag expression levels from peripheral blood from early stage cervical cancer radical patients before hysterectomy can aid to overcome the lack of radiographic examination and tumor markers measurement, and provide clues for postoperative treatment and prognosis determination.
... Twelve eligible studies, including 23 sets of data, contained 2363 patients with non-mCRC [19,20,[28][29][30][31][32][33][34][35][36][37]. The studies were conducted in seven countries (Australia, China, Croatia, Germany, Japan, Spain and the UK) and were published between 2002 and 2016. ...
... Seventeen sets of data included in all enrolled studies contained the data on DFS [19,20,[28][29][30][31][32][33][34][35][36][37]; the pooled analysis indicated CTC-positive was also associated with a significantly decreased DFS (HR = 2.58, 95% CI: [2.00-3.32], P < 0.001) with no between-study heterogeneity (I 2 = 34.0%, ...
Abstract Background Circulating tumor cells (CTCs) have been accepted as a prognostic marker in patients with metastatic colorectal cancer (mCRC, UICC stage IV). However, the prognostic value of CTCs in patients with non-metastatic colorectal cancer (non-mCRC, UICC stage I-III) still remains in dispute. A meta-analysis was performed to investigate the prognostic significance of CTCs detected by the RT-PCR method in patients diagnosed with non-mCRC patients. Methods A comprehensive literature search for relevant articles was performed in the EmBase, PubMed, Ovid, Web of Science, Cochrane library and Google Scholar databases. The studies were selected according to predetermined inclusion/exclusion criteria. Using the random-effects model of Stata software, version12.0 (2011) (Stata Corp, College Station, TX, USA), to conduct the meta-analysis, and the hazard ratio (HR), risk ratio (RR) and their 95% confidence intervals (95% CIs) were regarded as the effect measures. Subgroup analyses and meta-regression were also conducted to clarify the heterogeneity. Results Twelve eligible studies, containing 2363 patients with non-mCRC, were suitable for final analyses. The results showed that the overall survival (OS) (HR = 3.07, 95% CI: [2.05–4.624], P
... Circulating tumor cells (CTCs) 5 are defined as cells that originate in primary tumors, recurrences, or metastases. They circulate freely in peripheral blood and have antigenic and genetic characteristics specific to the tumor of origin (1 ). ...
... In the last few years, emerging data have challenged the traditional theory of sequential metastasis development (3 ) (see Fig. 1 in the Data Supplement that accompanies the online version of this article at http://www.clinchem.org/content/vol62/issue4). Several studies have pointed out that CTCs can be isolated in patients at relatively early stages of tumor growth (4,5 ), even before the primary tumor mass is detected by conventional methods (6 ). Furthermore, current highresolution imaging technology is not sensitive enough to detect micrometastases or early tumor cell dissemination, which are the key events in tumor progression (see online Supplemental Fig. 1). ...
Background:
Circulating tumor cells (CTCs) are biomarkers for noninvasively measuring the evolution of tumor genotypes during treatment and disease progression. Recent technical progress has made it possible to detect and characterize CTCs at the single-cell level in blood.
Content:
Most current methods are based on epithelial cell adhesion molecule (EpCAM) detection, but numerous studies have demonstrated that EpCAM is not a universal marker for CTC detection because it fails to detect both carcinoma cells that undergo epithelial-mesenchymal transition (EMT) and CTCs of mesenchymal origin. Moreover, EpCAM expression has been found in patients with benign diseases. A large proportion of the current studies and reviews about CTCs describe EpCAM-based methods, but there is evidence that not all tumor cells can be detected using this marker. Here we describe the most recent EpCAM-independent methods for enriching, isolating, and characterizing CTCs on the basis of physical and biological characteristics and point out the main advantages and disadvantages of these methods.
Summary:
CTCs offer an opportunity to obtain key biological information required for the development of personalized medicine. However, there is no universal marker of these cells. To strengthen the clinical utility of CTCs, it is important to improve existing technologies and develop new, non-EpCAM-based systems to enrich and isolate CTCs.
... Investigations have demonstrated that miRNAs are involved in regulating more than 30% of the human genome [42,43]. It is postulated that miRNAs may be involved in numerous biological pathways, including proliferation and metastasis. ...
Background: Colorectal cancer (CRC) is the most common type of gastrointestinal cancer. Genetic, epigenetic, and lifestyle factors have been implicated in the development of CRC. Non-coding RNAs such as HOX transcript antisense RNA (HOTAIR) and miR-3117genes have been associated with cell proliferation, progression, invasion, and metastasis as well as poor survival in several cancers. This study examines the potential association between the HOTAIR rs920778 and miR-3117variants and the clinicopathological features of CRC in Mexican patients.
Methods: The study included peripheral blood samples from 588 individuals (289 CRC patients and 299 controls). The variants were identified by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The association was calculated using the odds ratio (OR) test. P-values were adjusted using the Bonferroni test (0.016).
Results: Individuals carrying the T/C and T/T genotypes for the HOTAIR rs920778 variant exhibited a higher susceptibility to CRC (OR=1.73, 95% CI: 1.15-2.58, P=0.009 and OR=2.78, 95% CI: 1.74-4.45, P=0.001, respectively). Male patients older than 50 years and carrying the C/C genotype demonstrated an increased susceptibility for developing CRC (OR=1.73, 95% CI: 1.15-2.58, P=0.009). Additionally, C/C genotype carriers exhibited an association with advanced TNM stage. Furthermore, for the rs7512692 variant of the miR-3117 gene, patients carrying the C/T genotype exhibited increased susceptibility for developing CRC (OR=1.92, 95% CI: 1.35-2.74, P=0.001). Male patients over 50 years of age and carrying the C/T genotype demonstrated increased susceptibility for early TNM stages and tumor location in the colon.
Conclusion: The results obtained suggest that the HOTAIR rs920778 and miR-3117rs7512692 variants play a significant role in colorectal cancer risk.
... Thus, 59% of preoperatively asymptomatic breast cancer patients developed circulating tumour cells in the 22 years following mastectomy [9]. Cancer cell presence in plasma correlates strongly with increased risk of recurrence and poor long-term survival [10][11][12]. ...
Recurrence of cancer after primary tumour resection is a leading cause of cancer-related mortality. Preclinical research indicates that surgery induces a stress response that inhibits cell-mediated immunity as a possible basis for risk of recurrence. Other preclinical evidence suggests that, conversely, propofol and local anaesthetics diminish the effects of the surgical stress response and so could directly inhibit cancer progression, and this is supported by several retrospective cohort studies and meta-analyses. However, the first large-scale randomised clinical trial (RCT), comparing recurrence after mastectomy in patients anaesthetised with either propofol/local anaesthetic or sevoflurane/opioids, concluded that recurrence was not significantly improved in the propofol/local anaesthetic group (p = 0.84). Other cancers may prove more responsive and results from a number of ongoing RCTs, encompassing several cancer types, are currently awaited. These trials should establish whether choice of anaesthetic technique is an important determinant of cancer recurrence risk.
... Many in vivo and in vitro studies showed the upregulation of HO-TAIR expression with enhanced tumor invasion and metastasis [39][40][41]. In CRC patients, many studies revealed a higher expression of HOTAIR in CRC tissue as compared to corresponding noncancerous tissue [42][43][44]. The SNPs rs920778 and rs12826786 are reported to correlate with HOTAIR upregulation [31][32][33]. ...
Genetic polymorphism in long noncoding RNA (lncRNA) HOTAIR is linked with the risk and susceptibility of various cancers in humans. The mechanism involved in the development of CRC is not fully understood but single nucleotide polymorphisms (SNPs) can be used to predict its risk and prognosis. In the present case-control study, we investigated the relationship between HOTAIR (rs12826786, rs920778, and rs1899663) polymorphisms and CRC risk in the Saudi population by genotyping using a TaqMan genotyping assay in 144 CRC cases and 144 age- and sex-matched controls. We found a significant (p < 0.05) association between SNP rs920778 G > A and CRC risk, and a protective role of SNPs rs12826786 (C > T) and rs1899663 (C > A) was noticed. The homozygous mutant “AA” genotype at rs920778 (G > A) showed a significant correlation with the female sex and colon tumor site. The homozygous TT in SNP rs12816786 (C > T) showed a significant protective association in the male and homozygous AA of SNP rs1899663 (C > A) with colon tumor site. These results indicate that HOTAIR can be a powerful biomarker for predicting the risk of colorectal cancer in the Saudi population. The association between HOTAIR gene polymorphisms and the risk of CRC in the Saudi population was reported for the first time here.
... The selection of anesthesia method for cancer tissue resection is crucial for the therapy since it has correlation with the recurrence of cancer [14]. Although the performance of resection is capable for removing most of the cancer tissue, some cancer cells remain in the body of patient [15]. For those cancer cells, their survival and spread could be triggered by the stress caused by surgical performance and the immunosuppression induced by anesthesia. ...
Background
A new technique for analgesia called pectoral nerve block is widely used in surgeries of breast cancer. Pectoral nerve block type II (Pecs II) block has less influence on immunity when compared with general anesthesia method. The purpose of this research is to demonstrate whether Pecs II block has influence on the recurrence of breast cancer after surgical operation.
Methods
526 breast cancer patients were recruited in this research and randomized into general anesthesia group and general anesthesia with Pecs II block group. Recurrence-free survival (RFS), distant recurrence-free survival (DRFS), and overall survival (OS) were evaluated for the two groups.
Results
Based on the statistical data, only the consumption of remifentanil was dramatically reduced by the performance of Pecs II block when compared with general anesthesia method. The performance of Pecs II block had no significant influence on OS, RFS, and DRFS of breast cancer patients after surgery. ASA physical status III, TNM stage 2 + 3, and mastectomy were proved to have association with lower recurrence-free survival.
Conclusion
In conclusion, the performance of Pecs II block declined the remifentanil consumption during surgery of breast cancer. Meanwhile, the performance of Pecs II block had no significant influence on the OS, RFS, and DRFS of breast cancer patients after surgical resection.
... Looking to the pN stage, no positive relation between this variable and PPLC was found in our study (p = 0.115). This was in agreement with what was reported by Hase et al, [24], Yamamoto et al, [2] and Lloyd et al, [25]. However, in multivariate analysis, Hara et al; [22] Noura et al, [4]; Katoh et al, [17] and Temesi et al, [20] reported a strong correlation between this variable and PPLC . ...
Background: Positive peritoneal lavage cytopathology (PPLC) is an established poor prognostic factor in CRC that has been proven in many studies and was associated with an increase in peritoneal recurrence , overall recurrence and mortality. The incidence of PPLC among CRC patients varied in different studies between 2.1-52%. Similarly, different variables were reported to correlate with peritoneal lavage positivity in published studies. The aim of this trial was to study the prevalence of free intraperitoneal malignant cells at the time of radical resection of colon cancer and to assess its relation to different clinico-pathological characteristics.
Patients and methods: This cohort study was conducted at the gastrointestinal surgery unit, general surgery department and the emergency hospital at Tanta University during the period from January 2020 ending in December 2020. Forty patients with non-metastatic primary colonic carcinoma were included in the study. Peritoneal lavage fluid was collected before radical resection of the tumour. One hundred milliliters of warm normal saline solution was installed into the peritoneal cavity and at least 80 ml of the lavage fluid was collected for cytopathological examination. After preparation, the sample was stained with Haematoxylin and Eosin and examined under a light microscope by an experienced cytopathologist.
Results: Eighteen smears (45%) were found positive for malignant cells. Among variables tested, a positive correlation was found between PPLC and a low BMI (< 25 kg/m2), the histopathological tumour type, an advanced pT stage, a high lymph node ratio and an advanced overall TNM stage. Conclusion: In non-metastatic AJCC stage II and III colon cancer, the prevalence of PPLC detected by conventional cytopathology was found to be 45%. A low BMI <25kg/m2 , the presence of intraperitoneal free fluid at the time of the operation , a high lymph node ratio, an advanced T stage, histopathological type and an advanced overall TNM stage correlated positively with PPLC.
... Understanding them it means that we can improve early detection, treatment management and overall free survival rate of cancer patients. Studies show that CTCs can be detected in peripheral blood samples during early tumor growth [2,3]. Husemann et al. states that CTCs can be detected even before the primary tumor mass is discovered by using conventional diagnosis [4]. ...
Circulating tumor cells (CTCs) can be detected using newly emerging non-invasive liquid biopsy techniques and they can be used for early diagnosis, for cancer treatment management and treatment efficiency assessment, precision medicine and to better understand the metastasis process. The number of CTCs can be as low as 1 cell/mL of blood thus there is a need for very high detection sensitivity and specificity. In this article we propose a label-free detection method based on a microfluidic device integrated with an electrochemical impedance spectroscopy biosensor capable of capturing and quantifying CTCs. We propose an interdigitated gold electrode functionalized with specific antibodies encapsulated in PDMS. The sensor was functionalized with anti-EpCAM and anti-CD36 antibodies, molecules which are expressed by CTCs and which are absent on normal blood cells. The microfluidic device was tested on MCF-7 breast cancer cells and on blood samples from canines with mammary carcinomas. The device proved to be highly sensitive to the attachment of CTCs, being able to detect the attachment of only 3 MCF-7 cells on the surface of the sensor. Thus, we report that the developed microfluidic device is a promising tool for CTCs detection, quantification and characterization.
... The protocol for LC (amount of lavage saline, site of lavage fluid, and timing of lavage) varied in previous studies [18]. The positive rates of LC in previous studies ranged from 2.2 to 35.6% [8,[10][11][12][13][14][19][20][21][22][23][24][25][26][27][28], whereas it was 6.5% in our study. The wide difference in the positive LC rate may be due to the differences in the LC protocol. ...
Background
The prognostic value of positive intraoperative peritoneal cytology and lavage cytology, including the differences in their prognostic impact, in colorectal cancer is controversial. We aimed to investigate the prognostic values of positive peritoneal cytology and lavage cytology findings for colorectal cancer and compare their prognostic impact.Methods
We retrospectively evaluated 592 clinical stage II–IV colorectal cancer patients who underwent peritoneal cytology (n = 225) or lavage cytology (n = 367) between November 1993 and December 2018. The prognostic factors for cancer-specific survival were identified, and the differences in cancer-specific survival were examined between the patients.ResultsThe cytology-positive rate was 10.8% (64/592), 17.8% (40/225), and 6.5% (24/367) in the overall, peritoneal cytology, and lavage cytology groups, respectively. Both positive peritoneal cytology (hazard ratio: 2.196) and lavage cytology (hazard ratio: 2.319) were independent prognostic factors. The peritoneal cytology-positive group showed significantly poorer cancer-specific survival than the cytology-negative group (5-year: 3.5% vs. 59.5%; 10-year: 3.5% vs. 46.1%, p < 0.001). Similar results were obtained for lavage cytology (5-year: 14.1% vs. 73.9%; 10-year: 4.7% vs. 63.5%, p < 0.001). The cancer-specific survival was not significantly different between the peritoneal cytology-positive and lavage cytology-positive groups (p = 0.058). Both positive peritoneal and lavage cytology were associated with poorer cancer-specific survival across all colorectal cancer stages.Conclusions
Positive peritoneal and lavage cytology are associated with worse cancer-specific survival in colorectal cancer. The prognostic impact was comparable between positive lavage and peritoneal cytology. Thus, cytology should be a standard assessment modality for colorectal cancer.
... As a form of 'liquid biopsy', CTCs are noninvasive and safe compared with traditional tissue biopsy, which can be used for real-time monitoring of therapy response and tumor progression. Some studies have shown that CTCs can be detected (3,4), while the primary tumor mass is not observed by conventional imaging methods owing to their limitation of sensitivity during the early stages of tumor development (5). The demand for clinical utility of CTCs, e.g., early diagnosis, prediction of prognosis, assessment of recurrent risk, supervision of curative effects and individualized treatment has pushed forward research in this field. ...
Circulating tumor cells (CTCs) are cells derived from the primary sites of tumor patients into peripheral blood and serve as seeds that initiate tumor metastasis to distant sites. As a primary form of “liquid biopsy”, CTC enumeration has exhibited great potential as a mean to obtain diagnostic and prognostic biomarker information in various cancers. The comprehensive clinical utility of CTC tests, however, is still restricted due to the scarcity and heterogeneity of CTCs, which necessitates reliable techniques for their efficient enrichment and characterization. Numerous methods have been developed to improve yield and purity of CTC enrichment as well as detection sensitivity. In this review, we comprehensively summarize techniques for CTC enrichment and detection.
... Lung cancer is the most commonly diagnosed malignancy worldwide, and its incidence continues to grow. 1 An estimated 2.1 million new cases of lung cancer were diagnosed and 1.76 million lung cancer deaths occurred globally in 2018. 1 Surgical removal of the primary tumour is the mainstay of treatment for patients with non-small-cell lung cancer staged I through IIIA. 2 However, surgical dissection and manipulation are associated with unintentional dispersal of cancer cells into the blood and lymphatic systems. 3 Whether the residual neoplastic cell would develop into a metastasis depends on the perioperative immune competence of the patient. Surgically induced stress hormone, as well as inhaled volatile anaesthetics and systemic opioids, can diminish natural killer cell function, the primary defense against cancer cells. ...
Objectives: Previous studies showed reductions in recurrence and mortality rate of several cancer types in patients receiving perioperative epidural analgesia. This study aimed to investigate the effects of thoracic epidural analgesia on oncological outcomes after resection for lung cancer.
Design: Retrospective study using propensity score matching methodology.
Setting: Single medical centre in Taiwan.
Participants: Patients with stages I–III non-small-cell lung cancer undergoing primary tumour resection between January 2005 and December 2015 and had either epidural analgesia, placed preoperatively and used intra- and postoperatively, or intravenous analgesia were evaluated through May 2017.
Primary and secondary outcome measures: Primary endpoint was postoperative recurrence-free survival and secondary endpoint was overall survival.
Results: The 3-year recurrence-free and overall survival rates were 69.8% (95% CI 67.4% to 72.2%) and 92.4% (95% CI 91% to 93.8%) in the epidural group and 67.4% (95% CI 62.3% to 72.5%) and 89.6% (95% CI 86.3% to 92.9%) in the non-epidural group, respectively. Multivariable Cox regression analysis before matching demonstrated no significant difference in recurrence or mortality between groups (adjusted HR: 0.93, 95% CI 0.76 to 1.14 for recurrence; 0.81, 95% CI 0.58 to 1.13 for mortality), similar to the results after matching (HR: 0.97, 95% CI 0.71 to 1.31; 0.94, 95% CI 0.57 to 1.54). Independent risk factors for both recurrence and mortality were male, higher pretreatment carcinoembryonic antigen level, advanced cancer stage, poor differentiation, lymphovascular invasion, microscopic necrosis and postoperative radiotherapy.
Conclusions: Thoracic epidural analgesia was not associated with better recurrence-free or overall survival in patients receiving surgical resection for stages I–III non-small-cell lung cancer.
... 6 A few studies have suggested that surgery itself induces the spread of tumor cells into the peritoneal cavity in patients with gastric cancer 7,8 and colorectal cancer. 9,10 During open pancreatic resection, the tumor is regularly manipulated and potentially even compressed by hand during dissection along the superior mesenteric artery, although this differs depending on the surgical technique applied. Intraoperative tumor manipulation may induce dissemination of tumor cells into the peritoneal cavity. ...
Background:
Intraoperative tumor manipulation may induce the dissemination of occult peritoneal tumor cells (OPTC) into the peritoneal cavity.
Methods:
A systematic review was performed in the PubMed, Embase and Cochrane databases from inception to March 15, 2017. Eligible were studies that analyzed the presence of OPTC in peritoneal fluid, by any method, both before and after resection in adults who underwent intentionally curative pancreatic resection for histopathologically confirmed pancreatic ductal adenocarcinoma in absence of macroscopic peritoneal metastases.
Results:
Four studies with 138 patients met the inclusion criteria. The pooled rate of OPTC prior to tumor manipulation was 8% (95% CI 2%-24%). The pooled detection rate of OPTC in patients in whom OPTC became detectable only after tumor manipulation was 33% (95% CI 15-58%). Only one study (28 patients) reported on survival, which was worse in patients with OPTC (median 11.1 months versus 30.3 months; p = 0.030).
Conclusion:
This systematic review suggests that tumor manipulation induces OPTC in one third of patients with pancreatic cancer. Since data on survival are lacking, future studies should determine the prognostic consequences of tumor manipulation, including the potential therapeutic effect of 'no-touch' and minimally invasive resection strategies.
... In cancer immunology, a clear role of MMP7 and of other MMPs has been shown in tumour growth and invasion (17,(20)(21)(22)(23)(24)(25). Increased MMP7 expression in tumour tissue, serum, lymph nodes and peritoneal liquid generally correlates with worse prognosis, a tendency for metastatic disease and reduced overall survival (18,(26)(27)(28)(29)(30)(31)(32). This suggests a possible role for MMP7 in the determination of locally advanced cancer in resected specimens, and in staging and planning for eventual adjuvant therapy, attesting to a potential role of MMP7 as prognostic factor and tumour marker (33). ...
Background/aim:
Matrix metalloproteinase 7 (MMP7) expression is highly associated with colorectal cancer and modulates tumour growth and invasion. Radiation injury induces inflammation with increases in MMP7 and in transforming growth factor beta (TGFβ). The aim of this study was to investigate the effect on MMP7 and TGFβ. expression in patients with rectal cancer undergoing different regimens of neoadjuvant radiotherapy (RT).
Patients and methods:
We studied 53 patients in three RT treatment groups receiving RT of 25 Gy, long-term RT 50 Gy and controls receiving no RT. Three biopsies were obtained from each patient during the treatments: before RT, after RT and after surgery. Tissue samples were formalin fixed, paraffin embedded and tissue microarrays were constructed and stained for MMP7 and TGFβ. Mann-Whitney U-tests and Wilcoxon Z-tests were used to determine differences between patients before and after RT, and after surgery, as well as between the RT groups.
Results:
In all three patient groups, increases of MMP7 and TGFβ expression were observed after surgery. MMP7 expression was significantly increased in patients receiving short-term RT but TGFβ expression was not affected by RT.
Conclusion:
50 Gy Irradiation of rectal cancer gives less tumour activation of MMP7, whilst it is up-regulated by 25 Gy and surgery regardless of RT.
... The CK20 gene is mainly expressed in gastric and intestinal epithelium, urothelium and Merkel cells [13]. Its expression has also been observed in colorectal cancer [14][15][16]. Until now several different markers for the enrichment of CICs are described. The five-transmembrane glycoprotein CD133 is one of the first colon CIC markers identified. ...
Purpose: Disseminated tumor cells (DTCs) are critically involved in tumor relapse and survival in several invasive tumors. We previously showed that the ATP-binding cassette (ABC) transporter, ABCB5, is a chemoresistance mediator expressed on specific cell subsets in colorectal cancer (CRC) and other malignancies. This study evaluated the molecular signature expression and its clinical relevance of DTCs in bone marrow from patients with colon cancer.
Methods: This study included 49 consecutive patients (UICC stage I-IV) that underwent curatively intended or palliative surgery for CRC. We analyzed cells from bone marrow aspirates obtained before surgery and derived from patients that had completed minimally a 5-year follow-up. The gene expression of ABCB5 in comparison to CD133 (molecule for identifying cancer initiating cells), Lgr5 (an intestinal stem cell marker) as well as Cytokeratin (CK) 20 (terminally differentiated tumor cells of epithelial origin) in these cells was evaluated.
Results: Bone marrow analysis showed differential expression between the analyzed genes. ABCB5 and Lgr5 and to lesser extent CD133 and CK20 genes were significantly expressed in the analyzed cells from bone marrow aspirates while only ABCB5 and Lgr5 were significantly negative associated with tumor progress and overall survival.
Conclusion: Overexpression of ABCB5 and Lgr5 in bone marrow negatively influenced patient survival pointing to a specific chemo resistant and pluripotent cell subgroup of DTCs in the bone marrow. ABCB5 like Lgr5 positive cells seem to be involved in limited tumor related patient survival, suggesting that ABCB5- and Lgr5-positive cells may be relevant for specific clinical intervention strategies.
... 19 Similar results were found in CRC. 20 Moreover, quantitative RT-PCR results (CK20 and/or CEA levels) were an independent prognostic factor in GC patients with R0 resection. 21 These studies suggest that we can perform RT-PCR analysis of sHLA-G in cytology-negative ascites to further explore and evaluate the diagnostic value of ascitic sHLA-G. ...
The overexpression of soluble human leukocyte antigen-G is associated with malignant tumours. The purpose of our study was to detect soluble human leukocyte antigen-G concentrations in ascites and to evaluate the value of ascitic soluble human leukocyte antigen-G for the diagnosis of malignant ascites. Enzyme-linked immunosorbent assay was used to detect soluble human leukocyte antigen-G levels in 64 patients with malignant ascites and 30 patients with benign ascites. Receiver operating characteristic curves were used to evaluate the diagnostic efficacy of ascitic soluble human leukocyte antigen-G for the detection of malignant ascites. Ascitic soluble human leukocyte antigen-G levels were significantly higher in the malignant ascites group than in the benign ascites group (20.718 ± 3.215 versus 12.467 ± 3.678 µg/L, t = 7.425, p
... In general, the prognostic significance of CTC is supported by several studies on the level of primary disease: in primary BC pre-and postoperatively [21,22], in early CRC preoperatively [23], from the postoperative lavage of the peritoneal cavity [24] and after the adjuvant chemotherapy [25], or in early NSCLC [26]. ...
Circulating tumor cells (CTC) present in peripheral blood are assigned precursors of advanced tumor disease. Simplicity of blood withdrawal procedure adds practically an unlimited possibility of the CTC-monitoring and the advantages of the repeated biopsies over time. CTC got prognostic, predictive and diagnostic status with the technologic advance. Although the clinical utility of CTC has reached the high evidence, the significance of CTC testing was presented in the treatment strategy mostly with palliative intention. We report on the experiences with the CTC-testing in the CLIA-like laboratory working with the size-based CTC separation and in vitro culture. The data is presented in the form of case reports in patients with breast (BC), colorectal (CRC), prostate (PC) and lung cancer (NSCLC) to support the clinical utility of CTC during the neoadjuvant, adjuvant and palliative treatment. The presented findings support the evidence for liquid biopsy clinical implementation and enhance the ability of malignant disease monitoring and the treatment efficacy prediction.
... For a long time, immunomagnetic separation (IMS) was performed using Dynabeads (52,53). These are magnetic beads coated with antibodies against specific cell surface antigens. ...
Circulating tumor cells (CTCs) represent a submicroscopic fraction detached from a primary tumor and in transit to a secondary site. The prognostic significance of CTCs in metastatic cancer patients was demonstrated for the first time more than ten years ago. To date, it seems clear enough that CTCs are highly heterogeneous and dynamically change their shape. Thus, the inadequacy of epithelial cell adhesion molecule (EpCAM) as universal marker for CTCs detection seems unquestionable and alternative methods able to recognize a broader spectrum of phenotypes are definitely needed. In this review the pleiotropic functions of EpCAM are discussed in detail and the role of the molecule in the biology of CTCs is critically dissected.
Conventional laparoscopic-assisted right hemicolectomy requires a small abdominal incision to extract the specimen, which becomes an important source of postoperative complications and impairs perioperative experience. Transvaginal natural orifice specimen extraction surgery (NOSES VIIIA) avoids this small incision by extracting the specimen through the vagina. Here we describe the design of a multicenter, open-label, parallel, noninferior, phase III randomized controlled trial (NCT 05495048). The aim of this study is to confirm that the NOSES VIIIA procedure is not inferior to small-incision assisted right hemicolectomy in long-term oncological efficacy. A total of 352 female patients with right colon adenocarcinoma/high-grade intraepithelial neoplasia will be randomly assigned to the NOSES VIIIA arm and the small-incision arm in a 1:1 ratio. The primary end point of this trial is 3 year disease-free survival.
Clinical Trial Registration: NCT05495048 ( ClinicalTrials.gov )
Currently, multidrug combinations are often used clinically to improve the efficacy of oncology chemotherapy, but multidrug combinations often lead to multidrug resistance and decreased performance, resulting in more severe side effects than monotherapy. Therefore, sequential drug release strategies in time and space as well as nano-carriers that respond to the tumor microenvironment have been developed. First, the advantage of the sequential release strategy is that they can load multiple drugs simultaneously to meet their spatiotemporal requirements and stability, thus exerting synergistic effects of two or more drugs. Second, in some cases, sequential drug delivery of different molecular targets can improve the sensitivity of cancer cells to drugs. Control the metabolism of cancer cells, and remodel tumor vasculature. Finally, some drug combinations with built-in release control are used for sequential administration. This paper focuses on the use of nanotechnology and built-in control device to construct drug delivery carriers with different stimulation responses, thus achieving the sequential release of drugs. Therefore, the nano-sequential delivery carrier provides a new idea and platform for the therapeutic effect of various drugs and the synergistic effect among drugs.
Background:
The incidence of colorectal cancer (CRC) in patients under 50 years of age, i.e., early-onset CRC, has increased in the past two decades. Colorectal peritoneal metastases (CPM) will develop in 10-30% of CRC patients. CPM traditionally had a dismal prognosis, but surgery and novel systemic treatments appear to increase survival. Determining potential age-associated risk and prognostic factors is optimized when analyses use standardized age groupings.
Methods:
We performed a review of early-onset CPM studies and compared variables used, e.g., age stratification and definitions of synchronous and metachronous CPM. We included studies published in PubMed up to November 2022 if results were stratified by age.
Results:
Of 114 screened publications in English, only 10 retrospective studies met inclusion criteria. Incidence of CPM was higher in younger CRC patients (e.g. 23% vs. 2% for <25 vs. ≥25 years, P < 0.0001; and 57% vs. 39% vs. 4% for <20 vs. 20-25 vs. >25 years, P < 0.001); two studies reported higher proportion of younger African American CPM patients (e.g. 16% vs. 6% for <50 vs. ≥50 years). Studies used seven different age-stratification methods, presenting comparison challenges.
Conclusion:
Studies showed a higher proportion of CPM in younger patients, but directly comparing results was not possible due to inconsistent reporting. To better address this issue, CRC and CPM studies stratified by standard age groups (e.g. <50 vs. ≥50) are needed.
Peritoneal carcinomatosis is malignancy of the peritoneum with a low incidence caused primary by peritoneum itself or secondary due to spread from the other organs, especially from ovarian, gastrointestinal system including colorectal, appendical and gastric malignancies. It is resistant to conventional chemotherapy and has a poor prognosis. Stages of the peritoneal metastatic cascade include dissociation from primary tumor, spreading to peritoneum, invasion of subperitoneal area, proliferation and angiogenesis. To improve treatment outcomes, survival and quality of life, various therapies have been developed and combination the cytoreductive surgery (CRS) with the hyperthermic intraperitoneal chemotherapy (HIPEC) is the most popular approach due to its potentially curative and aggressive nature. The cancer should be isolated to the peritoneal cavity, a form of locoregional disease, to benefit from the effective CRS–HIPEC. The aim of CRS is to remove the peritoneum and organs if necessary, untill no visible tumor remains. Elimination of the microscopic tumor foci in the peritoneal space is aimed by applying HIPEC using warmed solution (41–43C) after the surgical removal of macroscopic tumor and tumor foci. With the administration of chemotherapeutic drugs to the intraperitoneal cavity instead of systemic administration, regional high concentration levels are reached and a stronger drug effect can be achieved with less systemic side effects.
Circulating tumor cells (CTCs) released from the primary tumor to peripheral blood are promising targets for liquid biopsies. Their biological information is vital for early cancer detection, efficacy assessment, and prognostic monitoring. Despite the tremendous clinical applications of CTCs, development of effective separation techniques are still demanding. Traditional separation methods usually use batch processing for enrichment, which inevitably destroy cell integrity and affect the complete information acquisition. Considering the rarity and heterogeneity of CTCs, it is urgent to develop effective separation methods. Microfluidic chips with precise fluid control at the micron level are promising devices for CTC separation. Their further combination with micro-/nanostructure arrays adds more biomolecule binding sites and exhibit unique fluid barrier effect, which significantly improve the CTC capture efficiency, purity, and sensitivity. This review summarized the recent advances in micro-/nanostructure array integrated microfluidic devices for CTC separation, including microrods, nanowires, and 3D micro-/nanostructures. The mechanisms by which these structures contribute to improved capture efficiency are discussed. Two major categories of separation methods, based on the physical and biological properties of CTCs, are discussed separately. Physical separation includes the design and preparation of micro-/nanostructure arrays, while chemical separation additionally involves the selection and modification of specific capture probes. These emerging technologies are expected to become powerful tools for disease diagnosis in the future.
Synergistic action of combination therapy can be enhanced by appropriate selection of drugs combination that might reduce the likelihood acquired resistance to chemotherapy in cancer. Nano based formulations offer a parallel opportunity to design advance combination drug delivery systems with specific internal and external stimulus. In recent years, there has been a lot of interest in the study of metal–organic frameworks (MOFs) for biomedical applications. Because of their extraordinary chemical properties such as tunable porous structure with high surface area MOFs are an infancy material used in drug delivery systems as a nacarrier. MOFs are regarded as a promising class of nanocarriers for drug delivery owing to well‐defined structure, ultrahigh surface area and porosity, tunable pore size, and easy chemical functionalization. Herein we summarize the most recent progress in stimuli‐based dual drug‐delivery systems including inorganic and organic nanocarriers. Moreover, we have highlighted the specific stimuli responsive nano‐MOFs as dual drug delivery systems, which offer a fresh perspective for development of hybrid nanocarrier to overcome the drawbacks of pure organic and inorganic carriers, such as toxicity, lower payload capacity and burst effect.
Introduction
The growing interest on how peri-operative interventions, especially regional anaesthesia, during cancer surgery can alter oncological outcome increasing disease free survival is probably responsible for the birth of the new subspecialty called onco-anaesthesia. A paradigm shift in the concept of anaesthetic management has occurred recently owing to the innumerable diverse revelations from the ongoing research in this field.
Discussion
Long lasting but reversible epigenetic changes can occur due to surgical stress and perioperative anesthetic medications. The exact relationship between these factors and tumor biology is being studied further. A popular topic under research now is the influence of regional anaesthesia on cancer recurrence. Combining nerve blocks with total intravenous anesthesia (TIVA) brings down the requirement of opioids and volatile anesthetic agents implicated in cancer recurrence. The study of mechanism of pain at the molecular level has led to the discovery of novel modes of prevention of chronic post-surgical pain. Newer combination aggressive treatment therapies -intraoperative chemotherapy and radiotherapy, isolated limb perfusion, photodynamic therapy and robotic surgery require specialized anaesthetic management. The COVID pandemic introduced new guidelines for safe management of oncosurgical patients .Use of genomic mapping to personalize pain management will be the breakthrough of the decade.
Conclusion
The discovery that anesthetic strategy could have significant oncological sequel is a quantum leap forward. Avoiding some anesthetic medications may decrease cancer recurrence. Comprehensive cancer care and translational research will pave the way to uncover safe anesthetic practices.
Background:
Lavage cytology is a method to detect cancer cells released within the abdominal cavity. It has been widely utilized, particularly for gastric cancer. However, its clinical significance has not yet been determined in colorectal cancer.
Objective:
This study aimed to investigate the frequency of lavage cytology positivity and its influence on the prognosis of colorectal cancer patients.
Design:
This was a single-institution retrospective observational study.
Setting:
The study was conducted at a comprehensive cancer center.
Patients:
We retrospectively analyzed 3,135 colorectal cancer cases from 2007 to 2013 at our institution. Intraoperative peritoneal washing cytology was performed just after the start of the operation. Fluids were centrifuged for 5 min at 2,500 rpm, cell pellets were smeared on microscope glass slides, and Papanicolaou staining was performed.
Main outcome measures:
The primary outcome was the 5-year overall survival rates. The secondary outcome was the 5-year recurrence rates.
Results:
Lavage cytology positivity was detected in 19 (2.0%) and 86 (16.9%) cases of stage III and IV colorectal cancer, respectively; however, no positive cases were found in stage I and II colorectal cancer. Lavage cytology positivity was an independent prognostic factor in stage III and IV colorectal cancer in the multivariate analysis [5-year mortality hazard ratio 3.59 (1.69-7.64), in stage III, 2.23 (1.15-4.31), in stage IV]. The prognosis of the 5-year survival rate was significantly worse in the lavage cytology-positive group in stages III and IV. In terms of recurrence, the results of the lavage cytology-positive group in stage III were similar to those of the lavage cytology-positive/negative group in stage IV (73.7%, 70.0%, and 75.0%).
Limitations:
This study was limited by its retrospective study design.
Conclusions:
Lavage cytology positivity is an independent prognostic and regulatory factor of stage IV colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B770.
Rare cancer cells, such as circulating tumor cells (CTCs) and cancer stem cells (CSCs), are small cell population found in cancer patients. CTCs have been recognized as tumor avatars for real‐time cancer monitoring, while CSCs are the most malignant tumor cells that play a dominant role in drug resistance and metastasis. Interestingly, these two types of cells share the same surface markers, such as EpCAM, CD44, and CD133. While capturing these rare cells is available, the expansion of these cells is still challenging due to the limited cell number. These cells are susceptible to the microenvironment and lose the capability to grow in vitro, especially after an intense capturing process. A technology called patient‐derived tumor organoids (PDOs) or tumoroids is a rising start in cancer modeling but the applicability is still questionable. Recently, assembloids containing multiple tumor‐related cells have been developed which is one step closer to the real tumor. In this review, strategies for in vitro expansion of tumoroids are summarized implying that artificial tumor niche composed of optimized biophysical and biological cues is vital in the tumoroid generation. Tumoroids containing rare cancer cells is believed to be beneficial in the diagnosis, therapeutic regimen, and drug discovery for personalized therapy.
The combination of cytoreductive surgery and intraperitoneal chemotherapy has demonstrated very promising clinical results in patients with peritoneal carcinomatosis. The underlying rationale for intraperitoneal chemotherapy is dose intensification. This chapter explores the pharmacokinetics and pharmacodynamics of different modalities of intraperitoneal chemotherapy (NIPS, HIPEC, EPIC, PIPAC). It aims to define a relevant translational endpoint for intraperitoneal chemotherapy and to provide guidelines for dosimetry.
Background:
In the management of peritoneal metastases from colon and rectal cancer, the most favorable results are reported with an aggressive combined treatment on patients who have a small extent of the disease. A test to detect occult peritoneal metastases would greatly facilitate the management of this component of colorectal dissemination.
Methods:
Currently, the standard test by which to confirm the diagnosis of the peritoneal spread of colorectal cancer is peritoneal cytology. To study the utility of this test, we gathered information from patients with biopsy-proven peritoneal metastases. The clinical, histologic, and treatment-related features of these patients at the time of a cytoreductive surgery were statistically correlated with the results of the peritoneal cytology test.
Results:
Forty-nine patients with colorectal cancer peritoneal metastases and a peritoneal cytology determination at the time of a cytoreductive surgery were available for analysis. Twenty-eight patients (55.1%) had a positive test. Patients with a high peritoneal cancer index and mucinous histology were most likely to have positive peritoneal cytology.
Conclusion:
Peritoneal cytology identified patients with mucinous histology and a large extent of disease but was consistently negative in patients who had a small extent of disease compatible with a favorable response to treatment.
Background
To investigate whether the use of Pecs II block benefit patients with the respect to the immune functions.
Methods
Totally 196 patients were included in this study. These patients were randomized to two groups, general anesthesia alone group (G group) and Pectoral nerve (Pecs) II block under general anesthesia group (PG group).
Results
It was found that remifentanil consumption was less in PG group than it in G group. PG group showed a higher proportion of NK cells in peripheral blood mononuclear cell (PBMC) and an improved killing activity than G groups after surgery. We also found that postoperative interleukin (IL)-2 concentration in the plasma of PG group was dramatically higher than it of G group. Interestingly, there was even no significant change between preoperative and postoperative IL-2 levels in PG group, suggesting the less inhibitory effect of Pecs II block on immune system of those patients.
Conclusions
In conclusion, these results indicate that Pecs II block use in patients may have an enhanced immunity compared with general anesthesia method.
The main objective of this study was to investigate the incidence of free tumour cells in peritoneal lavage cytology performed using a standard method before and after the resection of the tumour, and to assess the usefulness of this technique in scheduled interventions on colorectal cancer patients. Peritoneal lavage cytology was performed on a homogeneous sample of 188 patients undergoing colorectal cancer curative resection before and after the resection of the tumour. The procedure was performed systematically in all cases. Malignant cells were detected in the peritoneal lavage cytology performed before the resection of the tumour in three patients. Lymph node affection was the variable most associated with the prognosis of these colorectal cancer patients. Peritoneal lavage cytology can provide additional information for a small group of patients who need to be closely monitored and studied to decide on the most effective type of chemotherapy.
Approximately 15% to 20% of colorectal cancers are developed through the serrated pathway of tumorigenesis, which is associated with BRAF mutation, CpG island methylation phenotype, and MLH1 methylation. However, the detailed process of progression from sessile serrated adenoma (SSA) to dysplasia and carcinoma has not been elucidated. To further characterize mechanisms involved in the dysplastic progression of SSA, we investigated differential expressions of mRNAs between areas with and without dysplasia within the same SSA polyps. Significantly dysregulated genes in paired samples were applied for functional annotation and biological significance. The same lysates from a subset of matched samples were subjected for miRNA expression profiling. Differentially expressed miRNAs were determined, and their targeted mRNAs were compared in parallel to the list of differentially expressed mRNAs from an RNA sequencing study. Fourteen common mRNA targets were identified, which include AXIN2, a known indicator of WNT/β-catenin pathway activation. Together, in this study, different genes, pathways, and biological processes involved in the initiation and progression of dysplasia in the serrated pathway are documented. One of the most significant findings is the involvement of the WNT/β-catenin pathway in the dysplastic progression of SSAs with different genes being targeted in early versus advanced dysplasia.
In der Vergangenheit setzten Onkologen und Chirurgen die Peritonealkarzinose mit einer Fernmetastasierung gleich und betrachteten sie somit als unheilbaren Ausdruck einer fortgeschrittenen malignen Neubildung. Seit mehr als drei Jahrzehnten wurden neue Behandlungsprotokolle entwickelt, die auf einer Kombination aus zytoreduktiver Chirurgie (CRS) und hyperthermer perioperativer intraperitonealer Chemotherapie basieren und ermutigende klinische Resultate in verschiedenen Phase-II- und -III-Studien erbracht haben. Solche kombinierten Protokolle sind inzwischen Behandlungsstandard für einen peritonealen Befall bei Appendixkarzinomen, kolorektalen Karzinomen und beim Peritonealmesotheliom. Wenngleich es – basierend auf den Arbeiten von Sugarbaker et al. – zu einer nahezu universellen Standardisierung der zytoreduktiven Chirurgie gekommen ist, existieren noch immer keine standardisierten und allgemein anerkannten Protokolle für die intraperitoneale Chemotherapie. Dieses Kapitel gibt einen Überblick über die verschiedenen Modalitäten der intraperitonealen Chemotherapie und legt den Fokus dabei auf pharmakologische Variablen.
Metastasis is the main cause of death in cancer patients world-wide. During metastasis cancer cells detach from the primary tumor and invade distant tissue. The cells that undergo this process are called circulating tumor cells (CTCs). Studies show that the number of CTCs in the peripheral blood can predict progression-free survival and overall survival, and can be informative concerning the efficacy of treatment. Research is now concentrated on developing devices that can detect CTCs in the blood of cancer patients with improved sensitivity and specificity that can lead to improved clinical evaluation. This review focuses on devices that detect and capture CTCs using different cell properties (surface markers, size, deformability, electrical properties, etc.). We also discuss the process of tumor cell dissemination, the biology of CTCs, epithelial-mesenchymal transition (EMT) and several challenges and clinical applications of CTC detection.
The aim of this narrative review was to summarize the current evidence on Krukenberg tumors (KTs), addressing what is known on their natural history and their impact on the clinical prognosis and which are the most appropriate management strategies to treat this condition. A literature search was conducted on Pubmed up to December 2016, selecting the most relevant studies on the basis of the scope of the review. KTs are ovarian metastases from primary signet-ring cell carcinomas., characterized by the presence of a sarcoma-like stroma. They have three possible routes of diffusion (lymphatic, peritoneal and hematogenous), but the preferential one is still unclear. Prognosis is dismal. When KTs are encountered in the clinical practice, it is reasonable to offer surgical resection to young, fit patients with limited disease. Palliative surgery should be considered for all patients with symptomatic disease. Further studies should clarify the clinicopathologic characteristics of KTs, their main routes of diffusion, and the possible role of prophylactic oophorectomy, lymphadenectomy and intraperitoneal chemotherapy. Molecular and transitional research should parallel the clinical one to help understanding the natural history of signet-ring cell carcinomas.
Combination cancer therapy possesses considerable appeal due to its many merits such as enhancing efficacy by synergistic effects and overcoming drug resistance as compared to monotherapy. Nanomedicine-mediated co-delivery of multiple anticancer agents is more effective than conventional cocktail-based physical mixture of free drugs. A strategy is required to differentiate their unique targets for maximizing the synergistic effects based on individual sites of action of different drugs. This review summarizes the recent progresses in nanomedicine-based combination cancer therapies using site-specific co-delivery strategies, which have been classified by different target sites at the anatomical scales such as tissue, cellular and subcellular levels. In particular, the design of materials and formulations functionalized with tumor-associated signal-responsive elements has been highlighted. The potential and perspective of future developments have also been discussed.
The term peritoneal surface malignancy (PSM) applies to a wide range of epithelial or, less frequently, mesenchymal neoplasms that originate from the primitive structure of the peritoneum (primary PSM), or spread over the peritoneum as metastases from tumors of intra-abdominal, retroperitoneal, or extra-abdominal organs (secondary PSM). Primary PSMs, including peritoneal mesothelioma and primary peritoneal carcinoma, are rare. Peritoneal dissemination of colorectal, gastric, and ovarian cancers, known as peritoneal carcinomatosis (PC), represents the most frequent types of secondary PSM (Treatment of peritoneal surface malignancies, Milan, 2015). As the focus of this monograph, three secondary PSM entities, including colorectal and gastric PCs and the pseudomyxoma peritonei (PMP) syndrome, are revisited in this chapter. Hematogenous and lymphatic metastases of gastrointestinal cancers follow a well-defined pattern of distribution, with the regional lymph nodes and the liver being the initial sites for cancer spread. Peritoneal dissemination is a third mechanism that can result from serosal invasion or visceral perforation by tumor, or may develop as an iatrogenic complication following diagnostic or therapeutic interventions. Distinctions in gene expression profiles and the involvement of certain molecular pathways are believed to determine the metastatic site of gastrointestinal cancer (peritoneum versus liver) (Varghese et al., Annals of Surgical Oncology 14: 3460–3471, 2007). The past assumption that peritoneal dissemination is a random process has been challenged by meticulous observations that have identified different patterns and mechanisms governing the dissemination of tumor cells. In this regard, anatomic site of the primary tumor, histologic type of tumor, changes in intra-abdominal pressure, gravity, peritoneal surface motion (peristalsis), peritoneal fluid resorption, viscosity and volume of fluid within the abdomen, peritoneal adhesions, and fibrin entrapment are among factors that affect the pattern of spread (Carmignani et al., Cancer and Metastasis Reviews 22: 465–472, 2003). Also classified as a secondary PSM with an appendiceal primary origin, PMP represents the prototype for the peritoneal neoplasms associated with mucin secretion and accumulation. PSM is usually associated with poor prognosis regardless of the origin of the primary tumor. By virtue of the recent advances, however, the treatment paradigm has shifted from palliative to curative (Sugarbaker, Langenbeck’s Archives of Surgery 384: 576–587, 1999a; Esquivel, Surgical Oncology Clinics of North America 21: xv–xviii, 2012; Mohamed et al., Current Oncology 18: e84–e96, 2011). The classification of PSM is outlined in Table 1.1.
Aim:
To detect the expression of the long noncoding RNA HOTAIR in colon cancer and analyze its relationship with clinicopathological parameters of colon cancer.
Methods:
Total RNA was extracted from 80 colon cancer tissues and matched tumor-adjacent normal colon tissues and reverse transcribed. Quantitative polymerase chain reaction was used to detect the expression of HOTAIR. The relationship between the expression of HOTAIR and clinicopathological parameters of colon cancer was analyzed.
Results:
The expression of HOTAIR was significantly higher in colon cancer tissues than in matched tumor-adjacent normal colon tissues (P < 0.05). HOTAIR expression was significantly higher in cases with lymph node metastasis than in those without metastasis; in lowly differentiated and undifferentiated cases than in highly and moderately differentiated cases; and in stages III + IV cases than in stages I + II cases (P < 0.05).
Conclusion:
HOTAIR expression is upregulated in colon cancer, suggesting that HOTAIR plays an important role in the tumorigenesis, development and metastasis of colon cancer. HOTAIR may act as an oncogene and represents a new molecular target for the treatment of colon cancer.
Background:
Intraperitoneal-free cancer cells are considered as an important prognostic tool in gastric and ovarian cancer. However, their significance in colorectal cancer remains more controversial.
Objective:
This study aimed to determine the role of intraperitoneal-free cancer cells as a prognostic tool in the outcome in colorectal peritoneal carcinomatosis treated with curative intent by complete cytoreductive surgery.
Design:
This study is an analysis of a prospectively maintained database.
Patients:
Between 1991 and 2012, all patients treated in a single institution for colorectal peritoneal carcinomatosis by complete cytoreductive surgery with peritoneal cytology available were evaluated. Peritoneal cytology was stained in the conventional way (May Grumwald Giemsa).
Results:
Among a population of 162 patients treated for colorectal peritoneal carcinomatosis by complete cytoreductive surgery, 38 presented positive intraperitoneal-free cancer cells (23.5%). Systemic chemotherapy was administered to 135 patients (85%) during the preoperative course. Median follow-up was 34.5 months. Median overall survival was 19 and 44 months for positive and negative intraperitoneal-free cancer cells (p = 0.018). In multivariate analysis, Peritoneal Carcinomatosis Index and positive intraperitoneal-free cancer cells were significant prognostic factors of overall survival (HR, 2.3 (1.18-4.52), p = 0.014; HR, 1.9 (1.08-3.38), p = 0.027).
Limitations:
Retrospective analysis and the long period were limitations of study.
Conclusion:
Along with the Peritoneal Carcinomatosis Index, intraperitoneal-free cancer cells are a strong prognostic factor for patients treated with curative intent for colorectal peritoneal carcinomatosis by complete cytoreductive surgery. The presence of intraperitoneal-free cancer cells should lead to the consideration of different treatment strategies such as extensive intraperitoneal lavage, targeted intraperitoneal therapies, or repeated intraperitoneal chemotherapy.
Background: The aim of the present study was to detect circulating tumor cells (CTCs) in the peripheral blood of patients with non-metastatic colon cancer and to evaluate whether there is a diurnal variation in the CTC counts. Furthermore, the study aimed to examine the correlation between CTCs and TNM stage, other paraclinical variables and prognosis. Patients and Methods: Blood samples were collected from 20 consecutive patients with colon cancer TNM stage I-III at four different perioperative time points. Detection of CTCs was performed using the immunological assay CellSearch (R). Results: CTCs were detected in 1 out of 60 preoperative blood samples, resulting in a detection rate of 1 in 20 patients (5%; 95% confidence interval=0.1-25%). None of the postoperative blood samples had CTC levels above the cut-off value (>= 2 CTCs/7.5ml blood). Conclusion: The presence of CTCs in non-metastatic colon cancer is rare and barely detectable with the only commercially available assay for detection of CTCs, the CellSearch System.
PURPOSE: The laminin-5 γ2 chain plays an important role in cell migration during tumor invasion and tissue remodeling. Although this chain has been reported to be expressed in tumor-stroma interface of colorectal carcinoma, prognostic significance of its expression has not been elucidated in these tumors, so we investigated the clinicopathologic significance of Laminin-5 γ2 chain expression in colorectal carcinoma. METHODS: Laminin-5 γ2 chain expression was investigated immunohistochemically in 103 colorectal carcinoma patients with Stage II, III, and IV disease. The patients were categorized into three groups according to the number of immunopositive tumor cells in the sections containing the maximum diameter of the tumor as follows: +, less than 20 tumor cells were positive; ++, 20 to 500 tumor cells were positive; +++, more than 500 tumor cells were positive. RESULTS: Laminin-5 γ2 chain expression was observed in cytoplasm of tumor cells, especially those in the invasive front of the tumor penetration. Eighteen (17 percent) of tumors showed +, 60 (58 percent) showed ++, and 25 (24 percent) showed +++. The increased number of immunopositive tumor cells was significantly associated with synchronous liver metastasis ( P = 0.048). The univariate ( P = 0.036) and multivariate ( P = 0.001) analysis of the patients’ survival revealed that the prognosis became significantly poorer in patients with the increased number of immunopositive tumor cells. CONCLUSIONS: Increased laminin-5 γ2 chain immunoreactivity, suggesting a high invasive potential of tumor cells, was a significant poor prognostic indicator for the patients with colorectal carcinoma.
Background
Immunomagnetic enrichment followed by RT-PCR (immunobead RT-PCR) is an efficient methodology to identify disseminated carcinoma cells in the blood and bone marrow. The RT-PCR assays must be both specific for the tumor cells and sufficiently sensitive to enable detection of single tumor cells. We have developed a method to test RT-PCR assays for any cancer. This has been investigated using a panel of RT-PCR markers suitable for the detection of breast cancer cells.
Methods
In the assay, a single cell line-derived tumor cell is added to 100 peripheral blood mononuclear cells (PBMNCs) after which mRNA is isolated and reverse transcribed for RT-PCR analysis. PBMNCs without added tumor cells are used as specificity controls. The previously studied markers epidermal growth factor receptor (EGFR), mammaglobin 1 (MGB1), epithelial cell adhesion molecule (EpCAM/TACSTD1), mucin 1 (MUC1), carcinoembryonic antigen (CEA) were tested. Two new epithelial-specific markers ELF3 and EphB4 were also tested.
Results
MUC1 was unsuitable as strong amplification was detected in 100 cell PBMNC controls. Expression of ELF3, EphB4, EpCAM, EGFR, CEA and MGB1 was found to be both specific for the tumor cell, as demonstrated by the absence of a signal in most 100 cell PBMNC controls, and sensitive enough to detect a single tumor cell in 100 PBMNCs using a single round of RT-PCR.
Conclusions
ELF3, EphB4, EpCAM, EGFR, CEA and MGB1 are appropriate RT-PCR markers for use in a marker panel to detect disseminated breast cancer cells after immunomagnetic enrichment.
Background
We have used commercially available cDNA arrays to identify EphB4 as a gene that is up-regulated in colon cancer tissue when compared with matched normal tissue from the same patient.
Results
Quantitative RT-PCR analysis of the expression of the EphB4 gene has shown that its expression is increased in 82% of tumour samples when compared with the matched normal tissue from the same patient. Using immunohistochemistry and Western analysis techniques with an EphB4-specific antibody, we also show that this receptor is expressed in the epithelial cells of the tumour tissue and either not at all, or in only low levels, in the normal tissue.
Conclusion
The results presented here supports the emerging idea that Eph receptors play a role in tumour formation and suggests that further elucidation of this signalling pathway may identify useful targets for cancer treatment therapies.
Using in vitro amplification of cDNA by the polymerase chain reaction, we have detected spliced transcripts of various tissue-specific genes (genes for anti-Müllerian hormone, beta-globin, aldolase A, and factor VIIIc) in human nonspecific cells, such as fibroblasts, hepatoma cells, and lymphoblasts. In rats, erythroid- and liver-type pyruvate kinase transcripts were also detected in brain, lung, and muscle. The abundance of these "illegitimate" transcripts is very low; yet, their existence and the possibility of amplifying them by the cDNA polymerase chain reaction provide a powerful tool to analyze pathological transcripts of any tissue-specific gene by using any accessible cell.
The presence of tumor cells in the circulation may predict disease recurrence and metastases. We have developed a sensitive technique for the detection of carcinoma cells in blood, using immunomagnetic beads to enrich for epithelial cells and the polymerase chain reaction to identify a tumor marker. The colon carcinoma cell line SW480, homozygous for a K-ras codon 12 mutation, was used to establish optimal conditions. The SW480 cells were serially diluted in normal blood and incubated with immunomagnetic beads labeled with a monoclonal antibody specific for epithelial cells. Cells bound to the beads were retrieved using a magnetic field and the presence of K-ras codon 12 mutations determined by a polymerase chain reaction based analysis. SW480 cells could be detected in dilutions up to 1 SW480 cell/10(5) leukocytes in whole blood.
Detection of circulating tumor cells and micrometastases in patients with cancer should prove useful in determining prognosis and in planning and monitoring systemic therapies. We have developed immunomagnetic isolation of carcinoma cells followed by reverse transcription polymerase chain reaction (immunobead RT-PCR) as a method for identifying very small numbers of breast cancer cells in blood. The expression of cytokeratin 19 (K19) was used as the marker by which the isolated tumor cells were identified. The immunobead RT-PCR technique allowed detection of one tumor cell per 10(6) leukocytes in whole blood. Immunobead RT-PCR is a highly sensitive method of detecting cancer cells in a hematopoietic environment.
Neovascularization promotes tumor growth by facilitating nutrient exchange and by the paracrine effect. To investigate the relationship between tumor angiogenesis and patient outcome in colorectal cancer, 133 primary tumors were immunostained for CD34 antigen. Blood vessels within five microscopic fields at x200 were counted, and the mean was assigned. Mean patient age was 62.9 years, mean follow-up was 56.4 months, and mean vessel count was 112 (range, 23-298). Cox proportional hazards model and multivariate logistic regression analyses showed that the vessel count was the most important prognostic factor and correlated significantly with hematogenous, but not peritoneal or lymph node, metastasis.
Several reverse transcriptase polymerase chain reaction (RT-PCR) assays have been described for the detection of circulating tumour cells in blood and bone marrow. Target mRNA sequences for this purpose are the cytokeratins (CK) 19 and 20, the carcinoembryonic antigen (CEA), and the prostate-specific antigen messages. In this study, we investigated biological factors influencing the specificity of the CK19 and CEA RT-PCR assays. Bone marrow, granulocyte colony-stimulating factor (G-CSF)-mobilized blood stem cells and peripheral blood samples obtained from healthy volunteers (n = 15; CEA n = 7), from patients with epithelial (n = 29) and haematological (n = 23) cancer and from patients with chronic inflammatory diseases (n = 16) were examined. Neither CEA nor cytokeratin 19 messages could be amplified from bone marrow samples from healthy subjects and from patients with haematological malignancies. In contrast, specimens from patients with inflammatory diseases scored positive up to 60%. To investigate the influence of inflammation on target mRNA expression, haemopoietic cells were cultured with and without cytokine stimulation in vitro. CK19 messages could be easily detected in cultured marrow cells without further stimulation, CEA messages only after gamma-interferon (gamma-INF) stimulation. In contrast, G-CSF-mobilized peripheral blood stem cells were positive for CK19 messages only after stem cell factor (SCF) or interleukin stimulation. We conclude that transcription of so-called tissue-specific genes is inductible in haemopoietic tissues under certain conditions. These factors have to be considered in future applications of RT-PCR for the detection of minimal residual disease.
Circulating tumour cells play a central role in the metastatic process, but little is known about the relationship between this cellular subpopulation and the development of secondary disease. This study was aimed at assessing the presence of colonic cells in peripheral blood of patients with colorectal cancer in different evolutionary stages, by means of reverse transcriptase polymerase chain reaction (RT-PCR) targeted to carcinoembryonic antigen (CEA) mRNA. In vitro sensitivity was established in a recovery experiment by preparing serial colorectal cancer cell dilutions. Thereafter, 95 colorectal cancer patients and a control group including healthy subjects (n=11), patients with other gastrointestinal neoplasms (n=11) or inflammatory bowel disease (n=9) were analysed. Specific cDNA primers for CEA transcripts were used to apply RT-PCR to peripheral blood samples. Tumour cells were detected down to five cells per 10 ml blood, thus indicating a sensitivity limit of approximately one tumour cell per 10(7) white blood cells. CEA mRNA expression was detected in 39 out of 95 colorectal cancer patients (41.1%), there being a significant correlation with the presence of distant metastases at inclusion. None of the healthy volunteers and only 1 of 11 patients (9.1%) with other gastrointestinal neoplasms had detectable CEA mRNA in peripheral blood. By contrast, CEA mRNA was detected in five of the nine patients (55.6%) with inflammatory bowel disease. These results confirm that it is feasible to amplify CEA mRNA in the peripheral blood, its presence being almost certainly derived from circulating malignant cells in colorectal cancer patients. However, CEA mRNA detectable in blood of patients with inflammatory bowel disease suggests the presence of circulating non-neoplastic colonic epithelial cells.
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Figure 2
Figure 3
Whereas large numbers of cells from a primary tumor may gain access to the circulation, few of them will give rise to metastases. The mechanism of elimination of these tumor cells, often termed "metastatic inefficiency," is poorly understood. In this study, we show that apoptosis in the lungs within 1-2 days of introduction of the cells is an important component of metastatic inefficiency. First, we show that death of transformed, metastatic rat embryo cells occurred via apoptosis in the lungs 24-48 h after injection into the circulation. Second, we show that Bcl-2 overexpression in these cells inhibited apoptosis in culture and also conferred resistance to apoptosis in vivo in the lungs 24-48 h after injection. This inhibition of apoptosis led to significantly more macroscopic metastases. Third, comparison between the extent of apoptosis by a poorly metastatic cell line to that by a highly metastatic cell line 24 h after injection in the lungs revealed more apoptosis by the poorly metastatic cell line. These results indicate that apoptosis, which occurs at 24-48 h after hematogenous dissemination in the lungs is an important determinant of metastatic inefficiency. Although prior work has shown an association between apoptosis in culture and metastasis in vivo, this work shows that apoptosis in vivo corresponds to decreased metastasis in vivo.
Angiogenesis is the development of blood vessels from an existing vasculature. This process is fundamental to both physiological wound healing and the growth of malignant tumors, as it restores or creates a blood supply to growing tissue. In both cases, the release of angiogenic molecules by macrophages recruited to the wound or tumor site is central to the formation of these neovessels. Reduced vascular perfusion in tissues generates tissue ischemia and a marked reduction in local levels of oxygen (hypoxia) and glucose. Cells adapt by switching to anaerobic metabolic pathways, with a concomitant increase in lactate production and reduction in extracellular pH. In tumors, these microenvironmental "stress" factors stimulate tumor cells to secrete a wide array of proangiogenic cytokines and enzymes, promoting the re-establishment of a local vascular supply. Here we review the evidence that these stress factors, in particular hypoxia and high lactate levels, stimulate macrophages to perform similar proangiogenic functions in both tumors and wounds. The resolution of wounds results in restoration of tissue integrity and perfusion, and macrophage presence is reduced to preinjury levels. However, in tumors a high number of macrophages persists and might contribute to the ongoing growth, neovascularization, and metastasis of malignant cells.
"A survey is given of the use of modern statistical techniques in event history analysis, and in particular in the study of multi-state life-tables in demography. Emphasis is placed on the interplay between partial likelihood and nonparametric maximum likelihood based methods, a) when analysing semi-Markov models or models with repeated spells, and b) in frailty models for unobservable heterogeneity."
Metastasis, the spread and growth of tumours at secondary sites, is an extremely important clinical event, since a majority of cancer mortality is associated with the metastatic tumours, rather than the primary tumour. In spite of the importance of metastasis in the clinical setting, the actual process is extremely inefficient. Millions of tumour cells can be shed into the vasculature daily; yet, few secondary tumours are formed. The classical hypothesis explaining the inefficiency was a series of secondary events occurring in the tumour, resulting in a small subpopulation of cells capable of completing all of the steps required to successfully colonise a distant site. However, recent discoveries demonstrating the ability to predict metastatic propensity from gene expression profiles in bulk tumour tissue are not consistent with only a small subpopulation of cells in the primary tumour acquiring metastatic ability, suggesting that metastatic ability might be pre-programmed in tumours by the initiating oncogenic mutations. Data supporting both of these seemingly incompatible theories exist. Therefore, to reconcile the observed results, additional variables need to be added to the model of metastatic inefficiency. One possible variable that might explain the discrepancies is genetic background effects. Studies have demonstrated that the genetic background on which a tumour arises on can have significant affects on the ability of the tumour to metastasise and on gene expression profiles. Thus, the observations could be reconciled by combining the theories, with genetic background influencing both metastatic efficiency and predictive gene expression profiles, upon which, subsequently, metastasis-promoting mutational and epigenetic events occur. If the genetic background is an important determinant of metastatic efficiency, it would have significant implications for the clinical prediction and treatment of metastatic disease, as well as for the design of potential prevention strategies.
Angiogenesis is the development of blood vessels from an existing vasculature. This process is fundamental to both physiological wound healing and the growth of malignant tumors, as it restores or creates a blood supply to growing tissue. In both cases, the release of angiogenic molecules by macrophages recruited to the wound or tumor site is central to the formation of these neovessels. Reduced vascular perfusion in tissues generates tissue ischemia and a marked reduction in local levels of oxygen (hypoxia) and glucose. Cells adapt by switching to anaerobic metabolic pathways, with a concomitant increase in lactate production and reduction in extracellular pH. In tumors, these microenvironmental “stress” factors stimulate tumor cells to secrete a wide array of proangiogenic cytokines and enzymes, promoting the re-establishment of a local vascular supply. Here we review the evidence that these stress factors, in particular hypoxia and high lactate levels, stimulate macrophages to perform similar proangiogenic functions in both tumors and wounds. The resolution of wounds results in restoration of tissue integrity and perfusion, and macrophage presence is reduced to preinjury levels. However, in tumors a high number of macrophages persists and might contribute to the ongoing growth, neovascularization, and metastasis of malignant cells.
Using in vitro amplification of cDNA by the polymerase chain reaction, we have detected spliced transcripts of various tissue-specific genes (genes for anti-Müllerian hormone, beta-globin, aldolase A, and factor VIIIc) in human nonspecific cells, such as fibroblasts, hepatoma cells, and lymphoblasts. In rats, erythroid- and liver-type pyruvate kinase transcripts were also detected in brain, lung, and muscle. The abundance of these "illegitimate" transcripts is very low; yet, their existence and the possibility of amplifying them by the cDNA polymerase chain reaction provide a powerful tool to analyze pathological transcripts of any tissue-specific gene by using any accessible cell.
In cancer metastasis, only a small percentage of cells released from a primary tumor successfully form distant lesions, but it is uncertain at which steps in the process cells are lost. Our goal was to determine what proportions of B16F1 melanoma cells injected intraportally to target mouse liver 1) survive and extravasate, 2) form micrometastases (4 to 16 cells) by day 3, 3) develop into macroscopic tumors by day 13, and 4) remain as solitary dormant cells. Using in vivo videomicroscopy, a novel cell accounting assay, and immunohistochemical markers for proliferation (Ki-67) and apoptosis (TUNEL), we found that 1) 80% of injected cells survived in the liver microcirculation and extravasated by day 3, 2) only a small subset of extravasated cells began to grow, with 1 in 40 forming micrometastases by day 3, 3) only a small subset of micrometastases continued to grow, with 1 in 100 progressing to form macroscopic tumors by day 13 (in fact, most micrometastases disappeared), and 4) 36% of injected cells remained by day 13 as solitary cancer cells, most of which were dormant (proliferation, 2%; apoptosis, 3%; in contrast to cells within macroscopic tumors: proliferation, 91%; apoptosis/necrosis, 6%). Thus, in this model, metastatic inefficiency is principally determined by two distinct aspects of cell growth after extravasation: failure of solitary cells to initiate growth and failure of early micrometastases to continue growth into macroscopic tumors.
The analysis of censored failure times is considered. It is assumed that on each individual are available values of one or more explanatory variables. The hazard function (age-specific failure rate) is taken to be a function of the explanatory variables and unknown regression coefficients multiplied by an arbitrary and unknown function of time. A conditional likelihood is obtained, leading to inferences about the unknown regression coefficients. Some generalizations are outlined. LIFEtables are one of the oldest statistical techniques and are extensively used by medical statisticians and by actuaries. Yet relatively little has been written about their more formal statistical theory. Kaplan and Meier (1958) gave a comprehensive review of earlier work and many new results. Chiang in a series of papers has, in particular, explored the connection with birth-death processes; see, for example, Chiang (1968). The present paper is largely concerned with the extension of the results of Kaplan and Meier to the comparison of life tables and more generally to the incorporation of regression-like arguments into life-table analysis. The arguments are asymptotic but are relevant to situations where the sampling fluctuations are large enough to be of practical importance. In other words, the applications are more likely to be in industrial reliability studies and in medical statistics than in actuarial science. The procedures proposed are, especially for the two-sample problem, closely related to procedures for combining contingency tables; see Mantel and Haenzel (1959), Mantel (1963) and, especially for the application to life tables, Mantel (1966). There is also a strong connection with a paper read recently to the Society by R. and J. Peto (1972). We consider a population of individuals; for each individual we observe either the time to "failure" or the time to ccloss" or censoring. That is, for the censored individuals we know only that the time to failure is greater than the censoring time. Denote by T a random variable representing failure time; it may be discrete or continuous. Let F(t) be the survivor function, %(t) = pr (T2 t)
The analysis of censored failure times is considered. It is assumed that on each individual are available values of one or more explanatory variables. The hazard function (age‐specific failure rate) is taken to be a function of the explanatory variables and unknown regression coefficients multiplied by an arbitrary and unknown function of time. A conditional likelihood is obtained, leading to inferences about the unknown regression coefficients. Some generalizations are outlined.
In colorectal cancer (CRC), a proportion of patients with early stage disease still die of metastatic or recurrent disease within 5 years of “curative” resection. Detection of carcinoma cells in the peripheral circulation at presentation may identify a subgroup of patients with micro-metastatic disease who may benefit from adjuvant chemotherapy or radiotherapy. Our aim was to determine the presence and clinical significance of colon carcinoma cells in peripheral blood at the time of surgery. Preoperative peripheral blood samples were collected from 94 patients with CRC and 64 patients undergoing bowel resection for benign conditions (adenoma, diverticular disease or Crohn's colitis). Blood was also obtained from 20 normal donors not undergoing bowel surgery. Immunomagnetic beads were used to isolate epithelial cells followed by reverse transcription-polymerase chain reaction (RT-PCR) analysis of expression of cytokeratin (CK) 19, CK 20, mucin (MUC) 1 and MUC 2. Nineteen of 94 (20%) CRC patients were positive for epithelial cells in preoperative blood, including 6 with early stage disease. Kaplan–Meier survival analysis showed that detection of epithelial cells in preoperative blood was associated with reduced disease-free and overall survival (log-rank test, p = 0.0001). Surprisingly, circulating epithelial cells were detected in 3/30 (10%) patients resected for adenoma, and in 4/34 (12%) patients resected for benign inflammatory conditions, suggesting that cells from nonmalignant colonic epithelium may also gain entry into the bloodstream in the presence of bowel pathology. All 20 normal control bloods were negative for epithelial cells. Int. J. Cancer (Pred. Oncol.) 89:8–13, 2000. © 2000 Wiley-Liss, Inc.
Purpose:
The reverse transcription polymerase chain reaction (RT-PCR) amplification of tumor-specific mRNA has been used for the detection of cancer cells in peripheral blood. More recently, an immunomagnetic isolation and reverse transcription polymerase chain reaction (immunobead RT-PCR) was developed which has reportedly significant advantages over the previous RT-PCR analysis. In our study, we compared these two methods using a model set of peripheral blood containing tumor cells under standardized conditions.
Material and methods:
In order to compare the false positive rate, normal peripheral blood samples from five volunteers were analyzed by both methods. A model set of peripheral blood containing tumor cells was established by adding SNUC4 human colon cancer cells to peripheral blood collected from normal volunteers not showing any nonspecific bands upon electrophoresis of the PCR products. RT-PCR amplification of carcinoembryonic antigen (CEA) mRNA was done with total RNA and mRNA prepared from this model sample. In immunobead RT-PCR analysis, mRNA was prepared from the cells isolated with anti-CEA antibody-coated magnetic beads or anti-Ber-EP4 antibody-coated magnetic beads before the RT-PCR analysis.
Result:
The immunobead RT-PCR yielded no non-specific band, while the regular RT-PCR using total RNA did show non-specific band formation in all five samples. When mRNA rather than total RNA was used, nonspecific bands were formed in three of the five samples. Immunobead RT-PCR allowed the detection of 10(1) tumor cells in 1 ml of peripheral blood. The regular RT-PCR analysis had a detection limit of 10(2) tumor cells in 1 ml of peripheral blood.
Conclusion:
The immunobead RT-PCR proved to be more sensitive and specific than the regular RT-PCR at least in our model system.
Matrilysin (MAT) is a member of the matrix metalloproteinase (MMP) family which is believed to degrade components of the extracellular matrix (ECM) during processes of tissue remodeling. Although MAT is similar to the stromelysins in its substrate specificity, and to interstitial collagenase in the crystal structure of its catalytic domain, this enzyme is unique in that it lacks the carboxy-terminal segments encoded by other MMP genes. Characterization of the human MAT gene has revealed that the promoter region contains typical MW promoter elements such as AP-1 and PEAS, which mediate responsiveness to growth factors, oncogenes, and phorbol esters. Activated recombinant forms of human MAT cleave ECM and basement membrane proteins such as fibronectin, collagen type IV, laminin, and particularly elastin, entactin, and cartilage proteoglycan aggregates. Furthermore, MAT appears to mediate the proteolytic processing of other molecules (e.g. tumor necrosis factor α precursor, urokinase plasminogen activator). MAT is expressed in a variety of tumors ranging from adenomas to carcinomas and adenocarcinomas of the breast, colon, prostate, stomach, upper aerodigestive tract, lung, and skin, where it may be involved in tumor formation as well as the tissue degradation which accompanies tumor cell extravasation. Localization of MAT mRNA and protein to the tumor cells is unusual in that the majority of MMPs are produced in the stroma. This distinctive tissue-restricted pattern of MAT expression is a recapitulation of the expression pattern in normal human tissue, where MAT protein localizes to secretory and ductal epithelium in the endometrium and in various exocrine glands. In the mouse, high constitutive levels of MAT mRNA are found in epithelial cells in the uterus, small intestine, and extra-testicular ducts. Taken together, these findings suggest that MAT may have a specific role in normal gland and organ function, a possibility which can be explored further by the genetic manipulation of MAT levels in vivo.
In lifetesting, medical follow-up, and other fields the observation of the time of occurrence of the event of interest (called a death) may be prevented for some of the items of the sample by the previous occurrence of some other event (called a loss). Losses may be either accidental or controlled, the latter resulting from a decision to terminate certain observations. In either case it is usually assumed in this paper that the lifetime (age at death) is independent of the potential loss time; in practice this assumption deserves careful scrutiny. Despite the resulting incompleteness of the data, it is desired to estimate the proportion P(t) of items in the population whose lifetimes would exceed t (in the absence of such losses), without making any assumption about the form of the function P(t). The observation for each item of a suitable initial event, marking the beginning of its lifetime, is presupposed.
For random samples of size N the product-limit (PL) estimate can be defined as follows: List and label the N observed lifetimes (whether to death or loss) in order of increasing magnitude, so that one has \(0 \leqslant t_1^\prime \leqslant t_2^\prime \leqslant \cdots \leqslant t_N^\prime .\) Then \(\hat P\left( t \right) = \Pi r\left[ {\left( {N - r} \right)/\left( {N - r + 1} \right)} \right]\), where r assumes those values for which \(t_r^\prime \leqslant t\) and for which \(t_r^\prime\) measures the time to death. This estimate is the distribution, unrestricted as to form, which maximizes the likelihood of the observations.
Other estimates that are discussed are the actuarial estimates (which are also products, but with the number of factors usually reduced by grouping); and reduced-sample (RS) estimates, which require that losses not be accidental, so that the limits of observation (potential loss times) are known even for those items whose deaths are observed. When no losses occur at ages less than t the estimate of P(t) in all cases reduces to the usual binomial estimate, namely, the observed proportion of survivors.
This study evaluates the clinical significance of detection of carcinoembryonic antigen (CEA) mRNA in the dissected lymph nodes and peripheral blood samples of patients with gastrointestinal or breast carcinomas.
A total of 406 lymph nodes obtained from 65 patients were analyzed by both histologic and molecular examination of CEA-specific reverse transcriptase-polymerase chain reaction (RT-PCR). Peripheral blood samples from another 102 patients were also analyzed by CEA-specific RT-PCR. Patients were followed up prospectively for 24 +/- 12 months.
Of 406 lymph nodes, the positive detection rate increased from 20% by histologic examination to 60% by RT-PCR examination. The recurrence rate was 40% in 15 cases showing positive results in both examinations, 14% in 29 cases showing histologically negative but RT-PCR positive results, and none in 21 cases showing negative results in both examinations. The positive detection rate for CEA mRNA in peripheral blood samples increased with advancing stage of disease. With respect to 62 curatively operated cases, CEA mRNA was detected in 12 cases. Four of these 12 cases developed metastatic disease after surgery whereas none of 50 cases negative by RT-PCR developed metastasis.
It has been shown that RT-PCR is a powerful tool to detect CEA mRNA in the lymph nodes or the peripheral blood. This is potentially very useful to determine high-risk patients for metastasis. Serial analysis is warranted to assess the long-term significance of this method and its therapeutic and prognostic implications.
Lymph node metastasis is known as a significant predictor of prognosis in colorectal cancer patients. Recently, reverse transcriptase polymerase chain reaction (RT-PCR) has been applied to detecting micrometastasis. To assess the risk of recurrence and accurately determine the spread of tumor cells, we examined lymph node micrometastases in a series of colorectal cancer patients.
We examined 202 lymph nodes obtained from 13 colorectal cancer patients who underwent curative operation and were histologically diagnosed to be node-negative, using RT-PCR to amplify mRNAs for two epithelial markers, carcinoembryonic antigen (CEA) and cytokeratin 20 (CK-20).
All the cases, including early stage patients, had micrometastases. A total of 102 among 202 lymph nodes (50.5%) were positive for either CEA or CK-20, or both (47.0, 40.1, and 36.6% respectively). Positive lymph nodes were spread along the courses of vascular trunks as well as being located in more distant regions.
Even in histologically negative lymph nodes, there is a considerable possibility that micrometastases may exist. Their detection by RT-PCR may improve clinical staging and indications for cancer therapy. We should also take care in the choice of surgical approach.
In cancer metastasis, only a small percentage of cells released from a primary tumor successfully form distant lesions, but it is uncertain at which steps in the process cells are lost. Our goal was to determine what proportions of B16F1 melanoma cells injected intraportally to target mouse liver 1) survive and extravasate, 2) form micrometastases (4 to 16 cells) by day 3, 3) develop into macroscopic tumors by day 13, and 4) remain as solitary dormant cells. Using in vivo videomicroscopy, a novel cell accounting assay, and immunohistochemical markers for proliferation (Ki-67) and apoptosis (TUNEL), we found that 1) 80% of injected cells survived in the liver microcirculation and extravasated by day 3, 2) only a small subset of extravasated cells began to grow, with 1 in 40 forming micrometastases by day 3, 3) only a small subset of micrometastases continued to grow, with 1 in 100 progressing to form macroscopic tumors by day 13 (in fact, most micrometastases disappeared), and 4) 36% of injected cells remained by day 13 as solitary cancer cells, most of which were dormant (proliferation, 2%; apoptosis, 3%; in contrast to cells within macroscopic tumors: proliferation, 91%; apoptosis/necrosis, 6%). Thus, in this model, metastatic inefficiency is principally determined by two distinct aspects of cell growth after extravasation: failure of solitary cells to initiate growth and failure of early micrometastases to continue growth into macroscopic tumors.
The aims of this study were to evaluate potential predictors of exfoliated free cancer cells in the peritoneal cavity and to assess intraoperative peritoneal lavage cytology as a prognostic indicator in patients with colorectal cancer.
From 1985 to 1987, intraoperative peritoneal lavage cytology was performed in 140 patients with colorectal cancer. Among them, 88 patients underwent curative resection and 52 patients had noncurative surgery. Cytology was examined twice, i.e., immediately after opening the peritoneal cavity (precytology) and just before closing the abdomen (postcytology). One hundred milliliters of saline was poured into the peritoneal cavity and it was retrieved by suction after irrigation. Cytologic examination was performed after staining with Papanicolaou, Giemsa, periodic acid-Schiff, and Alcian blue stains.
Among the 140 patients examined, the incidence of positive cytology in the prelavage was 15 percent, and that in the postlavage was 9 percent, although it was 16 percent in either lavage. Among patients with curative resection, 10 percent had positive cytology. Seven characteristics were identified as features of tumors which are prone to exfoliate cells into the peritoneal cavity: 1) macroscopic peritoneal dissemination, 2) liver metastasis, 3) more than 20 ml of ascites, 4) ulcerated tumors without definite borders, 5) invasion of the serosal surface or beyond, 6) semiannular or annular shape, and 7) moderate or marked lymphatic invasion. In patients undergoing curative surgery, among these features, circumferential involvement was the only one correlated closely with positive cytology (P < 0.02). Positive cytology was associated with a worse outcome. In patients who were resected curatively, the postcytology had a stronger influence on local recurrence than the precytology; the local recurrence rate in patients with positive postcytology was higher than in those with negative postcytology, regardless of the precytology. All patients with cancer cells in the peritoneal cavity at the end of surgery had recurrence.
Seven characteristics were identified as risk factors for exfoliation of cancer cells into the peritoneal cavity in patients with colorectal cancer. These findings may be helpful for the choice of laparoscopic surgery in this era of increasing port-site metastases after laparoscopic procedure. The results of peritoneal lavage cytology at the end of surgery were correlated with the long-term postoperative outcome of colorectal cancer. Thus, meticulous follow-up and possibly adjuvant chemotherapy may be beneficial for patients with free cancer cells in lavage fluid, even after curative surgery.
The objectives of this study were to assess whether the use of two reverse transcription-PCR (RT-PCR) cDNA assays and multiple blood sampling increased circulating tumor cell detection in colorectal cancer patients. Systemic blood was sampled three times at 1-min intervals in 100 colorectal cancer patients (50 primary tumors only and 50 liver metastases), and in 70 control patients without known cancer. After removal of the erythrocytes, samples were subjected to separate RT-PCR reactions using specific primers for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20). Statistical analysis was performed by the two-sample binomial test and the one-sided McNemar test. There were significant increases in circulating tumor cell positivity when CEA and CK20 assays were used together as compared with either CEA or CK20 assay used alone. There were also significant increases in circulating tumor cell positivity for either CEA or CK20 assay used alone when the results from two blood samples were compared with the results from one sample. Circulating colorectal cancer cell positivity rose from 48% (CEA) and 34% (CK20) with one assay of one sample to 74% when both assays of three samples were used to identify circulating tumor cells. Three non-cancer control patients (4.3%) were positive for either CEA (two patients) or CK20 (one patient). Tumor cells were identified more frequently in the circulation of colorectal cancer patients than had been suggested previously. RT-PCR-based studies of the clinical significance of circulating cancer cells in colorectal cancer should involve multiple blood samples with identification of multiple tumor-related cDNA products.
In colorectal cancer (CRC), a proportion of patients with early stage disease still die of metastatic or recurrent disease within 5 years of "curative" resection. Detection of carcinoma cells in the peripheral circulation at presentation may identify a subgroup of patients with micro-metastatic disease who may benefit from adjuvant chemotherapy or radiotherapy. Our aim was to determine the presence and clinical significance of colon carcinoma cells in peripheral blood at the time of surgery. Preoperative peripheral blood samples were collected from 94 patients with CRC and 64 patients undergoing bowel resection for benign conditions (adenoma, diverticular disease or Crohn's colitis). Blood was also obtained from 20 normal donors not undergoing bowel surgery. Immunomagnetic beads were used to isolate epithelial cells followed by reverse transcription-polymerase chain reaction (RT-PCR) analysis of expression of cytokeratin (CK) 19, CK 20, mucin (MUC) 1 and MUC 2. Nineteen of 94 (20%) CRC patients were positive for epithelial cells in preoperative blood, including 6 with early stage disease. Kaplan-Meier survival analysis showed that detection of epithelial cells in preoperative blood was associated with reduced disease-free and overall survival (log-rank test, p = 0.0001). Surprisingly, circulating epithelial cells were detected in 3/30 (10%) patients resected for adenoma, and in 4/34 (12%) patients resected for benign inflammatory conditions, suggesting that cells from nonmalignant colonic epithelium may also gain entry into the bloodstream in the presence of bowel pathology. All 20 normal control bloods were negative for epithelial cells.
We evaluated the incidence and prognostic relevance of microscopic intraperitoneal tumor cell dissemination of colon cancer in comparison with dissemination of gastric cancer as a rational for additive intraperitoneal therapy.
Peritoneal washouts of 90 patients with colon and 111 patients with gastric cancer were investigated prospectively. Sixty patients with benign diseases and 8 patients with histologically proven gross visible peritoneal carcinomatosis served as controls. Intraoperatively, 100 ml of warm NaCl 0.9 percent were instilled and 20 ml were reaspirated. In all patients hematoxylin and eosin staining (conventional cytology) was performed. Additionally, in 36 patients with colon cancer and 47 patients with gastric cancer, immunostaining with the HEA-125 antibody (immunocytology) was prepared. The results of cytology were assessed for an association with TNM category and cancer grade, based on all patients, and with patient survival, among the R0 resected patients.
In conventional cytology 35.5 percent (32/90) of patients with colon cancer and 42.3 percent (47/111) of patients with gastric cancer had a positive cytology. In immunocytology 47.2 percent (17/36) of patients with colon cancer and 46.8 percent (22/47) of patients with gastric cancer were positive. In colon cancer, positive conventional cytology was associated with pT and M category (P = 0.044 and P = 0.0002), whereas immunocytology was only associated with M category (P = 0.007). No association was found between nodal status and immunocytology in colon cancer and with the grading. There was a statistically significant correlation between pT M category and conventional and immunocytology in gastric cancer (P < 0.0015/P = 0.007 and P < 0.001/P = 0.009, respectively). Positive immunocytology was additionally associated with pN category (P = 0.05). In a univariate analysis of R0 resected patients (no residual tumor), positive immunocytology was significantly related to an unfavorable prognosis in patients with gastric cancer only (n = 30). Mean survival time was significantly increased in patients with gastric cancer with negative cytology compared with positive cytology (1,205 (standard error of the mean, 91) vs. 771 (standard error of the mean, 147) days; P = 0.007) but not in patients with colon cancer (1,215 (standard error of the mean, 95) vs. 1,346 (standard error of the mean, 106) days; P = 0.55).
Because microscopic peritoneal dissemination influences survival time after R0 resections only in patients with gastric but not with colon cancer, our results may provide a basis for a decision on additive, prophylactic (intraperitoneal) therapy in gastric but not colon cancer.
Reverse transcription polymerase chain reaction (RT-PCR)-based detection of tyrosinase mRNA is a frequently used method for the identification of circulating tumor cells in melanoma patients. The significance and practical value of this procedure for the diagnosis of tumor dissemination in melanoma patients are unclear. The conflicting results may at least partially be related to very low amounts of circulating tumor cells and to our observation that melanoma cells only transiently persist in the peripheral blood. The purpose of the present study was to evaluate the relevance of detection of extracellular melanoma-specific mRNA in serum and plasma samples in comparison to blood cell samples from patients with disseminated disease (stage IV). We therefore compared the presence of specific mRNA for tyrosinase, gp100, and MART-1 by RT-PCR amplification of specific cDNA from serum, plasma, and whole blood samples of 10 melanoma patients. Melanoma-specific mRNA was detectable in whole blood samples of all ten patients tested indicating the presence of circulating melanoma cells. In addition, tyrosinase mRNA could be detected in the serum and/or plasma of 6 of 10 melanoma patients whereas gp100 and MART-1 specific transcripts were not detectable in any of the samples tested. The presence and integrity of amplifiable RNA was shown in all serum and plasma samples of patients and controls by RT-PCR-specific amplification of porphobilinogen deaminase (PBDG) mRNA. We conclude that tyrosinase mRNA but not gp100 and MART-1 mRNA can be amplified from serum and/or plasma in a subset of melanoma patients showing circulating melanoma cells. Therefore, extracellular-directed assays appear to be less sensitive and efficacious in detecting melanoma-specific transcripts compared to cellular-based assays.
A variety of techniques have been employed for the detection of occult tumour cells in the blood, bone marrow and lymph nodes of patients with colorectal cancer. This review examines the methods used, results obtained and the clinical significance of studies in this field.
A Medline literature search was performed using the terms colorectal cancer, minimal residual disease, micrometastasis, polymerase chain reaction, reverse transcriptase polymerase chain reaction and immunocytochemistry; further references were obtained from key articles.
Immunocytochemical examination of bone marrow is the benchmark for detecting clinically significant occult disease. Larger standardized studies are required to confirm the prognostic significance of molecular assays for the detection of tumour cells in blood and bone marrow. The prognostic significance of lymph node tumour cells detected by either immunohistochemical or molecular methods awaits further affirmation.
Standardization of terminology and techniques used, combined with large prospective clinical studies, is required if detection of occult residual disease is to become a prognostic marker for recurrence in colorectal cancer.
The laminin-5 gamma2 chain plays an important role in cell migration during tumor invasion and tissue remodeling. Although this chain has been reported to be expressed in tumor-stroma interface of colorectal carcinoma, prognostic significance of its expression has not been elucidated in these tumors, so we investigated the clinicopathologic significance of Laminin-5 gamma2 chain expression in colorectal carcinoma.
Laminin-5 gamma2 chain expression was investigated immunohistochemically in 103 colorectal carcinoma patients with Stage II, III, and IV disease. The patients were categorized into three groups according to the number of immunopositive tumor cells in the sections containing the maximum diameter of the tumor as follows: +, less than 20 tumor cells were positive; ++, 20 to 500 tumor cells were positive; +++, more than 500 tumor cells were positive.
Laminin-5 gamma2 chain expression was observed in cytoplasm of tumor cells, especially those in the invasive front of the tumor penetration. Eighteen (17 percent) of tumors showed +, 60 (58 percent) showed ++, and 25 (24 percent) showed +++. The increased number of immunopositive tumor cells was significantly associated with synchronous liver metastasis (P = 0.048). The univariate (P = 0.036) and multivariate (P = 0.001) analysis of the patients' survival revealed that the prognosis became significantly poorer in patients with the increased number of immunopositive tumor cells.
Increased laminin-5 gamma2 chain immunoreactivity, suggesting a high invasive potential of tumor cells, was a significant poor prognostic indicator for the patients with colorectal carcinoma.
Peritoneal recurrence after curative resection of malignant tumor with negative cytology is considered to be caused by microscopic dissemination of the exfoliated cancer cells from primary tumors to serosal surfaces at the time of operation, not detectable with conventional diagnostic tools. We applied the reverse transcriptase-polymerase chain reaction (RT-PCR) for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK 20) to detect micrometastatic foci in the peritoneal cavity of colon cancer patients. Cytological samples taken by peritoneal lavage from a series of 79 colon cancer patients were analyzed microscopically, for CEA levels, and by RT-PCR analysis using nested primers for CEA and CK 20. Cases with both CEA and CK 20 signals were defined as PCR-positive. This RT-PCR method proved both sensitive (1 tumor cell/10(6) non-tumor cells on preparation of serial colorectal cancer cell dilutions) and specific (no false positive results, 0/23 tested in our control experiment). Intraperitoneal micrometastatic cells were detected in peritoneal lavage 7.6% by cytology, 17.7% by CEA levels, and 24.1% by RT-PCR (significantly higher than by cytology: p=0.0046). RT-PCR detection rate increased in parallel with pathological depth of tumor invasion, and also a pathological stage-dependence was suggested according to the tumor-node-metastasis classification of the International Union Against Cancer. Our results suggest that CEA and CK 20 mRNA identification by RT-PCR appeared to be reliable and may be useful for early diagnosis in peritoneal dissemination of colon cancer.
The objective of the present investigation was to assess the prognostic significance of disseminated tumour cells in peritoneal lavage, and peripheral and mesenteric venous blood in patients undergoing curative resection of colorectal cancer.
The prognostic impact of perioperative cytological and immunocytochemical detection of disseminated colorectal cancer cells was evaluated prospectively. Peritoneal lavage fluid, and peripheral and mesenteric venous blood from 53 consecutive patients undergoing curative surgery for colorectal cancer were analysed. The dichotomous results (positive versus negative) from the cytological and immunocytochemical analysis were used as a predictor along with other co-variates in proportional hazard regression models of disease-free and overall survival.
Disseminated colorectal cancer cells were found in 13 of 53 patients (25 per cent) using cytology (CYT) and/or immunocytochemistry (ICC). The median follow-up at the time of the analysis was 37 months. In multivariate proportional hazard regression models CYT/ICC status was a significant predictor for disease-free (P = 0.002) and overall (P = 0.006) survival.
Disseminated tumour cells detected by CYT and ICC represent an independent prognostic factor in patients undergoing surgery for colorectal cancer and may identify patients at high risk of recurrence.
Lymph node status is a key factor for disease staging and is the main determinant for adjuvant therapy of colorectal cancer. The current staging procedure is unable to identify occult metastasis in lymph nodes, which is likely to be an important cause of treatment failure in some early-stage patients. The detection of occult metastasis could identify a patient subgroup at risk for disease relapse that would benefit from adjuvant therapy. The purpose of this study was to establish and test a multimarker reverse transcriptase-polymerase chain reaction assay for the molecular detection of occult metastases in lymph nodes.
Forty-four patients with colorectal cancer and 14 patients with benign bowel diseases undergoing colonic resection were enrolled in the study. Reverse transcriptase-polymerase chain reaction was used to detect expression of three epithelial markers, carcinoembryonic antigen, cytokeratin 20, and guanylyl cyclase C, in fresh colorectal lymph node tissue.
Forty-six of 47 (97.9 percent) histologically positive lymph nodes were also positive by reverse transcriptase-polymerase chain reaction. Of 221 histologically negative nodes, 97 (43.9 percent) were positive for at least one of the three markers by reverse transcriptase-polymerase chain reaction: 24.9 percent for carcinoembryonic antigen, 16.7 percent for cytokeratin 20, and 24.9 percent for guanylyl cyclase C. Among these were 13 of 20 stage I and II cases, implying a staging shift to stage III by molecular diagnosis of occult metastasis. Fifty-nine additional nodes were found to be positive for occult metastases in 22 of 24 stage III and IV patients.
These results indicate that occult metastases are detectable by reverse transcriptase-polymerase chain reaction in histologically negative lymph nodes from colorectal cancer. The use of a panel of three markers improves the specificity of the method.
MMP-7, a member of the matrix metalloproteinase family, is believed to play a significant role in the growth and proliferation of colon cancer cells. The aim of this study was to evaluate MMP-7 gene expression in comparison with MMP-1, MMP-3, and MMP-13 in patients with resectable rectal and colon cancer by a semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR).
Biopsy samples of tumor ( n=30) and distant normal mucosa ( n=30) from 30 patients were obtained intraoperation. Messenger (m)RNA was extracted from all of the tissue samples and reverse transcribed to double-stranded cDNA. Semi-quantitative RT-PCR was performed to study the MMP gene expression in both the tumor and normal mucosal specimens. MMP mRNA values were expressed relative to glyceraldehyde-3-phosphate dehydrogenase (GAPDH) for each sample.
In all 30 cases an increase in MMP-7 mRNA expression was detected in the cancerous tissue ( p=0.00004). In 21 out of 30 cases an increase in MMP-13 mRNA ( p=0.023) and in 22 out of 30 cases an increase in MMP-3 mRNA ( p=0.075) was detected in the cancerous tissue. In contrast, there was no significant change in the MMP-1 expression of normal and cancerous mucosal specimens in either colon or rectal carcinomas. There were no significant differences between rectum and colon carcinomas.
Taking into account our earlier studies, we conclude that most cases of colorectal carcinogenesis are characterized by enhanced expression of MMP-7, -13, -3 and the gelatinases, whereas MMP-1-expression is very inconsistent and not overexpressed in many cases. MMP-7 inhibition as well as inhibition of MMP-13 and MMP-3 may be a useful preventive or therapeutic adjunct in colorectal cancer.
To address whether all medically fit patients with curatively resected stage II colon cancer should be offered adjuvant chemotherapy as part of routine clinical practice, to identify patients with poor prognosis characteristics, and to describe strategies for oncologists to use to discuss adjuvant chemotherapy in practice.
An American Society of Clinical Oncology Panel, in collaboration with the Cancer Care Ontario Practice Guideline Initiative, reviewed pertinent information from the literature through May 2003.
A literature-based meta-analysis found no evidence of a statistically significant survival benefit of adjuvant chemotherapy for stage II patients. Recommendations The routine use of adjuvant chemotherapy for medically fit patients with stage II colon cancer is not recommended. However, there are populations of patients with stage II disease that could be considered for adjuvant therapy, including patients with inadequately sampled nodes, T4 lesions, perforation, or poorly differentiated histology.
Direct evidence from randomized controlled trials does not support the routine use of adjuvant chemotherapy for patients with stage II colon cancer. Patients and oncologists who accept the relative benefit in stage III disease as adequate indirect evidence of benefit for stage II disease are justified in considering the use of adjuvant chemotherapy, particularly for those patients with high-risk stage II disease. The ultimate clinical decision should be based on discussions with the patient about the nature of the evidence supporting treatment, the anticipated morbidity of treatment, the presence of high-risk prognostic features on individual prognosis, and patient preferences. Patients with stage II disease should be encouraged to participate in randomized trials.
Every year, more than 945000 people develop colorectal cancer worldwide, and around 492000 patients die. This form of cancer develops sporadically, in the setting of hereditary cancer syndromes, or on the basis of inflammatory bowel diseases. Screening and prevention programmes are available for all these causes and should be more widely publicised. The adenoma-carcinoma sequence is the basis for development of colorectal cancer, and the underlying molecular changes have largely been identified. Prognosis depends on factors related to the patient, treatment, and tumour, and the expertise of the treatment team is one of the major determinants of outcome. New information on the molecular basis of this cancer have led to the development of targeted therapeutic options, which are being tested in clinical trials. Further clinical progress will largely depend on the broader implementation of multidisciplinary treatment strategies following the principles of evidence-based medicine.
Local peritoneal recurrence is a relatively common complication after intentionally curative surgery for colorectal cancer and has unfavourable prognosis.
This manuscript reviews the relevant experimental and clinical literature on surgical trauma and development of local recurrences, which was obtained by extensive search in the PubMed database.
Although surgery is required as the only option for treatment, operative trauma and subsequent wound healing promote development of local recurrences. Minimizing peritoneal trauma reduces local tumour outgrowth in animal models, but clinical trials have not been conclusive so far. Recognition of the increased susceptibility to tumour establishment in the early post-operative phase challenges the aim for further research, targeting at strategies that obstruct local tumour implantation or outgrowth and/or improve (local) anti-tumour response.
Clinicopathologic staging of colorectal cancer remains the best predictor of survival. Prognostication for an individual with colorectal cancer remains elusive. This study was designed to investigate the incidence of free surface colorectal cancer cells detected by cytology during elective open curative resection, to correlate their presence with particular clinicopathologic variables and determine whether their presence was predictive of cancer-specific survival.
Over a six-year period in one institution, all elective colon and intraperitoneal rectal cancer specimens were assessed during primary resection for the presence of free colorectal cancer cells by means of a simple and tested specimen imprint cytology methodology. Clinicopathologic variables were assessed prospectively and blinded to cytology results. All patients were followed up routinely until death and if the patient was not seen within the last six months, information was obtained from the New South Wales Registry of Births, Deaths and Marriages in Australia.
Overall, 26 of 281 (9.25 percent) colorectal cancers had positive cytology for cancer cells on the peritoneal surface of the bowel. Poorly differentiated tumors were significantly associated with positive cytology. Tumor penetration, presence of vascular or neural invasion, mucinous characteristics, lymph node status, and operative procedure performed were not statistically significant predictors of positive cytology. Overall, 43 of the 281 patients (15.3 percent) died during the mean follow-up period of 49.2 months from cancer-related deaths. Of these patients, 8 had positive cytology and 35 had negative cytology results. Cancer-specific survival assessed with the log-rank test was significantly associated with positive cytology in univariate (P = 0.008) and multivariate analysis (P < 0.001).
In this study, the presence of free surface colorectal cancer cells has been shown to be predictive of survival and is independent of direct peritoneal invasion and lymph node status. Thus, further assessment of this simple prognostic variable is warranted and selection of patients with positive cytology for possible adjuvant therapies may be beneficial.
Bethesda (MD): National Cancer Institute. http:// seer.cancer.gov/csr
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Detection of occult metastases in lymph nodes from colorectal cancer patients: a multiple-marker reverse transcription-PCR study
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Chen G, McIver CM, Texler MD, et al. Detection of occult metastases in lymph nodes from colorectal cancer patients: a multiple-marker reverse transcription-PCR study. Dis Colon Rectum 2004;47: 679 ^ 86.
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Bethesda (MD): National Cancer Institute
- Lag Ries
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Ries LAG, Eisner MP, Kosary CL, et al., editors.
SEER Cancer Statistics Review, 1975 ^ 2002.
Bethesda (MD): National Cancer Institute. http://
seer.cancer.gov/csr/1975_ 2002/.