Simultaneous Integrated Boost Volumetric Modulated Arc Therapy for Rectal Cancer: Long-Term Results after Protocol-Based Treatment.

Background: Volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) is an advanced form of radiotherapy (RT) technology. The purpose of this study was to report long-term treatment outcomes in patients with locally advanced rectal cancer undergoing VMAT-SIB based concurrent chemoradiotherapy (CRT). Methods: Between January 2016 and January 2018, a total of 22 patients with operable stage II-III rectal adenocarcinoma were recruited for the pre-designed VMAT-SIB RT protocol. All patients underwent standard diagnostic and staging work-up. The RT target volumes included the following areas: PTV1 = mesorectum that contained gross tumors and enlarged lymph node regions and PTV2 = mesorectum and regional lymphatics from L4-5/S1 to 3-4 cm below the tumor or levator ani muscle, excluding PTV1. The VMAT-SIB dose prescription was as follows: PTV1 = 52.5 Gy/daily 2.1 Gy/25 fractions, PTV2 = 45 Gy/daily 1.8 Gy/25 fractions. Results: The mean age of the study population was 64 (range, 18-84) years, and 15 (68.2%) patients were male. Radical operation (total mesorectal excision) was performed by either low anterior resection, ultralow anterior resection, or abdominal perineal resection. All five (22.7%) of the patients with confirmed increasing serum carcinoembryonic antigen (CEA) level at diagnosis showed normalization of serum CEA level after the planned treatment. Among 20 patients who underwent preoperative CRT and surgery, tumor down staging in T- and N-stages was achieved in 10 patients (50%) and 13 patients (65%), respectively, with 20% of ypT0/Tis. With a median follow-up of 54.2 (range, 22.6-61.1) months, the 5-year disease-free survival, overall survival, and local control rates were 64.6%, 81.8%, and 84.4%, respectively. Five patients developed distant metastasis and one developed local recurrence as a first event. Two cases with anastomosis site leakage, three with adhesive ileus, and two with abscess formation were observed during postoperative periods. Conclusions: The current VMAT-SIB-based CRT protocol provided acceptable treatment and toxicity outcomes.

The optimal time interval between the placement of self-expandable metallic stent and elective surgery in patients with obstructive colon cancer.

A bridge to surgery (BTS) after a colonic stent for obstructive colon cancer has not been accepted as a standard treatment strategy. Also, there is no consensus regarding the optimal time interval for BTS. We aimed to identify the optimal timing for BTS after stent placement to decrease the oncologic risk. We retrospectively collected data of 174 patients who underwent BTS after stent placement for stage II or III obstructive colon cancer from five hospitals. We divided the patients into three groups based on the time interval for BTS after stent placement: within 7 days (Group 1), from 8 to 14 days (Group 2), and after 14 days (Group 3). The primary outcome was to compare the oncologic outcomes including overall survival (OS), disease-free survival (DFS), and recurrence rate (RR) among the three groups. Groups 1, 2, and 3 involved 75, 56, and 43 patients, respectively. Postoperative morbidity rates were 17.3%, 10.8%, and 9.3% in Groups 1, 2, and 3, respectively (P = 0.337). RRs were 16.0%, 35.7%, and 30.2% in Groups 1, 2, and 3, respectively (P = 0.029). In multivariate analysis, the time interval for BTS was an independent risk factor for DFS (P < 0.001; HR, 14.463; 95% CI, 1.458-3.255) and OS (P = 0.027; HR, 4.917; 95% CI, 1.071-3.059). In conclusion, the perioperative short-term outcome was not affected by the time interval of BTS. However, elective surgery within 7 days after colonic stent might be suggested to balance the short-term benefits and long-term oncologic risks.

Outcome of bridge to surgery stenting for obstructive left colon cancer.

BACKGROUND: The aim of our study was to compare short- and long-term outcomes of stent insertion followed by surgery with those of emergency surgery for left colon malignant obstructions. METHODS: The medical records of patients who received curative resection due to obstructive primary left colon cancer and who were diagnosed with stage II or III from January 2004 to December 2010 in six hospitals affiliated with The Catholic University of Korea were reviewed. One hundred and twelve patients in self-expandable metallic stent (SEMS) group were matched to 56 patients in the emergency surgery (ES) group using propensity score matching method. Overall survival (OS) and disease-free survival (DFS) were compared between the groups. Perioperative outcomes and pathologic results were also compared. RESULTS: Baseline characteristics were comparable between the two groups after matching. The analysis of perioperative outcomes showed short-term advantages of stent insertion. Patients in the SEMS group were more likely (87.5 versus 75.0%, P = 0.049) to have a distal resection margin >5 cm. Harvesting ≥12 lymph nodes were more frequent (89.3 versus 71.4%, P = 0.007) in the SEMS group. Five-year DFS was 69.5% in the SEMS group and 73.1% in the ES group (P = 0.464). Five-year OS was not different between the groups (79.7 versus 77.7%, P = 0.989). CONCLUSIONS: SEMS can be a reasonable therapeutic option for malignant obstruction in patients with left colon cancer until definitive conclusion about the long-term survival effect of SEMS is made from further large-scale prospective randomized trials.

Comparison of Long-Term Outcomes Between Emergency Surgery and Bridge to Surgery for Malignant Obstruction in Right-Sided Colon Cancer: A Multicenter Retrospective Study.

BACKGROUND: Malignant obstruction in right-sided colon (MORC) has traditionally been treated by emergency resection with primary anastomosis. The aim of this study was to evaluate short-term postoperative and long-term oncologic outcomes according to the surgical approach adopted for MORC. METHODS: A total of 1785 patients who underwent curative surgery for stage II or III colon cancer in seven hospitals were reviewed retrospectively. Seventy-four of 1785 patients had MORC. We compared the postoperative outcome and long-term oncologic outcome between the emergency surgery (ES) group (49 patients) and the bridge to surgery (BS) group (25 patients) for 74 patients with MORC. RESULTS: There were no differences in the length of the distal and proximal resection margin (p = 0.820 and p = 0.620) or the number of metastatic lymph nodes (p = 0.221). There were no differences in flatus passage (p = 0.242), start of diet (p = 0.336), hospital stay (p = 0.444), or postoperative morbidity (p = 0.762). The 5-year overall survival rates were 73.2 % in the ES group and 90.7 % in the BS group (p = 0.172). Moreover, the 5-year disease-free survival rates were 71.9 % in the ES group and 76.2 % in the BS group (p = 0.929). CONCLUSIONS: On the basis of the above results, the postoperative course of the ES group was similar to that of the BS group. In addition, the long-term oncologic outcome of the BS group was similar or slightly better than that of the ES group. BS after colonic stent may be an alternative option for MORC.

Expression of CARD6, an NF-kappaB activator, in gastric, colorectal and oesophageal cancers.

AIMS: Activation of nuclear factor-kappa B (NF-kappaB) signalling is considered a crucial mechanism in the development of cancers. Caspase-associated recruitment domain 6 (CARD6) is a protein that activates NF-kappaB signalling evoked by RIP1, RIP2, Bcl-10 and MEKK. In this study, we analysed tissue expression of CARD6 protein in oesophageal squamous cell carcinoma (ESCC), gastric adenocarcinomas (GC) and colorectal adenocarcinomas (CRC). METHODS: We analysed the expression of CARD6 protein in 58 ESCC, 100 GC and 103 CRC patients' tissues by immunohistochemistry using a tissue microarray (TMA) approach. RESULTS: We found CARD6 immunostaining in cancer cells of ESCC (41/58; 70.7%), GC (45/100; 45.0%) and CRC (81/103; 78.6%). In the GC, intestinal-type GC (77.8%) showed higher expression of CARD6 than diffuse-type GC (20.0%) and mixed-type GC (50.0%). By contrast, corresponding normal epithelial cells of oesophagus (0%), stomach (8.0%) and colon (5.0%) displayed lower frequencies of CARD6 immunostaining. The CARD6 immunostaining was observed in nucleus/cytoplasm (ESCC) or cytoplasm (GC and CRC). The CARD6 expression was evident from an early TNM stage (stage I). CONCLUSION: The increased expression of CARD6 in ESCC, GC and CRC tissues compared to their corresponding normal cells suggested that neoexpression of CARD6 might be related to activation of NF-kappaB pathway in the cancers and might play a role in the development of most types of gastrointestinal cancers.

Mutational analysis of CASP10 gene in colon, breast, lung and hepatocellular carcinomas.

AIMS: Evasion of apoptosis is a feature of cancer cells. As a mechanism of apoptosis inactivation in cancer cells, somatic mutations of pro-apoptotic genes have been reported in many cancers. Caspase-10 is an initiation-phase caspase, and somatic mutation of CASP10 that encodes caspase-10 has been found in non-Hodgkin's lymphoma and gastric carcinoma. METHODS: The aim of this study was to explore whether CASP10 gene is somatically mutated in colon, breast, lung, and hepatocellular carcinomas. We analysed the entire coding region and all splice sites of CASP10 in 47 colon, 47 breast, 47 lung, and 47 hepatocellular carcinomas by a single-strand conformation polymorphism (SSCP) assay. RESULTS: We found two CASP10 mutations in the colon cancers (2/47; 4.3%), but none in breast, lung or hepatocellular carcinomas. One mutation [c.41A > C (p.Lys14Thr)] was a missense mutation, while the other was a substitution mutation in a splice site (c.684 + 4G > A). The colon cancer with the CASP10 missense mutation harboured additional CASP gene mutations (CASP3, 7 and 8). CONCLUSION: Our data indicate that somatic mutation of CASP10 is rare in colon, breast, lung, and hepatocellular carcinomas. However, the data also suggest that CASP10 mutation might contribute to the pathogenesis of some colon carcinomas together with other CASP gene mutations.

NF-kappaB signalling proteins p50/p105, p52/p100, RelA, and IKKepsilon are over-expressed in oesophageal squamous cell carcinomas.

AIMS: Nuclear factor-kappa B (NF-kappaB) activation has been recognised as an important mechanism in the development of cancers. However, expression status of NF-kappaB-related proteins in oesophageal squamous cell carcinoma (ESCC) tissues is largely unknown. In this study, we analysed expressions of NF-kappaB members (p50/105, p52/p100 and RelA) and IKKepsilon in ESCC tissues. METHODS: We analysed the expression of p50/105, p52/p100, RelA and IKKepsilon in 58 ESCC patients' tissues by immunohistochemistry using a tissue microarray (TMA) method. RESULTS: Normal oesophageal squamous cells expressed p50/105, p52/p100 and RelA in 5%, 79% and 10% of the tissues in cytoplasm, respectively; however, only p52/p100 was expressed in the nuclei (12%). The cancer tissues expressed p50/105, p52/p100 and RelA in 93%, 95% and 95% in cytoplasm and/or nuclei, respectively. Nuclear immunostainings of NF-kappaB members p50/105, p52/p100 and RelA, which are considered activation of NF-kappaB signalling, were observed in 34%, 60% and 26% of the cancers, respectively. IKKepsilon is expressed in cytoplasm in 50% of the normal squamous tissues and 84% of the cancer tissues. However, none of the expression of p50/105, p52/p100, RelA or IKKepsilon was associated with pathological characteristics, including differentiation, depth of invasion and TNM stage. CONCLUSION: The increased nuclear expressions of p50/105, p52/p100 and RelA as well as increased cytoplasmic expression of IKKepsilon in the ESCC tissues compared to the normal squamous cells suggested that over-expression of these proteins may be related to activation of the NF-kappaB pathway and might play a role in the development of ESCC.

Frameshift mutations of autophagy-related genes ATG2B, ATG5, ATG9B and ATG12 in gastric and colorectal cancers with microsatellite instability.

Mounting evidence indicates that alterations of autophagy processes are directly involved in the development of many human diseases, including cancers. Autophagy-related gene (ATG) products are main players in the autophagy process. In humans there are 16 known ATG genes, of which four (ATG2B, ATG5, ATG9B and ATG12) have mononucleotide repeats with seven or more nucleotides. Frameshift mutations of genes with mononucleotide repeats are features of cancers with microsatellite instability (MSI). It is not known whether ATG genes with mononucleotide repeats are altered by frameshift mutations in gastric and colorectal carcinomas with MSI. For this, we analysed the mononecleotide repeats in ATG2B, ATG5, ATG9B and ATG12 in 32 gastric carcinomas with high MSI (MSI-H), 13 gastric carcinomas with low MSI (MSI-L), 43 colorectal carcinomas with MSI-H and 15 colorectal carcinomas with MSI-L by a single-strand conformation polymorphism (SSCP) analysis. We found ATG2B, ATG5, ATG9B and ATG12 mutations in 10, 2, 13 and 0 cancers, respectively. The mutations were detected in MSI-H cancers but not in MSI-L cancers. Gastric and colorectal cancers with MSI-H harboured one or more ATG mutations in 28.1% and 27.9%, respectively. Our data indicate that frameshift mutations in ATG genes with mononucleotide repeats are common in gastric and colorectal carcinomas with MSI-H, and suggest that these mutations may contribute to cancer development by deregulating the autophagy process.

Prognostic value of CEA and CA 19-9 tumor markers combined with cytology from peritoneal fluid in colorectal cancer.

BACKGROUND: Early diagnosis and management of peritoneal metastases from colorectal cancer patients are difficult clinical challenges. The aims of this study were to evaluate the clinical significance of tumor markers and cytology in peritoneal effusions (PE) and peritoneal irrigation fluid (PI) and to determine their value as prognostic indicators in this disease. METHODS: Two hundred thirty-four consecutive patients who underwent abdominal surgery for colorectal cancer from January 2006 to December 2007 were included, and tumor markers and cytology in PE and PI were analyzed prospectively. RESULTS: The incidence of free cancer cells retrieved from peritoneal samples was 7.9%. Cytology was positive in 40.0% by Papanicolaou and Giemsa staining, 73.3% by hematoxylin and eosin staining of cell blocks, and 66.7% by carcinoembryonic antigen (CEA) and calretinin immunohistochemistry. Multivariate analysis revealed that peritoneal CEA and cancer antigen (CA) 19-9 in PI were correlated with peritoneal metastasis and cytology. Level of peritoneal fluid CEA was statistically significantly correlated with recurrence and peritoneal metastatic recurrence in patients with negative peritoneal cytology. Cytology, peritoneal CEA, and peritoneal CA 19-9 showed correlations with cancer-free survival and overall survival. CONCLUSIONS: These correlations demonstrate the importance of continuous follow-up of peritoneal metastasis if there is positive cytology or an increase in CEA and CA 19-9 in peritoneal fluid.

Mutational analysis of TTK gene in gastric and colorectal cancers with microsatellite instability.

PURPOSE: The TTK gene plays a crucial role in regulation of the mitotic checkpoint. The TTK gene has an A9 mononucleotide repeat in the coding sequences, which harbors mutations in gastric (GC) and colorectal cancers (CRC) with microsatellite instability (MSI). However, there are three more repeats (the A7s) in the coding sequences that have not been analyzed. The aim of this study was to explore whether the three A7s as well as the A9 are altered in GC and CRC, and to find any association of TTK mutation with clinocopathologic characteristics of GC and CRC. MATERIALS AND METHODS: We analyzed exon 5 (A7 and A7) and exon 22 (A9 and A7) which have repeat sequences in 30 GC with high MSI (MSI-H), 15 GC with low MSI (MSI-L), 35 CRC with MSI-H, and 15 CRC with MSI-L, by single-strand conformation polymorphism (SSCP) and DNA sequencing assays. RESULTS: Overall, we detected 23 frameshift mutations in the repeat sequences of TTK in the GC with MSI-H (11/30; 36.7%) and the CRC with MSI-H (12/35; 34.3%), but not in the cancers with MSI-L. The mutations were observed in both A9 and A7 of exon 22, but in neither of the two A7s of exon 5. The mutations consisted of c.2560delA, c.2560dupA, c.2571delA and c.[2560delA(+)2571delA]. All of the mutations were frameshift mutations and would result in premature stops of TTK protein synthesis. There was no significant difference in clinopathologic parameters of the cancers with the mutations. CONCLUSION: Our data indicate that frameshift mutations of TTK are common in both GC and CRC with MSI-H, and that the mutations occur not only in the A9 repeat but also in the A7 repeat. The data suggest that frameshift mutations of TTK might alter cell cycle control in the affected cells and contribute to pathogenesis of cancers with MSI-H.

Frameshift mutations of Wnt pathway genes AXIN2 and TCF7L2 in gastric carcinomas with high microsatellite instability.

Frameshift mutations of genes with mononucleotide repeats are features of colorectal and gastric cancers with microsatellite instability (MSI). Deregulation of Wnt pathway is involved in the mechanisms of cancer development, and mutations of the Wnt-pathway genes have frequently been detected in cancers, indicating somatic mutations are important deregulation mechanisms of the Wnt signaling in cancer development. Both AXIN2 and TCF7L2 genes in the Wnt pathway possess mononucleotide repeats in their coding sequences and are considered as candidate tumor suppressor genes. The aim of this study was to see whether AXIN2 and TCF7L2 are altered by frameshift mutations in gastric carcinomas with MSI. For this, we analyzed human AXIN2 exon 8 and TCF7L2 exon 14 in 32 gastric carcinomas with high MSI, 13 gastric carcinomas with low MSI, and 47 gastric carcinomas without MSI by a single-strand conformation polymorphism analysis. Overall, we detected 9 AXIN2 and 6 TCF7L2 frameshift mutations in the mononucleotide repeats in the cancers with MSH-H, and all of them were found in MSH-H cancers (AXIN2, 28.1%; TCF7L2, 18.8%). Of the 32 high MSI cancers, 13 cancers (40.6%) harbored at least one of AXIN2 and TCF7L2 mutation, whereas 19 cancers (59.4%) harbored neither. The present data indicate that frameshift mutations in both AXIN2 and TCF7L2 genes are common in gastric carcinomas with high MSI and suggest that these mutations may contribute to development of gastric cancers with high MSI by deregulating the Wnt signaling in the affected cancer cells.

Increased expression of endonuclease G in gastric and colorectal carcinomas.

AIMS: Endonuclease G (EndoG) is a mitochondrial protein that plays a role in DNA fragmentation during apoptosis. In addition, EndoG plays a role in cell proliferation and survival. It may be important to identify EndoG protein expression to predict its function in human cancers. The aim of this study was to explore whether alteration of EndoG expression might be a characteristic of colorectal or gastric carcinoma. METHODS: We investigated EndoG protein expression in 103 colorectal and 60 gastric carcinoma tissues by immunohistochemistry using a tissue microarray approach. RESULTS: Expression of EndoG was detected in 72 (70%) of the colorectal carcinomas and 41 (68%) of the gastric carcinomas in cytoplasm. By contrast, normal mucosal cells of both stomach and colon tissues showed no or very weak expression of EndoG. There was no significant association of EndoG expression with clinocopathological characteristics, including invasion, metastasis and stage. CONCLUSION: Our data indicate that EndoG inactivation by loss of expression may not occur in colorectal and gastric cancers. Rather, increased expression of EndoG in colorectal and gastric cancer cells compared to their normal mucosal epithelial counterparts suggests that neo-expression of EndoG may play a role in both colorectal and gastric tumorigenesis.

Frameshift mutation of UVRAG, an autophagy-related gene, in gastric carcinomas with microsatellite instability.

Alteration of autophagy is involved in tumor development. Beclin1, an important regulator of autophagy, acts as a tumor suppressor. Ultraviolet (UV) radiation resistance-associated gene (UVRAG) binds with Beclin1 and induces autophagy. There is a polyadenine tract in UVRAG gene (A10 in exon 8) that is a target for frameshift mutations in colorectal carcinomas with microsatellite instability (MSI). Functionally, colon cancer cells with the frameshift mutation of UVRAG show reduced autophagy formation and increased tumorigenicity. The aim of this study was to determine whether the frameshift mutations of UVRAG are also present in gastric carcinomas with MSI. For this, we analyzed human UVRAG exon 8 in 45 gastric carcinomas with MSI and 92 gastric carcinomas without MSI by a single-strand conformation polymorphism analysis. Overall, we detected 3 frameshift mutations of UVRAG in the polyadenine tract (3/45; 6.7%), and all of them were found in MSH-high (H) subtypes (3/32; 9.4%). The 3 mutations consisted of 2 c.708_709delA and 1 c.709delA which would result in premature stops of the UVRAG protein synthesis. The present data indicate that frameshift mutations in the polyadenine tract in UVRAG gene are present in gastric carcinomas as well and suggest that the affected gastric cancer cells with the mutations may have a reduced autophagy activity.

Mutational analysis of caspase 1, 4, and 5 genes in common human cancers.

Mounting evidence indicates that deregulation of apoptosis is involved in the mechanisms of cancer development. Mutations of genes encoding caspases, the executioners of apoptosis, have been detected in human cancers, indicating inactivation of apoptosis by the mutations of caspase is an important mechanism in cancer development. The aim of this study was to see whether genes encoding human caspases 1, 4, and 5 are mutated in human cancers. We analyzed the entire coding region and all splice sites of human caspase 1, 4, and 5 genes for the detection of somatic mutations in 337 human cancers, including 103 colorectal, 54 gastric, 60 breast, 60 hepatocellular, and 60 lung carcinomas by a single-strand conformation polymorphism assay. We detected 2 (0.6%) caspase-1, 2 (0.6%) caspase-4, and 15 (4.4%) caspase-5 mutations in the 343 cancers. The mutations were detected in 11 gastric carcinomas (2 caspase-1 and 9 caspase-5 mutations), 6 colorectal carcinomas (2 caspase-4 and 4 caspase-5 mutations), 1 breast carcinoma (1 caspase-5 mutation), and 1 lung carcinoma (1 caspase-5 mutation). The mutations consisted of 11 mutations in exons and 8 mutations in noncoding sequences. The 11 mutations in the exons consisted of 3 missense, 1 silent, and 7 frameshift mutation(s). Of note, most (6/9) of the caspase-5 mutations in the coding sequences were detected in microsatellite instability (MSI)-positive cancers. These data indicate that somatic mutations of caspase-1 and caspase-4 genes are rare in common solid cancers. In addition, the data indicate that caspase-5 gene is commonly mutated in the MSI-positive cancers, and suggest that inactivation of caspase-5 may play a role in the tumorigenesis of MSI-positive cancers.

Immunohistochemical analysis of phospho-BAD protein and mutational analysis of BAD gene in gastric carcinomas.

Mounting evidence indicates that deregulation of apoptosis contributes to the development of human cancers. BAD, a proapoptotic Bcl-2 family protein, regulates the intrinsic apoptosis pathway. The aim of this study was to explore whether alterations of phospho-BAD (p-BAD) protein that antagonizes apoptosis function of BAD and mutation of BAD gene are characteristics of human gastric cancers. We analyzed expression of p-BAD in 60 gastric adenocarcinomas by immunohistochemistry. Also, we analyzed BAD gene for detection of somatic mutations by single-strand conformation polymorphism (SSCP) assay. p-BAD expression was detected well in normal gastric mucosal epithelial cells, whereas it was detected in only 51% (31 of the 60) of the cancers. There was no somatic mutation of BAD gene in the 60 gastric cancer samples. The decreased expression of p-BAD in malignant gastric epithelial cells compared to normal mucosal epithelial cells suggested that loss of p-BAD expression may play a role in gastric tumorigenesis. The data also suggest that BAD mutation may not be a direct target of inactivation in gastric tumorigenesis.

Expression of beclin-1, an autophagy-related protein, in gastric and colorectal cancers.

Autophagy plays important roles in both cell death and cell survival. Beclin-1, a key regulator of autophagy formation, has been considered as a haploinsufficient tumor suppressor. Loss of expression or point mutation could serve as a mechanism of loss of beclin-1 tumor suppressor function in cancers. However, our recent study revealed that point mutation of the beclin-1 gene is a rare event in common human cancers. In this study we investigated beclin-1 protein expression in 103 colorectal and 60 gastric carcinoma tissues by immunohistochemistry using a tissue microarray approach. In the cancers, expression of beclin-1 was detected in 95% of the colorectal carcinomas and 83% of the gastric carcinomas. In contrast, normal mucosal cells of both stomach and colon showed no or very weak expression of beclin-1. There was no significant association of beclin-1 expression with clinocopathologic characteristics, including invasion, metastasis and stage. The beclin-1 expression of colorectal and gastric cancers in the present study is quite in contrast to that of the breast cancers in the previous study, which showed a decreased beclin-1 expression in breast cancer cells compared to normal breast cells. Our data indicate that beclin-1 inactivation by loss of expression may not occur in colorectal and gastric cancers. Rather, increased expression of beclin-1 in the malignant colorectal and gastric epithelial cells compared to their normal mucosal epithelial cells suggests that neo-expression of beclin-1 may play a role in both colorectal and gastric tumorigenesis.

The survival rate and prognostic factors in 26 perforated colorectal cancer patients.

PURPOSE: The treatment for perforated colorectal cancer is not easy and the prognosis for this disease is not so predictable. There are some controversies about performing radical operations because colorectal cancer perforation was considered as an advanced stage disease due to the possibility of tumor cell dissemination through the perforation site. METHODS: We selected and enrolled 26 patients with perforated colorectal cancers among the 1,227 patients who underwent operation for colorectal cancer. These cases were retrospectively analyzed by using their medical records and clinicopathological data. RESULTS: Twenty-eight cases (2.3%) with perforated colorectal cancers were studied and the overall operative mortality rate was 11%. The overall 5-year survival rate was 57.8% when excluding the operative mortality. The overall 5-year cancer-free survival rate was 52.8%. There were significant differences in the survival rate and the cancer-free survival rate between the stages (p=0.008 and p<0.001, respectively). A univariate analysis of the prognostic factors revealed that the number of the metastatic lymph nodes (p=0.018) and the perforation proximal to the cancer (p=0.005) were significantly correlated to worse survival, and the higher number of the metastatic lymph nodes was correlated to a poorer cancer-free survival rate (p<0.001). CONCLUSION: For the perforated colorectal cancers, the stage, the perforation proximal to the cancer, and the number of the metastatic lymph nodes were correlated, with the survival and the cancer-free survival as factors of a poor prognosis. The surgical approach selected for perforated colorectal cancer should be in line with the principles of an appropriate cancer operation because the clinical pathway of perforated colorectal cancer is similar to that of uncomplicated colorectal cancer.