Does chronic kidney disease affect the complications and prognosis of patients after primary colorectal cancer surgery?

BACKGROUNDThe effect of chronic kidney disease (CKD) on the outcomes of colorectal cancer (CRC) patients after primary CRC surgery is controversial.AIMTo analyze whether CKD had specific effect on the outcomes after CRC surgery.METHODSWe searched the PubMed, Embase, Cochrane Library databases and CNKI, from inception to March 14, 2022. Newcastle-Ottawa Scale was used for the quality assessment in this meta-analysis, and we used RevMan 5.3 was used for data analysis.RESULTSA total of nine studies including 47771 patients were eligible for this meta-analysis. No significant difference was found in terms of overall postoperative complications [odds ratio (OR) = 1.78, 95%CI: 0.64-4.94, P = 0.27]. We analyzed the specific complications and found that the CKD group had higher rates of pulmonary infection (OR = 2.70, 95%CI: 1.82-4.00, P < 0.01), cardiovascular complications (OR = 3.39, 95%CI: 2.34-4.91, P < 0.01) and short-term death (OR = 3.01, 95%CI: 2.20-4.11, P < 0.01). After pooling the hazard ratio (HR), the CKD group had worse overall survival (OS) (HR = 1.51, 95%CI: 1.04-2.20, P = 0.03). We performed subgroup analyses of the dialysis and non-dialysis groups, and no significant difference was found in the non-dialysis group (HR = 1.20, 95%CI: 0.98-1.47, P = 0.08). The dialysis group had worse OS (HR = 3.36, 95%CI: 1.92-5.50, P < 0.01) than the non-dialysis group. The CKD group had worse disease-free survival (DFS) (HR = 1.41, 95%CI: 1.12-1.78, P < 0.01), and in the subgroup analysis of the dialysis and non-dialysis groups, no significant difference was found in the non-dialysis group (HR = 1.27, 95%CI: 0.97-1.66, P = 0.08). The dialysis group had worse OS (HR = 1.95, 95%CI: 1.23-3.10, P < 0.01) than the non-dialysis group.CONCLUSIONPreexisting CKD was associated with higher rates of pulmonary infection, higher rates of short-term death, and worse OS and poorer DFS following CRC surgery.     

Repeat cytoreductive surgery (CRS) for recurrent colorectal peritoneal metastases: Yes or no?

Purpose

To clarify the role of repeat CRS for recurrent colorectal carcinoma (CRC) through: (i) Systematic review of the literature (ii) Analysis of survival outcomes in a prospective cohort.

Methods

(i) Pubmed and MEDLINE from 1980 to July 2013 searched using terms: colorectal carcinoma, peritonectomy, cytoreductive surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), redo, repeat, and iterative. (ii) Kaplan–Meier Survival analysis of consecutive patients undergoing repeat CRS at St George Hospital between Jan 2000 and July 2013.

Results

(i) The search strategy yielded 309 articles, 5 meeting inclusion criteria, reporting on 91 patients. Median overall survival from first CRS ranged from 39 to 57.6 months with 3-yr survival of 50%, and 5-year survival of 30%. Median survival from second CRS was 20-months with 1-yr survivals of 72% and 66% and 2-year survivals of 50% and 44%. (ii) Repeat CRS performed on 18 patients found median survival from first CRS was 59 months, with 1, 3, and 5-year survival of 100%, 52% and 26% respectively. Median survival from repeat CRS was 22.6 months with 1, 2, and 3-year survival of 94%, 48% and 12% respectively.

Conclusion

The current data on repeat CRS in CRC is relatively immature and more data is required before drawing clear conclusions. Patient selection should be on a case by case basis conducted through a MDT process with emphasis on surrogate markers for favourable outcomes.     

Management of colorectal cancer patients after resection of liver metastases: can we offer a tailored treatment?

Surgical resection remains the only option of cure for patients with colorectal liver metastases, and no patient should be precluded from surgery. There is much controversy not only regarding the most appropriate therapeutic approach in the neoadjuvant setting but also after surgery is performed. Many patients will experience early relapses but others will be long survivors. We need to establish reliable prognostic and predictive factors to offer a tailored treatment. Several prognostic factors after metastasectomy have been identified: high C-reactive protein levels, a high neutrophil-lymphocyte ratio, elevated neutrophil count and low serum albumin are related to a worst outcome. Elevated CEA and Ki 67 levels, intrahepatic and perihepatic lymph node invasion are also some of the markers related to a worst outcome. In contrast, the administration of preoperative chemotherapy has been associated with a better prognosis after hepatectomy. The administration of adjuvant chemotherapy should be done taking in consideration these factors. Regarding predictive factors, determination of ERCC1, TS, TP and DPD and UGT1 polymorphisms assessment could be considered prior to chemotherapy administration. This would avoid treatment related toxicities and increase this population quality of life.     

Ninety percent of the adverse outcomes occur in 10% of patients: can we identify the populations at high risk of developing peritoneal metastases after curative surgery for colorectal cancer?

Abstract

Background: Peritoneal metastases (PM) occur in 3.4–6.3% after curative surgery for non-metastatic colorectal cancer. Systematic “2nd look” surgery helps overcoming the diagnostic problem but can be only proposed to selected patients. The aim of this study was to update the knowledge on risk factors of developing PM after curative surgery for colorectal cancer.

Methods: A systematic review of the literature published between 2011 and 2016 was made, searching for all clinical studies reporting the incidence of recurrent PM after curative surgery for colorectal cancer and factors associated with the primary tumour that were likely to influence this recurrence rate.

Results: Seven new clinical studies were considered informative for risk factors and added to the 16 reviewed in 2013. Even if the level of evidence was low, data suggested rates of recurrent PM at 1?year between 54% and 71% after completely resected synchronous PM, between 62% and 71% after resection of isolated synchronous ovarian metastases, of 27% after surgery for a perforated primary tumour, of 16% after surgery for a pT4 tumour, and between 11% and 36% after surgery for a mucinous histological subtype. No new risk factor was identified.

Conclusions: Evidence regarding the incidence of recurrent PM after curative surgery for colorectal cancer is poor. Situations at higher risk of recurrent PM are synchronous PM, synchronous isolated ovarian metastases, perforated primary tumour with serosa invasion and mucinous histological subtype.     

Debulking surgery for colorectal liver metastases: Foolish or chance?

Even with the recent advances of surgical techniques and systemic therapies, we are often facing patients with multinodular bilateral disease for whom neither R0 nor R1 resection appears possible to perform. For such extensive cases, the tumor debulking approaches might provide a survival benefit, provided that an objective tumor response is obtained with chemotherapy. Here, we review all the arguments which may defend this strategy and propose some recommendations.     

Chemotherapy in patients with non-resectable colorectal cancer metastases to the liver: systemic or regional?

Efficacy of the-state-of-the-art modalities of systemic and regional chemo-infusion with oxalyplatin (FOLFOX) and irinotecan (FOLFIRI) (162) was compared. Objective response to the former was 40.8%, to the latter--11.9% (p = 0.0002); survival before intrasplenic relapse--9 and 5 months, respectively, (p = 0.0005); overall survival before relapse (median 7 and 4 months, respectively, (p = 0.01). The rate of survival before intrasplenic relapse in the systemic chemo-infusion group was significantly higher (median 10.5 vs. 8.1 months, respectively, (p = 0.03). No significant differences in overall survival were reported (median 15 vs. 13 months, respectively, in the latter group (p = 0.72).     

Hepatic arterial 5-fluorouracil in patients with liver metastases of colorectal?cancer: Single-centre experience in 145 patients

Background:Hepatic arterial chemotherapy for liver metastases ofcolorectal cancer is still under discussion. Mainly because of the technicalcomplications of this mode of treatment and the lack of a survival benefit inrandomized studies. We performed an analysis of hepatic arterial5-fluorouracil (5-FU) chemotherapy in 145 consecutive patients treated at asingle institution. Patients and methods:One hundred forty-five patients withinoperable liver metastases from colorectal cancer were included. 5-FU, 1000mg/m²/day continuous infusion for five days every three weeks, wasdelivered in the hepatic artery by percutaneous catheter or arterial accessdevice. Results:The response rate was 34% for all patients,40% in patients with extrahepatic disease, and 15% in patientswith i.v. 5-FU-based pretreatment. TTP and OS for all patients were 7.5 and14.3 months, respectively. In patients with extrahepatic disease or i.v.5-FU-based pretreatment, OS was significantly shorter compared to patientswithout extrahepatic disease or 5-FU-based pretreatment (9.7 vs. 19.3 monthsand 10.1 vs. 17.4 months, respectively). forty-seven percent of patientsstopped treatment because of a complication. Complications most often seen inpatients with arterial ports were hepatic artery thrombosis (48%) anddislocation of the catheter (22%). Conclusions:The results of our analysis are in line with previousphase III studies. Extrahepatic disease and i.v. 5-FU-based pretreatment wereprognostic for reduced OS. The complication rate of hepatic arterial deliverywas worrisome, although, no negative impact on survival could be established.There is a strong need for improvement of hepatic arterial delivery methodsbefore further evaluation of hepatic arterial 5-FU will be worthwhile.     

Does smoking or family history influence the prognosis of patients with non-small cell lung cancer?

The prognostic significance of pack-years smoked (PY) and family history of cancer (FH) was studied using the Cox proportional hazard model in 970 patients with non-small cell lung cancer. PY influenced survival only in women after other variables were adjusted [Hazard ratio (HR): 1.75 (1.45-2.11)]. FH also influenced survival with marginal significance in women with stage I disease [HR: 2.17 (0.89-5.29), p=0.088]. Furthermore, these two factors operated additively in women [HR for patients with both smoking and family histories over those without either: 2.25 (1.18-4.26)], but not in men.     

Is unexpected peritoneal carcinomatosis still a contraindication for resection of colorectal liver metastases?: Combined resection of colorectal liver metastases with peritoneal deposits discovered intra-operatively

Aims

The discovery of unexpected peritoneal carcinomatosis (PC) at the time of hepatectomy for colorectal liver metastases (CLM) is usually considered a contraindication for continuing resection. The first aim of this study was to assess the long-term outcome of patients operated for CLM, and who presented unexpected PC during laparotomy. The second aim was to identify preoperative predictors of PC.

Methods

All patients at a single center between 1985 and 2010 who had unexpected PC, discovered during planed resection of CLM, and negative preoperative imaging for PC were selected. Clinicopathological data were retrospectively analyzed to assess survival outcomes and to identify predictors of unexpected PC.

Results

Out of the 1340 operated patients for CLM, 42 (3%) had unexpected PC. Only patients (n = 30; 71%) who had PC limited to two abdominal regions (Median peritoneal cancer index (PCI): 2 (1–6)) were resected. Twelve patients were not resected due to the extent of peritoneal disease. The overall survival of the 30 patients resected for CLM who had limited PC was 18% at 5 years (median: 42 months). On multivariate analysis, a previous history of PC, a pT4 stage and bilobar CLM were independent predictors of unexpected PC.

Conclusion

Unexpected PC should not be a contraindication for resection provided that the PCI is low and complete resection of all peritoneal and hepatic lesions can be achieved. Previous history of PC, a pT4 primary tumor and bilobar CLM are associated with increased risk of unexpected PC.     

Do individuals with a family history of colorectal cancer adhere to medical recommendations for the prevention of colorectal cancer?

Individuals with a family history of colorectal cancer (CRC), have a two-to-five-fold increased lifetime risk to develop CRC. Thus, they are particularly likely to benefit from adherence to medical recommendations for CRC prevention. Despite this increased risk, previous studies have shown an underutilization of colonoscopy for screening and a paucity of data on lifestyle habits that could enhance colonoscopy rates in this population. The primary aims were (a) to assess CRC screening patterns and lifestyle choices among siblings and children of CRC patients, (b) to ascertain discrepancies between actual behavior and medical recommendations, and (c) to identify family members with multiple unhealthy lifestyle habits. The secondary aim was to test for possible associations between utilization rates for CRC screening and other preventive health services. A cross-sectional study was conducted among 318 first-degree relatives (FDRs) of 164 CRC patients treated at the Tel Aviv Sourasky Medical Center. Interviews were conducted with a structured questionnaire. There was significant underutilization of colonoscopy for screening with only 73 FDRs (23.0 %) adhering to the recommended screening schedule. This rate was slightly improved (N = 58, 31.9 %) among subjects aged 40 years and above, although it was still far below the optimum. A similar result (N = 70, 21.7 %) was observed for other cancer screening tests and routine medical check-ups. A significant association (P < 0.0001) was found for healthful lifestyles, overall use of preventive health services, and adherence to CRC screening recommendations. CRC screening is significantly underutilized among FDRs of CRC patients. FDRs who do not comply with CRC screening guidelines, lead unhealthy lifestyles, and avoid other cancer screening tests are at increased risk and should be addressed specifically in future interventions.     

Use of different comorbidity scores for risk-adjustment in the evaluation of quality of colorectal cancer surgery: Does it matter?

Aims

Comorbidity affects outcomes after colorectal cancer surgery. However, it's importance in risk adjustment is unclear and different measures are being used. This study aims to assess its impact on post-operative outcomes.

Methods

All 2204 patients who were operated on for stage I–III colorectal cancer in the Midwestern region of the Netherlands between January 1, 2006 and December 31, 2008 were analyzed. A multivariate two-step enter-model was used to evaluate the effect of the American Society of Anaesthesiologists Physical Status classification (ASA) score, the sum of diseased organ systems (SDOS), the Charlson Comorbidity Index (CCI) and a combination of specific comorbidities on 30-day mortality, surgical complications and a prolonged length of stay (LOS). For each retrieved model, and for a model without comorbidity, a ROC curve was made.

Results

High ASA score, SDOS, CCI, pulmonary disease and previous malignancy were all strongly associated with 30-day mortality and a prolonged LOS. High ASA score and gastro-intestinal comorbidity were risk factors for surgical complications. Predictive values for all comorbidity measures were similar with regard to all adverse post-operative outcomes. Omitting comorbidity only had a marginal effect on the predictive value of the model.

Conclusion

Irrespective of the measure used, comorbidity is an independent risk factor for adverse outcome after colorectal surgery. However, the importance of comorbidity in risk-adjustment models is limited. Probably the work and costs of data collection for auditing can be reduced, without compromising risk-adjustment.     

Placement of an arterial hepatic catheter after a major hepatectomy for colorectal liver metastases: Is this safe?

Background

Studies have suggested that hepatic arterial infusion of chemotherapy (HAI) after resection of colorectal liver metastasis (CRLM) may improve patient's survival. The placement of a catheter in the hepatic artery at the time of hepatic surgery should therefore be considered in patients at high risk of hepatic recurrence. The aim of this study was to compare post-operative outcomes in patients who underwent at least a major hepatectomy (≥3 segments) for CRLM with or without catheter placement.

Methods

From 2000 to 2010, 57 patients who underwent at least a major hepatectomy for CRLM resection were selected from a prospective database. Among them, 22 had had a catheter insertion during surgery.

Results

The two groups were similar in terms of age, body mass index (BMI), ASA score, and the average number of pre-operative courses of systemic chemotherapy (11 ± 5). The rate of overall complications was slightly higher after catheter insertion (63% vs. 51%) although not significant (p = 0.36). Two patients had died post-operatively from liver insufficiency; both had undergone catheter insertion after a major hepatectomy associated with contralateral procedures resulting in a small remnant liver volume with low outflow capacity. Thrombosis of the common hepatic artery and portal venous gas were depicted on both CT scan.

Conclusion

Although the placement of an arterial catheter during a major hepatectomy does not significantly increase the rate of postoperative complications two patients died post-operatively in this study from vascular thrombosis. In case of extended and complex hepatectomy, with a higher risk of post-operative complications, delaying the catheter placement could be recommended.     

Quality of life in older and frail patients after surgery for colorectal cancer—A follow-up study

ObjectiveThe incidence of colorectal cancer is increasing, mainly due to the aging of the population. Frailty, describing a state of increased vulnerability, is common in older patients, but frailty and high age are not necessarily contraindications to surgical treatment. However, limited data describing long-term outcomes after surgery in this patient group exist. In this clinical follow-up study, we aimed to examine long-term health-related quality of life in older surgical patients with colorectal cancer.Materials and MethodsPatients were recruited from a prospective multicenter study investigating frailty as a predictor of postoperative complications after surgery for colorectal cancer. A preoperative geriatric assessment was performed, and patients were classified as frail or non-frail. Patients responded to version 3.0 of The European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire-C30 before surgery, 3 months postoperatively and at a long-term follow-up 16–28 months (median 22 months) after surgery. One-way repeated-measures analyses of variance were performed to examine changes in scores over time.Results180 patients with a mean age of 80 years were included at baseline, 138 at 3 months postoperatively, and 84 patients (69% of survivors) at long-term follow-up. A significant improvement in quality of life-scores was present 3 months after surgery, also in the subgroup of frail patients. At long-term follow-up, scores decreased, but to values above baseline.ConclusionHealth-related quality of life may be improved in older patients after surgery for colorectal cancer, even in patients who are classified as frail preoperatively.     

Histopathologic patterns as markers of prognosis in patients undergoing hepatectomy for colorectal cancer liver metastases – Pushing growth as an independent risk factor for decreased survival

Introduction

Liver resection combined with neoadjuvant chemotherapy (NAC) has reported notable results in patients with colorectal liver metastases (CRLM). Tumoral response to NAC is associated with specific histopathologic patterns with prognostic implications. The main objective of this study was to evaluate the influence of pathological findings on overall survival (OS), disease-free survival (DFS) and liver recurrence-free survival (LRFS).