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Objectives: To clarify whether self-expandable metallic stent (SEMS) placement for obstructive colorectal cancer (CRC) increases perineural invasion (PNI), thereby worsening the prognosis. Methods: In total, 1022 patients with pathological T3 or T4 colon or rectosigmoid cancer who underwent resection were retrospectively reviewed. The study patients were divided into a no obstruction group (n=693), obstruction without stent group (n=251), and obstruction with stent group (n=78), and factors demonstrating an independent association with PNI, the difference in PNI incidence and severity between groups, and the association between PNI and the duration from SEMS placement to surgery were investigated. Survival analysis was performed for each group. Results: On multivariate analysis, SEMS placement (hazard ratio [HR]: 2.08) was independently associated with PNI whereas SEMS placement was not. PNI occurred in 39%, 45%, and 68% of the no obstruction, obstruction without stent, and obstruction with stent group, respectively. In the obstruction with stent group, the proportion of PNI was not associated with the duration from SEMS placement to surgery. Extramural PNI, an advanced form of PNI, demonstrated no increase with increasing interval. The five-year OS was 86.3%, 76.7%, and 73.1% in no obstruction, obstruction without stent, and obstruction with stent group, respectively. On multivariate analysis, obstruction was an independent risk factor of decreased OS (HR: 1.57) whereas SEMS placement was not. Conclusions: The prognosis was comparable between patients with SEMS placement and those with an obstruction who did not undergo SEMS placement, thus demonstrating that SEMS is a viable, therapeutic option for BTS.
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BACKGROUND: The diagnostic criteria for lateral lymph node metastasis in rectal cancer have not been established. This research aimed to investigate the risk factors for lateral lymph node metastasis and develop machine learning models combining these risk factors to improve the diagnostic performance of standard imaging. METHOD: This multicentre prospective study included patients who underwent lateral lymph node dissection without preoperative treatment for rectal cancer between 2017 and 2019 in 15 Japanese institutions. First, preoperative clinicopathological factors and magnetic resonance imaging findings were evaluated using multivariable analyses for their correlation with lateral lymph node metastasis. Next, machine learning diagnostic models for lateral lymph node metastasis were developed combining these risk factors. The models were tested in a training set and in an internal validation cohort and their diagnostic performance was tested using receiver operating characteristic curve analyses. RESULTS: Of 212 rectal cancers, 122 patients were selected, including 232 lateral pelvic sides, 30 sides of which had pathological lateral lymph node metastasis. Multivariable analysis revealed that poorly differentiated/mucinous adenocarcinoma, extramural vascular invasion, tumour deposit and a short-axis diameter of lateral lymph node ≥ 6.0 mm were independent risk factors for lateral lymph node metastasis. Patients were randomly divided into a training cohort (139 sides) and a test cohort (93 sides) and machine learning models were computed on the basis of a combination of significant features (including: histological type, extramural vascular invasion, tumour deposit, short- and long-axis diameter of lateral lymph node, body mass index, serum carcinoembryonic antigen level, cT, cN, cM, irregular border and mixed signal intensity). The top three models with the highest sensitivity in the training cohort were as follows: support vector machine (sensitivity, 1.000; specificity, 0.773), light gradient boosting machine (sensitivity, 0.950; specificity, 0.918) and ensemble learning (sensitivity, 0.950; specificity, 0.917). The diagnostic performances of these models in the test cohort were as follows: support vector machine (sensitivity, 0.750; specificity, 0.667), light gradient boosting machine (sensitivity, 0.500; specificity, 0.852) and ensemble learning (sensitivity, 0.667; specificity, 0.864). CONCLUSION: Machine learning models combining multiple risk factors can contribute to improving diagnostic performance of lateral lymph node metastasis.
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Ganglios Linfáticos , Metástasis Linfática , Aprendizaje Automático , Neoplasias del Recto , Humanos , Metástasis Linfática/patología , Neoplasias del Recto/patología , Femenino , Masculino , Persona de Mediana Edad , Factores de Riesgo , Estudios Prospectivos , Anciano , Ganglios Linfáticos/patología , Ganglios Linfáticos/diagnóstico por imagen , Imagen por Resonancia Magnética , Escisión del Ganglio Linfático , Curva ROC , AdultoRESUMEN
BACKGROUND: The significance of resection of paraaortic lymph node metastasis in colorectal cancer is controversial. OBJECTIVE: To clarify the prognosis of colorectal cancer after paraaortic lymph node metastasis resection. DESIGN: Multicenter retrospective study. SETTINGS: Thirty-six institutions in Japan participated in this study. PATIENTS: Patients with resected and pathologically proven paraaortic lymph node metastasis of CRC between 2010 and 2015. DATA SOURCES: Database and medical records at each institution. MAIN OUTCOME MEASURES: Overall survival after paraaortic lymph node metastasis resection, recurrence-free survival, and recurrence patterns after R0 resection of paraaortic lymph node metastasis. RESULTS: A total of 133 patients were included in the primary analysis population in this study. The 5-year overall survival rate (95% confidence interval [CI]) was 41.0% (32.0, 49.8), and the median survival (95% CI) was 4.1 (3.4, 4.7) years. Independent prognostic factors for overall survival were the pathological T stage (pT4 vs. pT1- 3, adjusted hazard ratio [aHR]: 1.91, p = 0.006), other organ metastasis (present vs. absent, aHR: 1.98, p = 0.005), time to metastases (synchronous vs. metachronous, aHR: 2.02, p = 0.02), and number of paraaortic lymph node metastasis (≥3 vs. <3, aHR: 2.13, p = 0.001). The 5-year recurrence-free survival rate (95% CI) was 21.1% (13.5, 29.7), with a median (95% CI) of 1.2 (0.9, 1.4) years. The primary tumor location (left- vs. right-sided colon, aHR: 4.77, p = 0.01; rectum vs. right-sided colon, aHR: 5.27, p = 0.006), other organ metastasis (present vs. absent, aHR: 1.90, p = 0.03), number of paraaortic lymph node metastasis (≥3 vs. <3, aHR: 2.20, p = 0.001), and hospital volume (<10 vs. ≥10, aHR: 2.18, p = 0.02) were identified as independent prognostic factors for recurrence-free survival. Paraaortic lymph node recurrence was the most common at 33.3%. LIMITATIONS: Selection bias cannot be ruled out because of the retrospective nature of the study. CONCLUSIONS: Less than three paraaortic lymph node metastasis was a favorable prognostic factor for both overall survival and recurrence-free survival. However, paraaortic lymph node metastases were considered to be a systemic disease and the significance of resection was limited. See Video Abstract.
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Background: This study aimed to evaluate the efficacy of lateral lymph node dissection (LLND) for rectal cancer by comparing the local control in patients with and without pathological lateral lymph node metastasis (LLNM). Methods: We included 189 patients with rectal cancer who underwent total mesorectal excision and LLND at 13 institutions between 2017 and 2019. Patients with and without pathological LLNM were defined as the pLLNM (+) and (-) groups, respectively. Propensity score-matching helped to balance the basic characteristics of both groups. The incidences of local recurrence (LR) and lateral lymph node recurrence (LLNR) were compared between the groups. Results: In the entire cohort, 39 of the 189 patients had pathological LLNM. The 3-year LR and LLNR rates were 18.3% and 4.0% (p = 0.01) and 7.7% and 3.3% (p = 0.22) in the pLLNM (+) and (-) groups, respectively. After propensity score matching, the data from 62 patients were analyzed. No significant differences in LR or LLNR were observed between both groups. The 3-year LR and LLNR rates were 16.4% and 9.8% (p = 0.46) and 9.7% and 9.8% (p = 0.99) in the pLLNM (+) and (-) groups, respectively. Conclusion: LLND would lead to comparable local control in the pLLNM (+) and (-) groups if the clinicopathological characteristics except for LLNM are similar.
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AIM: The significance of lymphadenectomy and its indications in patients with inguinal lymph node metastasis (ILNM) of anorectal adenocarcinoma is unclear. This study aimed to clarify the surgical outcomes and prognostic factors of inguinal lymphadenectomy for ILNM. METHOD: This study included patients who underwent surgical resection for ILNM of rectal or anal canal adenocarcinoma with pathologically positive metastases between 1997 and 2011 at 20 participating centres in the Study Group for Inguinal Lymph Node Metastasis from Colorectal Cancer organized by the Japanese Society for Cancer of the Colon and Rectum. Clinicopathological characteristics and short- and long-term postoperative outcomes were retrospectively analysed. RESULTS: In total, 107 patients were included. The primary tumour was in the rectum in 57 patients (53.3%) and in the anal canal in 50 (46.7%). The median number of ILNMs was 2.34. Postoperative complications of Clavien-Dindo Grade III or higher were observed in five patients. The 5-year overall survival rate was 38.8%. Multivariate analysis identified undifferentiated histological type (P < 0.001), pathological venous invasion (P = 0.01) and pathological primary tumour depth T0-2 (P = 0.01) as independent prognostic factors for poor overall survival. CONCLUSION: The 5-year overall survival after inguinal lymph node dissection was acceptable, and it warrants consideration in more patients. Further larger-scale studies are needed in order to clarify the surgical indications.
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Adenocarcinoma , Neoplasias del Ano , Conducto Inguinal , Escisión del Ganglio Linfático , Ganglios Linfáticos , Metástasis Linfática , Neoplasias del Recto , Humanos , Masculino , Femenino , Neoplasias del Ano/cirugía , Neoplasias del Ano/patología , Neoplasias del Ano/mortalidad , Persona de Mediana Edad , Anciano , Escisión del Ganglio Linfático/métodos , Estudios Retrospectivos , Adenocarcinoma/cirugía , Adenocarcinoma/patología , Adenocarcinoma/secundario , Adenocarcinoma/mortalidad , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Neoplasias del Recto/mortalidad , Ganglios Linfáticos/patología , Ganglios Linfáticos/cirugía , Resultado del Tratamiento , Adulto , Anciano de 80 o más Años , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Tasa de Supervivencia , Pronóstico , Análisis MultivarianteRESUMEN
BACKGROUND: Comprehensive genomic profiling (CGP) can aid the discovery of clinically useful, candidate antitumor agents; however, the variant annotations sometimes differ among the various types of CGP tests as well as the public database. The aim of this study is to clarify the genomic landscape of evaluating detected variants in patients with a malignant solid tumor. METHODS: The present, cross-sectional study used data from 57,084 patients with a malignant solid tumor who underwent CGP at the Center for Cancer Genomics and Advanced Therapeutics (C-CAT) between June 1, 2019 and August 18, 2023. The pathogenicity of the variants was annotated using public databases. RESULTS: As a result of re-annotation of the detected variants, 20.1% were pathogenic and 1.4% were benign. The mean number of pathogenic variants was 4.30 (95% confidence interval: 4.27-4.32) per patient. Of the entire cohort, 5.7% had no pathogenic variant. The co-occurrence of the genes depended on the tumor type. Germline findings were detected in 6.2%, 8.8%, and 15.8% of the patients using a tumor/normal panel, tumor-only panel, and liquid panel, respectively, with the most common gene being BRCA2 followed by TP53 and BRCA1. CONCLUSIONS: The detected variants should be re-annotated because several benign variants or variants of unknown significance were included in the CGP, and the genomic landscape derived from these results will help researchers and physicians interpret the results of CGP tests. The method of extracting presumptive, germline, pathogenic variants from patients using a tumor-only panel or circulating tumor DNA panel requires improvement.
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PURPOSE: Although lateral lymph node dissection has been performed to prevent lateral pelvic recurrence in locally advanced lower rectal cancer, the incidence of lateral pelvic recurrence after this procedure has not been investigated. Therefore, this study aimed to investigate the long-term outcomes of patients who underwent lateral pelvic lymph node dissection, with a particular focus on recurrence patterns. METHODS: This was a retrospective study conducted at a single high-volume cancer center in Japan. A total of 493 consecutive patients with stage II-III rectal cancer who underwent lateral lymph node dissection between January 2005 and August 2022 were included. The primary outcome measures included patterns of recurrence, overall survival, and relapse-free survival. Patterns of recurrence were categorized as lateral or central pelvic. RESULTS: Among patients who underwent lateral lymph node dissection, 18.1% had pathologically positive lateral lymph node metastasis. Lateral pelvic recurrence occurred in 5.5% of patients after surgery. Multivariate analysis identified age > 75 years, lateral lymph node metastasis, and adjuvant chemotherapy as independent risk factors for lateral pelvic recurrence. Evaluation of the recurrence rate by dissection area revealed approximately 1% of recurrences in each area after dissection. CONCLUSION: We demonstrated the prognostic outcome and limitations of lateral lymph node dissection for patients with advanced lower rectal cancer, focusing on the incidence of recurrence in the lateral area after the dissection. Our study emphasizes the clinical importance of lateral lymph node dissection, which is an essential technique that surgeons should acquire.
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Escisión del Ganglio Linfático , Recurrencia Local de Neoplasia , Pelvis , Neoplasias del Recto , Humanos , Neoplasias del Recto/cirugía , Neoplasias del Recto/patología , Femenino , Masculino , Anciano , Recurrencia Local de Neoplasia/patología , Persona de Mediana Edad , Pelvis/cirugía , Pelvis/patología , Metástasis Linfática , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Adulto , Estudios Retrospectivos , Factores de Riesgo , Análisis MultivarianteRESUMEN
BACKGROUND: The neoadjuvant rectal score (NAR score) has recently been proposed as a better prognostic model than the conventional TNM classification for rectal cancer patients that have undergone neoadjuvant chemoradiotherapy. We recently developed an apoptosis-detection technique for assessing the viability of residual tumors in resected specimens after chemoradiotherapy. This study aimed to establish an improved prognostic classification by combining the NAR score and the assessment of the apoptosis of residual cancer cells. METHODS: We retrospectively enrolled 319 rectal cancer patients who underwent chemoradiotherapy followed by radical surgery. The recurrence-free survival and overall survival of the four models were compared: TNM stage, NAR score, modified TNM stage by re-staging according to cancer cell viability, and modified NAR score also by re-staging. RESULTS: Downstaging of the ypT stage was observed in 15.5% of cases, whereas only 4.5% showed downstaging of ypN stage. C-index was highest for the modified NAR score (0.715), followed by the modified TNM, TNM, and NAR score. Similarly, Akaike's information criterion was smallest in the modified NAR score (926.2), followed by modified TNM, TNM, and NAR score, suggesting that the modified NAR score was the best among these four models. The overall survival results were similar: C-index was the highest (0.767) and Akaike's information criterion was the smallest (383.9) for the modified NAR score among the four models tested. CONCLUSION: We established a novel prognostic model, for rectal cancer patients that have undergone neoadjuvant chemoradiotherapy, using a combination of apoptosis-detecting immunohistochemistry and neoadjuvant rectal scores.
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Quimioradioterapia , Terapia Neoadyuvante , Estadificación de Neoplasias , Neoplasias del Recto , Humanos , Neoplasias del Recto/terapia , Neoplasias del Recto/patología , Neoplasias del Recto/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Anciano , Pronóstico , Estudios Retrospectivos , Quimioradioterapia/métodos , Adulto , Apoptosis , Supervivencia sin Enfermedad , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Lynch-like syndrome (LLS) has recently been proposed as a third type of microsatellite instability (MSI) tumor after Lynch syndrome (LS) and sporadic MSI colorectal cancer (CRC) without either a germline variant of mismatch repair (MMR) genes or hypermethylation of the MLH1 gene. The present study aimed to clarify and compare the clinicopathological characteristics of LLS with those of the other MSI CRC subtypes. METHODS: In total, 2634 consecutive patients with CRC who underwent surgical resection and subsequently received universal tumor screening (UTS), including MSI analysis were enrolled between January 2008 and November 2019. Genetic testing was performed in patients suspected of having Lynch syndrome. RESULTS: UTS of the cohort found 146 patients with MSI CRC (5.5%). Of these, excluding sporadic MSI CRC, 30 (1.1%) had a diagnosis of LS, and 19 (0.7%) had no germline pathogenic variants of the MMR gene. The CRC type in the latter group was identified as LLS. LLS occurred significantly more often in young patients, was left-sided, involved a KRAS variant and BRAF wild-type, and had a higher concordance rate with the Revised Bethesda Guidelines than sporadic MSI CRC. No significant differences were observed in terms of the clinicopathological factors between LLS and LS-associated MSI CRC; however, LLS had a lower frequency of LS-related neoplasms compared with LS. CONCLUSIONS: Distinguishing clinically between LS and LLS was challenging, but the incidence of neoplasms was higher in LS than in LLS, suggesting the need for different screening and surveillance methods for the two subtypes.
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Neoplasias Colorrectales Hereditarias sin Poliposis , Inestabilidad de Microsatélites , Humanos , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/patología , Femenino , Masculino , Persona de Mediana Edad , Anciano , Adulto , Homólogo 1 de la Proteína MutL/genética , Reparación de la Incompatibilidad de ADN/genética , Proteínas Proto-Oncogénicas B-raf/genética , Anciano de 80 o más Años , Proteínas Proto-Oncogénicas p21(ras)/genética , Neoplasias Colorrectales/genética , Neoplasias Colorrectales/patología , Pruebas GenéticasRESUMEN
BACKGROUND: Laparoscopic colon surgery frequently requires performing maneuvers under mirror-images conditions; the complexity differs depending on the surgical site location in the abdominal cavity. However, no previous reports have examined this. METHODS: Eleven surgeons participated in this study. Operations were performed on 25 points placed at the bottom and sides of a laparoscopic training box under mirror-image conditions. The mean time-point required to operate at each point and variation between surgeons were evaluated. RESULTS: When the right hand was used, time-points to touch the right side-superficial ends were 0.50 to 0.58 and 0.27 to 0.45 for the other sites. With the left hand, time-points to touch the left side-superficial ends were 0.58 to 0.63 and 0.28 to 0.51 for the other sites, indicating that the most difficult manipulation was at the proximal site of the surgical port. The variation in the difficulty according to the spots increased with a decrease in the surgeon's experience (right hand, r =-0.248; left hand, r =-0.491). CONCLUSIONS: In performing laparoscopic surgery under mirror-image conditions, the technical difficulty varies by location, and operating in locations close to the forceps port is the most difficult.
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Competencia Clínica , Laparoscopía , Humanos , Laparoscopía/métodos , Tempo Operativo , MasculinoRESUMEN
BACKGROUND AND OBJECTIVES: Mean survival time (MST) is used as the indicator of prognosis in patients with a colorectal cancer (CRC) recurrence. The present study aimed to visualize the changes in death risk after a CRC recurrence using hazard function analysis (HFA) to provide an alternative prognostic indicator to MST. METHODS: The medical records of 725 consecutive patients with a recurrence following R0 radical surgery for CRC were retrospectively reviewed. RESULTS: The five-year, post-recurrence survival rate was 37.8%, and the MST was 3.5 years while the risk of death peaked at 2.9 years post-recurrence. Seven variables were found to predict short-term survival, including the number of metastatic organs ≥ 2, non-surgical treatment for the recurrence, and a short interval before recurrence. In patients with a recurrence in one organ, the MST was four years, the peak time of death predicted by HFA was 2.9 years, and the five-year survival rate was 45.8%. In patients with a surgical resection of the recurrence, the MST was 8 years, the peak time of death was 3.3 years, and the five-year survival rate was 62%. CONCLUSIONS: The present study established a novel method of assessing changes in mortality risk over time using HFA in patients with a CRC recurrence.
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Neoplasias Colorrectales , Humanos , Estudios Retrospectivos , Pronóstico , Neoplasias Colorrectales/cirugíaRESUMEN
Aim: The aim of this study was to clarify the significance of resection of ovarian metastases from colorectal cancer and to identify the clinicopathologic characteristics. Methods: In this multicenter retrospective study, we evaluated data on ovarian metastases from colorectal cancer obtained from patients at 20 centers in Japan between 2000 and 2014. We examined the impact of resection on the prognosis of patients with ovarian metastases and examined prognostic factors. Results: The study included 296 patients with ovarian metastasis. The 3-y overall survival rate was 68.6% for solitary ovarian metastases. In all cases of this cohort, the 3-y overall survival rates after curative resection, noncurative resection, and nonresection were 65.9%, 31.8%, and 6.1%, respectively (curative resection vs noncurative resection [P < 0.01] and noncurative resection vs nonresection [P < 0.01]). In the multivariate analysis of prognostic factors, tumor size of ovarian metastasis (P < 0.01), bilateral ovarian metastasis (P = 0.01), peritoneal metastasis (P < 0.01), pulmonary metastasis (P = 0.04), liver metastasis (P < 0.01), and remnant of ovarian metastasis (P < 0.01) were statistically significantly different. Conclusion: The prognosis after curative resection for solitary ovarian metastases was shown to be relatively favorable as Stage IV colorectal cancer. Resection of ovarian metastases, not only curative resection but also noncurative resection, confers a survival benefit. Prognostic factors were large ovarian metastases, bilateral ovarian metastases, the presence of extraovarian metastases, and remnant ovarian metastases.
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BACKGROUND: Patients with familial adenomatous polyposis (FAP) have an increased risk of developing gastric neoplasms. However, the clinical course of FAP with these gastric lesions has not yet been fully clarified. The present study aimed to clarify the changes in the incidence risk of developing gastric adenoma or gastric cancer during the lifespan of patients with FAP. METHODS: Four hundred forty-three patients with data regarding gastric adenoma and gastric cancer retrospectively registered in a nationwide Japanese multicenter study were enrolled. The cumulative incidences and hazard rates (HRs) of gastric neoplasms were evaluated. RESULTS: The cumulative incidence rates in 50-year-old patients with FAP were 22.8% for gastric adenoma and 7.6% for gastric cancer, respectively. No significant association was found between gastric neoplasms and the colonic phenotype. The peak age for the HR of gastric adenoma was 65 years, with the highest HR (0.043). Regarding the incidence of gastric cancer, the HR increased moderately up to the age of 40 years, but the increase accelerated from the age of 50 years (HR = 0.0067). CONCLUSION: Careful surveillance of the upper gastrointestinal tract in elderly patients with FAP, such as shortening the interval of follow-up according to age, may be helpful for early diagnosis of gastric cancer.
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Adenocarcinoma , Poliposis Adenomatosa del Colon , Pólipos Adenomatosos , Neoplasias Gástricas , Humanos , Anciano , Adulto , Persona de Mediana Edad , Neoplasias Gástricas/etiología , Neoplasias Gástricas/genética , Japón/epidemiología , Poliposis Adenomatosa del Colon/complicaciones , Poliposis Adenomatosa del Colon/epidemiología , Poliposis Adenomatosa del Colon/genética , Adenocarcinoma/epidemiología , Adenocarcinoma/etiología , Adenocarcinoma/patologíaRESUMEN
BACKGROUND: Oxaliplatin-based regimens are commonly used as adjuvant chemotherapy following surgery for colorectal cancer. Adverse events associated with oxaliplatin include blue liver, which is caused by sinusoidal dilation and diffuse peliosis hepatis. We report herein a case of localized peliosis hepatis closely resembling a metastatic liver tumor. CASE PRESENTATION: The patient, a 50-year-old male, underwent a robotically assisted colectomy for rectosigmoid colon cancer, which was discovered when hematochezia occurred. The patient received a diagnosis of pStage IIIb and was treated with four courses of CAPOX as adjuvant chemotherapy starting at postoperative month 1. At postoperative month 4, contrast-enhanced computed tomography (CT) of the abdomen revealed a 20-mm, low-density area with heterogeneous internal structure in S6/7 of the liver. Abdominal ultrasound and gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) findings led to a diagnosis of metastatic liver tumor, for which a laparoscopic partial hepatectomy was performed. The resected lesion was a dark reddish-brown nodule with indistinct margins that appeared to be continuous with the surrounding area. Histopathological analysis revealed severe, localized dilatation of the sinusoids and congestion consistent with the gross nodule. Based on these findings, localized peliosis hepatis associated with oxaliplatin-induced sinusoidal damage was diagnosed. CONCLUSIONS: Localized peliosis hepatis associated with oxaliplatin use can be difficult to distinguish from a metastatic liver tumor on imaging studies.
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BACKGROUND: Many studies have reported a correlation between lymph node metastasis and prognosis in patients with colorectal cancer. However, the clinical significance of enlarged lymph nodes for prognosis has scarcely been explored. OBJECTIVE: This study aimed to assess the clinical significance of enlarged lymph nodes in stage II colorectal cancer. DESIGN: This is a multicenter retrospective observational study with a median follow-up period of 66.8 months. SETTINGS: Patients' medical records were retrospectively collected from the Japanese Study Group for Postoperative Follow-up of Colorectal Cancer database. PATIENTS: This study included 2212 patients with stage II colorectal cancer who underwent surgical resection between January 2009 and December 2012. Patients were classified into the enlarged lymph node and nonenlarged lymph node groups and their data were compared. MAIN OUTCOME MEASURES: Clinicopathological characteristics and prognoses of the 2 groups were compared. The main outcomes measured were recurrence-free survival and overall survival. RESULTS: The enlarged lymph node group showed significantly better overall survival and recurrence-free survival in pT4b cases but not in pT3 or pT4a cases. In pT4b cases, an enlarged lymph node (HR, 0.53; 95% CI, 0.29-0.98) was an independent prognostic factor for longer recurrence-free survival, whereas a rectal lesion (HR, 3.46; 95% CI, 1.90-6.29) was an independent prognostic factor for shorter recurrence-free survival. An enlarged lymph node was associated with a lower distant recurrence rate (HR, 0.49; 95% CI, 0.26-0.92) and a tendency to correlate with better overall survival (HR, 0.50; 95% CI, 0.22-1.14). LIMITATIONS: The retrospective design may have increased the risk of selection bias. Inadequate information regarding enlarged lymph nodes is another study limitation. CONCLUSIONS: This study showed that enlarged lymph nodes are associated with a favorable prognosis in patients with pT4b stage II colorectal cancer. See Video Abstract at http://links.lww.com/DCR/C246 . IMPORTANCIA PRONSTICA DE LOS GANGLIOS LINFTICOS AGRANDADOS EN EL CNCER COLORRECTAL EN ESTADIO II: ANTECEDENTES:Muchos estudios han informado una correlación entre la metástasis en los ganglios linfáticos y el pronóstico en pacientes con cáncer colorrectal. Sin embargo, apenas se ha explorado la importancia clínica de los ganglios linfáticos agrandados para el pronóstico.OBJETIVO:El objetivo fue evaluar la importancia clínica de los ganglios linfáticos agrandados en el cáncer colorrectal en estadio II.DISEÑO:Este es un estudio observacional retrospectivo multicéntrico con una mediana de seguimiento de 66,8 meses.CONFIGURACIÓN:Los registros médicos de los pacientes se recopilaron retrospectivamente de la base de datos del Grupo de estudio japonés para el seguimiento posoperatorio del cáncer colorrectal.PACIENTES:Incluimos 2212 pacientes con cáncer colorrectal en estadio II que se sometieron a resección quirúrgica entre enero de 2009 y diciembre de 2012. Los pacientes se clasificaron en grupos de ganglios linfáticos agrandados y no agrandados y se compararon sus datos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las características clinicopatológicas y los pronósticos de los dos grupos. Los principales resultados medidos fueron la supervivencia sin recurrencia y la supervivencia general.RESULTADOS:El grupo de ganglios linfáticos agrandados mostró una supervivencia general significativamente mejor y una supervivencia libre de recurrencia en los casos pT4b, pero no en los casos pT3 ni pT4a. En los casos de pT4b, el agrandamiento de los ganglios linfáticos (CRI, 0,53; IC 95 %, 0,29-0,98) fue un factor pronóstico independiente para una supervivencia sin recidiva más prolongada, mientras que la lesión rectal (CRI, 3,46; IC 95%, 1,90-6,29) fue un factor pronóstico independiente para RFS más cortos. Los ganglios linfáticos agrandados se relacionaron con una tasa más baja de recurrencia a distancia (CRI, 0,49; IC 95%, 0,26-0,92) y una tendencia a correlacionarse con una mejor supervivencia general (CRI, 0,50; IC 95%, 0,22-1,14).LIMITACIONES:El diseño retrospectivo puede haber aumentado el riesgo de sesgo de selección. La información inadecuada sobre el agrandamiento de los ganglios linfáticos es otra limitación del estudio.CONCLUSIONES:Este estudio mostró que los ganglios linfáticos agrandados están asociados con un pronóstico favorable en pacientes con cáncer colorrectal pT4b en estadio II. Consulte Video Resumen en http://links.lww.com/DCR/C246 . ( Traducción - Dr. Mauricio Santamaria ).
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INTRODUCTION: We previously developed risk models for mortality and morbidity after low anterior resection using a nationwide Japanese database. However, the milieu of low anterior resection in Japan has undergone drastic changes since then. This study aimed to construct risk models for 6 short-term postoperative outcomes after low anterior resection, i.e., in-hospital mortality, 30-day mortality, anastomotic leakage, surgical site infection except for anastomotic leakage, overall postoperative complication rate, and 30-day reoperation rate. METHODS: This study enrolled 120,912 patients registered with the National Clinical Database, who underwent low anterior resection between 2014 and 2019. Multiple logistic regression analyses were performed to generate predictive models of mortality and morbidity using preoperative information, including the TNM stage. RESULTS: We developed new risk prediction models for the overall postoperative complication and 30-day reoperation rates for low anterior resection, which were absent from the previous version. The concordance indices for each endpoint were 0.82 for in-hospital mortality, 0.79 for 30-day mortality, 0.64 for anastomotic leakage, 0.62 for surgical site infection besides anastomotic leakage, 0.63 for complications, and 0.62 for reoperation. The concordance indices of all four models included in the previous version showed improvement. CONCLUSION: This study successfully updated the risk calculators for predicting mortality and morbidity after low anterior resection using a model based on vast nationwide Japanese data.
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Fuga Anastomótica , Neoplasias del Recto , Humanos , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Neoplasias del Recto/cirugía , Factores de Riesgo , Morbilidad , Anastomosis Quirúrgica/efectos adversos , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Metastatic lateral lymph node dissection can improve survival in patients with rectal adenocarcinoma, with or without chemoradiotherapy. However, the optimal imaging diagnostic criteria for lateral lymph node metastases remain undetermined. OBJECTIVE: To develop a lateral lymph node metastasis diagnostic artificial intelligence tool using deep learning, for patients with rectal adenocarcinoma who underwent radical surgery and lateral lymph node dissection. DESIGN: Retrospective study. SETTINGS: Multicenter study. PATIENTS: A total of 209 patients with rectal adenocarcinoma, who underwent radical surgery and lateral lymph node dissection at 15 participating hospitals, were enrolled in the study and allocated to training (n = 139), test (n = 17), or validation (n = 53) cohorts. MAIN OUTCOME MEASURES: In the neoadjuvant treatment group, images taken before pretreatment were classified as baseline images and those taken after pretreatment as presurgery images. In the upfront surgery group, presurgery images were classified as both baseline and presurgery images. We constructed 2 types of artificial intelligence, using baseline and presurgery images, by inputting the patches from these images into ResNet-18, and we assessed their diagnostic accuracy. RESULTS: Overall, 124 patients underwent surgery alone, 52 received neoadjuvant chemotherapy, and 33 received chemoradiotherapy. The number of resected lateral lymph nodes in the training, test, and validation cohorts was 2418, 279, and 850, respectively. The metastatic rates were 2.8%, 0.7%, and 3.7%, respectively. In the validation cohort, the precision-recall area under the curve was 0.870 and 0.963 for the baseline and presurgery images, respectively. Although both baseline and presurgery images provided good accuracy for diagnosing lateral lymph node metastases, the accuracy of presurgery images was better than that of baseline images. LIMITATIONS: The number of cases is small. CONCLUSIONS: An artificial intelligence tool is a promising tool for diagnosing lateral lymph node metastasis with high accuracy. DESARROLLO DE UNA HERRAMIENTA DE INTELIGENCIA ARTIFICIAL PARA EL DIAGNSTICO DE METSTASIS EN GANGLIOS LINFTICOS LATERALES EN CNCER DE RECTO AVANZADO: ANTECEDENTES:Disección de nódulos linfáticos laterales metastásicos puede mejorar la supervivencia en pacientes con adenocarcinoma del recto, con o sin quimiorradioterapia. Sin embargo, aún no se han determinado los criterios óptimos de diagnóstico por imágenes de los nódulos linfáticos laterales metastásicos.OBJETIVO:Nuestro objetivo fue desarrollar una herramienta de inteligencia artificial para el diagnóstico de metástasis en nódulos linfáticos laterales mediante el aprendizaje profundo, para pacientes con adenocarcinoma del recto que se sometieron a cirugía radical y disección de nódulos linfáticos laterales.DISEÑO:Estudio retrospectivo.AJUSTES:Estudio multicéntrico.PACIENTES:Un total de 209 pacientes con adenocarcinoma del recto, que se sometieron a cirugía radical y disección de nódulos linfáticos laterales en 15 hospitales participantes, se inscribieron en el estudio y se asignaron a cohortes de entrenamiento (n = 139), prueba (n = 17) o validación (n = 53).PRINCIPALES MEDIDAS DE RESULTADO:En el grupo de tratamiento neoadyuvante, las imágenes tomadas antes del tratamiento se clasificaron como imágenes de referencia y las posteriores al tratamiento, como imágenes previas a la cirugía. En el grupo de cirugía inicial, las imágenes previas a la cirugía se clasificaron como imágenes de referencia y previas a la cirugía. Construimos dos tipos de inteligencia artificial, utilizando imágenes de referencia y previas a la cirugía, ingresando los parches de estas imágenes en ResNet-18. Evaluamos la precisión diagnóstica de los dos tipos de inteligencia artificial.RESULTADOS:En general, 124 pacientes se sometieron a cirugía solamente, 52 recibieron quimioterapia neoadyuvante y 33 recibieron quimiorradioterapia. El número de nódulos linfáticos laterales removidos en los cohortes de entrenamiento, prueba y validación fue de 2,418; 279 y 850, respectivamente. Las tasas metastásicas fueron 2.8%, 0.7%, y 3.7%, respectivamente. En el cohorte de validación, el área de recuperación de precisión bajo la curva fue de 0.870 y 0.963 para las imágenes de referencia y antes de la cirugía, respectivamente. Aunque tanto las imágenes previas a la cirugía como las iniciales proporcionaron una buena precisión para diagnosticar metástasis en los nódulos linfáticos laterales, la precisión de las imágenes previas a la cirugía fue mejor que la de las imágenes iniciales.LIMITACIONES:El número de casos es pequeño.CONCLUSIÓN:La inteligencia artificial es una herramienta prometedora para diagnosticar metástasis en los nódulos linfáticos laterales con alta precisión. (Traducción-Dr. Aurian Garcia Gonzalez ).
Asunto(s)
Adenocarcinoma , Neoplasias del Recto , Humanos , Metástasis Linfática , Estudios Retrospectivos , Inteligencia Artificial , Ganglios Linfáticos/diagnóstico por imagen , Ganglios Linfáticos/patología , Estadificación de Neoplasias , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/terapia , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirugíaRESUMEN
BACKGROUND: Total neoadjuvant therapy (TNT) is a novel treatment strategy that is an alternative to preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC). However, an optimal protocol for TNT has not yet been established. The present study will be an open-label, single-arm, single-center trial to develop a new protocol. METHODS: Thirty LARC patients at high risk of distant metastasis will receive CRT consisting of long-course radiation, concurrent with tegafur/uracil, oral leucovorin, irinotecan (TEGAFIRI), followed by mFOLFOX-6 or CAPOX before undergoing surgery. DISCUSSION: Since previous findings showed a high percentage of grade 3-4 adverse events with the TEGAFIRI regimen for CRT and TNT, the primary outcome of this study will be safety and feasibility. Our regimen for CRT consists of the biweekly administration of irinotecan for good patient compliance. The novel combination approach of this treatment may improve the long-term outcomes of LARC. TRIAL REGISTRATION: Japan Registry of Clinical Trials jRCTs031210660.
Asunto(s)
Neoplasias del Recto , Tegafur , Humanos , Irinotecán/uso terapéutico , Oxaliplatino , Leucovorina , Terapia Neoadyuvante/métodos , Neoplasias del Recto/tratamiento farmacológico , Neoplasias del Recto/patología , Resultado del Tratamiento , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Quimioradioterapia/métodos , Fluorouracilo/uso terapéutico , Estadificación de Neoplasias , Ensayos Clínicos Fase II como AsuntoRESUMEN
AIM: The preoperative prediction of lymph node metastasis of well-differentiated rectal neuroendocrine tumours is highly desirable and useful in defining surgical indication more accurately. We aimed to evaluate lymph node metastasis in rectal neuroendocrine neoplasms using multiple imaging modalities. METHODS: The clinical records and radiological images of 70 patients with well-differentiated rectal neuroendocrine tumours who received treatment at the University of Tokyo Hospital between 2010 and 2022 were retrospectively analysed. The relationship between evaluation by multiple imaging modalities and pathological lymph node metastasis was analysed. RESULTS: The receiver operating characteristic curves showed that a maximum lymph node diameter ≥4 mm on computed tomography and ≥8 mm on magnetic resonance imaging were the optimal predictive factors for lymph node metastasis. Accumulation in the lymph nodes on somatostatin receptor scintigraphy (P = 0.058) and Delle's findings on colonoscopy (P = 0.014) were also significant predictors of pathological lymph node positivity, and combination of multiple modalities was useful. Pathologically, lymphatic (P = 0.0030)/venous (P = 0.0007) invasion were risk factors for lymph node metastasis. CONCLUSIONS: In addition to pathological risk factors, a combination of multiple radiological imaging modalities is useful for predicting lymph node metastasis in well-differentiated rectal neuroendocrine tumours.