Recurrent Colorectal Cancers Research Articles

Open versus robotic-assisted techniques for multivisceral pelvic resections of locally advanced or recurrent colorectal and anal cancers: short-term outcomes from a single centre

BackgroundPelvic exenterations are now established as a standard of care for locally advanced and recurrent rectal cancer. Traditionally, these radical and complex operations have been performed via an open approach, but with the increasing expertise in robotic-assisted surgery (RAS), there is scope to perform such cases robotically. This study compares outcomes from open and RAS pelvic exenterations.MethodsThis retrospective observational study includes all pelvic exenterations for locally advanced or recurrent colorectal cancers performed in a single centre between September 2018 and September 2023. Cases were grouped into open or RAS surgery and classified in terms of operative extent and complexity. The primary outcome was resection margin status. Secondary outcomes were postoperative morbidity, length of stay and blood loss.ResultsThirty-three patients were included. Nineteen (57.6%) cases utilised an open technique, and 14 (42.4%) used RAS. Patient characteristics and operative complexity were equivalent between groups. R0 rate (63.1% vs 71.4%, p = 0.719), median haemoglobin drop (19 (11–30) g/L vs 13 (5–26) g/L, p = 0.208) and postoperative morbidity (18/19 (94.7%) vs 9/14 (64.3%), p = 0.062) were equivalent. Length of stay (16.0 days (8–25) vs 9.5 days (6–16), p = 0.047) was shorter in the RAS group.ConclusionsShort-term surgical and histopathological outcomes are equivalent in this small cohort of patients. This study suggests that RAS may be a safe and effective method for performing pelvic exenterations for colorectal malignancies. Larger-scale and robustly designed prospective studies are required to confirm these preliminary findings and report on long-term oncological outcomes.

Evaluation of 68Ga-FAPI PET/CT and 18F-FDG PET/CT for the diagnosis of recurrent colorectal cancers

ObjectiveThe present study aimed to compare the diagnostic value of gallium-68-labeled fibroblast activation protein inhibitor positron emission tomography/computed tomography (68Ga-FAPI PET/CT) and fluorine-18-labeled fluorodeoxyglucose PET/CT (18F-FDG PET/CT) for detecting recurrent colorectal cancers (CRCs). Materials and MethodsFifty-six patients (age: 18–80 years, 31 men and 25 women) with suspected recurrent CRC were enrolled and underwent 18F-FDG PET/CT and 68Ga-FAPI PET/CT sequentially within 1 week. The maximum standard uptake value (SUVmax), tumor-to-background ratio (TBR), and diagnostic accuracy were estimated and compared between the two modalities by using Student’s t-test. The Wilcoxon signed-rank test was used to compare peritoneal carcinoma index (PCI) scores between the two imaging modalities. Results68Ga-FAPI PET/CT showed higher sensitivity for detecting recurrence (93 % vs. 79 %); lymph node metastasis (89 % vs. 78 %), particularly peritoneal lymph node metastasis (92 % vs. 63 %); and metastatic implantation on the intestinal wall (100 % vs. 25 %) compared to 18F-FDG PET/CT. However, 68Ga-FAPI PET/CT showed lower sensitivity for detecting bone metastasis (67 % vs. 100 %). The mean SUVmax values of peritoneal metastases and metastatic implantation on the intestinal wall were 4.28 ± 2.70 and 7.58 ± 1.66 for 18F-FDG PET/CT and 5.66 ± 1.97 and 6.70 ± 0.25 for 68Ga-FAPI PET/CT, respectively. Furthermore, 68Ga-FAPI PET/CT showed significantly higher TBR for peritoneal metastatic lesions (4.22 ± 1.47 vs. 1.41 ± 0.89, p < 0.0001) and metastatic implantation on the intestinal wall (5.63 ± 1.24 vs. 2.20 ± 0.5, p = 0.02) compared to 18F-FDG PET/CT. For the same patient, 68Ga-FAPI PET/CT yielded a more accurate PCI score and a greater area under the curve value for the receiver operating characteristic curve (p < 0.01) than 18F-FDG PET/CT. Conclusion68Ga-FAPI PET/CT was superior to 18F-FDG PET/CT for detecting recurrence and peritoneal metastases. Hence, we propose the combination of these two modalities for better clinical diagnosis and management of patients with CRC.

Abstract 2401: Changes in skeletal muscle mass after gastrointestinal cancer surgery by body composition

Abstract Background: Previous studies have extensively explored the correlation between preoperative skeletal muscle mass and long-term survival in gastrointestinal cancers. However, investigations into postoperative skeletal muscle mass alterations are limited. In gastrointestinal cancers, factors such as the tumor and surgical interventions can significantly impact dietary intake, nutritional status, and skeletal muscle mass, affecting postoperative body composition. This study aimed to examine these postoperative changes in skeletal muscle mass across different gastrointestinal cancers, including esophageal, gastric, and colorectum. Methods: This study encompassed 969 patients with Stage I-III esophageal (307 cases), gastric (278 cases), and colorectal (384 cases) cancers who underwent radical resection between 2005 and 2019. Skeletal muscle mass was quantified as the total psoas volume (TPV), measured using Ziostation2® imaging software from preoperative and postoperative CT scans at 1, 2, and 3 years. The study compared postoperative TPV trends across the different cancer types. Results: The study cohort comprised patients with esophageal (median age 66 years, 85% male), gastric (65 years, 60%), and colorectal cancers (67 years, 55%). Median BMIs were 21.5, 19.4, and 22.6 kg/m2, and median TPVs were 352.0, 305.8, and 309.5 cm3 for esophageal, gastric, and colorectal cancers, respectively. Esophageal cancer patients had significantly higher TPV and male predominance, while gastric cancer patients had notably lower BMI. Relative to preoperative TPV, the postoperative TPV at three years was 0.92, 0.91, and 0.96 for esophageal, gastric, and colorectal cancers, respectively. A year-by-year decrease in TPV was observed for each cancer type, with colorectal cancer demonstrating a less pronounced decrease compared to esophageal and gastric cancers (p&amp;lt;0.01). Stage-wise analysis revealed no significant differences among the cancer types. Regarding gender, no significant differences were noted between gastric and colorectal cancers, but esophageal cancer showed a more marked decrease in TPV in males compared to females. In recurrent cases, no significant TPV differences were observed in esophageal cancer, while recurrent gastric and colorectal cancers exhibited significant TPV decreases. Conclusions: The study indicates a general decline in TPV following gastrointestinal cancer surgery, with the extent of reduction varying according to the type of tumor and treatment. Citation Format: Yuto Maeda, Yuji Miyamoto, Mayuko Ohuchi, Yukiharu Hiyoshi, Naoya Yoshida, Hideo Baba. Changes in skeletal muscle mass after gastrointestinal cancer surgery by body composition [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2401.

Carbon-Ion Radiation Therapy for Unresectable Locally Recurrent Colorectal Cancer: A Promising Curative Treatment for Both Radiation Therapy: Naïve Cases and Reirradiation Cases

It is difficult to effectively cure patients with unresectable locally recurrent colorectal cancers (LRCRCs) using conventional chemotherapy or chemoradiation therapy. Furthermore, treatment options vary depending on the patient's history of radiation therapy. Carbon-ion radiation therapy (CIRT) is a potentially curative treatment for these patients. Here, we compare the treatment outcomes of radiation therapy-naïve cases (nRT) and re-irradiation cases (reRT). Patients with LRCRC treated with CIRT at QST Hospital between 2003 and 2019 were eligible. CIRT was administered daily 4 d/wk for 16 fractions. The total irradiated dose was set at 73.6 Gy (relative biologic effectiveness-weighted dose [RBE]) for nRT and 70.4 Gy (RBE) for reRT patients. We included 390 nRT cases and 83 reRT cases. The median follow-up period from the initiation of CIRT was 48 (5-208) months. The 3-year overall survival (OS) rates for nRT and reRT were 73% (95% CI, 68%-77%) and 76% (65%-84%), respectively. The 5-year OS rates were 50% (45%-55%) and 50% (38%-61%), respectively. These rates did not differ significantly (P=.55). The 3-year local control (LC) rates for nRT (73.6 Gy) and reRT (70.4 Gy) cases were 80% (75%-84%) and 80% (68%-88%), respectively. The 5-year LC rates were 72% (67%-78%) and 69% (55%-81%), respectively, without a significant difference (P=.56). Our results suggest that CIRT for LRCRC is a very effective and promising treatment for both nRT and reRT cases.

The value of inflammatory indexes in colorectal cancers

In recent years, a relationship has been established between inflammatory indexes and the prognosis of many cancers. Although there are many studies investigating their relationship with colorectal cancers (CRC), there is a serious difference between the results in the related literature. The present study aimed to share our own experience with inflammatory indexes in CRC patients. Patients with a diagnosis of CRC who underwent surgery between January 2019 and June 2022 were retrospectively scanned. Exclusion criteria were as follows; being in a septic state before surgery, accompanying hematological disease, receiving neoadjuvant chemotherapy/radiotherapy, being diagnosed with recurrent CRC, undergoing emergency surgery, receiving immunosuppressive or anti-inflammatory treatment. Therefore, the study was conducted with 52 patients. Demographic information, tumor localization, stages and pathology data of the patients were examined. The relationship between these variables and the systemic immune-inflammation index (SII), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) was investigated. A significant correlation was found between pathological T stages and SII (p=0.008), NLR (p&lt;0.001) and PLR (p=0.035). No correlation was found between inflammatory indexes and Age, Tumor Diameter, N Stage, Total Lymph Node Count, Metastatic Lymph Node Count. In our study, inflammatory indexes were found to be associated only with the T stage. Considering our results together with the variable results in the literature, more evidence is needed for the safe and active use of SII, NLR and PLR as markers of colorectal cancers.

Correlation of long interspersed element-1 open reading frame 1 and c-Met proto-oncogene protein expression in primary and recurrent colorectal cancers

Background: Colorectal cancer is one of the most common cancers worldwide. Colorectal cancer that has recurred and metastasized to other organs also has a very poor prognosis. According to recent studies, the long interspersed element-1 (LINE-1) retrotransposon open reading frame (ORF) is located in the intron of the c-Met proto-oncogene, which is involved in cancer progression and metastasis, and regulates its expression. However, no study has compared the expression patterns of LINE-1 ORF1 and c-Met, which are closely related to cancer progression and metastasis, and their correlation in primary and recurrent cancers.Methods: In the present study, we compared the expression patterns of LINE-1 ORF1 and c-Met in both primary and recurrent colorectal cancer tissues from 10 patients. Expression patterns and correlations between LINE-1 ORF1 and c-Met proto-oncogene proteins were analyzed by immunofluorescence staining using both LINE-1 ORF1 and c-Met antibodies.Results: The expression patterns of LINE-1 ORF1 and c-Met showed significant individual differences, and the expression of both proteins was correlated in all colorectal cancer patients. However, the expression levels of LINE-1 ORF1 and c-Met were not significantly different between primary and recurrent colorectal cancers. Conclusions: The protein expression levels of LINE-1 ORF1 and c-Met were correlated, but did not change significantly in cases of recurrent colorectal cancer in the same patient.

Biopsy of Non-tumor Sites After Biopsy of a Colorectal Cancer is not Associated With Metachronous Cancers: A Case-control Study

Recent research has demonstrated biologic plausibility for iatrogenic tumor seeding via colonoscopy as a cause of metachronous colorectal cancers (CRC). This study evaluated the association between biopsy of non-tumor sites after CRC biopsy and risk of metachronous CRC in a large community-based health care organization. This was a retrospective case-control study of adults with an initial CRC diagnosed by colonoscopy between January 2006 and June 2018 who underwent curative resection. Cases developed a second primary (metachronous) CRC diagnosed 6 months to 4 years after the initial CRC, and were matched by age, sex, diagnosis of inflammatory bowel disease, race, and ethnicity with up to 5 controls without a second CRC diagnosis. The exposure was biopsy in the colonic segment of the metachronous CRC (or corresponding segment in controls) after tumor biopsy, ascertained with blinding to case status. Associations were evaluated using conditional logistic regression and adjusted for potential cofounders. Among 14,119 patients diagnosed with an initial CRC during colonoscopy, 107 received a second CRC diagnosis. After exclusions for recurrent or synchronous CRC, 45 cases and 212 controls were included. There was no significant association between biopsy of non-tumor sites after initial CRC biopsy and risk of metachronous CRC in the segment of the additional biopsy site (adjusted odds ratio, 2.29; 95% confidence interval, 0.77-6.81). Metachronous cancers are not significantly associated with biopsy of non-tumor sites after biopsy of the primary cancer. Although the sample size does not allow definite exclusion of any association, these findings do not support iatrogenic tumor seeding as a common risk factor for metachronous CRC.

The Utility of Pathology Reports to Identify Persons With Cancer Recurrence.

Cancer recurrence is an important measure of the impact of cancer treatment. However, no population-based data on recurrence are available. Pathology reports could potentially identify cancer recurrences. Their utility to capture recurrences is unknown. This analysis assesses the sensitivity of pathology reports to identify patients with cancer recurrence and the stage at recurrence. The study includes patients with recurrent breast (n=214) or colorectal (n=203) cancers. This retrospective analysis included patients from a population-based cancer registry who were part of the Patient-Centered Outcomes Research (PCOR) Study, a project that followed cancer patients in-depth for 5 years after diagnosis to identify recurrences. Information abstracted from pathology reports for patients with recurrence was compared with their PCOR data (gold standard) to determine what percent had a pathology report at the time of recurrence, the sensitivity of text in the report to identify recurrence, and if the stage at recurrence could be determined from the pathology report. One half of cancer patients had a pathology report near the time of recurrence. For patients with a pathology report, the report's sensitivity to identify recurrence was 98.1% for breast cancer cases and 95.7% for colorectal cancer cases. The specific stage at recurrence from the pathology report had a moderate agreement with gold-standard data. Pathology reports alone cannot measure population-based recurrence of solid cancers but can identify specific cohorts of recurrent cancer patients. As electronic submission of pathology reports increases, these reports may identify specific recurrent patients in near real-time.

Doxorubicin-Loaded Tumor-Targeting Peptide-Decorated Polypeptide Nanoparticles for Treating Primary Orthotopic Colon Cancer.

Colorectal cancer is the third most common malignant disease worldwide, and chemotherapy has been the standard treatment for colorectal cancer. However, the therapeutic effects of chemotherapy are unsatisfactory for advanced and recurrent colorectal cancers. Thus, increasing the treatment efficacy of chemotherapy in colorectal cancer is a must. In this study, doxorubicin (DOX)-loaded tumor-targeting peptide-decorated mPEG-P(Phe-co-Cys) nanoparticles were developed to treat orthotopic colon cancer in mice. The peptide VATANST (STP) can specifically bind with vimentin highly expressed on the surface of colon cancer cells, thus achieving the tumor-targeting effects. The nanoparticles are core-shell structured, which can protect the loaded DOX while passing through the blood flow and increase the circulation time. The disulfide bonds within the nanoparticles are sensitive to the glutathione-rich microenvironment of tumor tissues. Rupture of disulfide bonds of the nanoparticles leads to the continuous release of DOX, thus resulting in the apoptosis of the tumor cells. The in vivo experiments in mice with orthotopic colon cancer demonstrated that the synthesized DOX-loaded tumor-targeting peptide-decorated polypeptide nanoparticles showed properties of drug delivery systems and exhibited good antitumor properties. The synthesized nanoparticles show appropriate properties as one of the drug delivery systems and exhibit good antitumor properties after encapsulating DOX.

Clinical Features and Genomic Characterization of Post-Colonoscopy Colorectal Cancer.

INTRODUCTION:Some colorectal cancers (CRCs) may be missed during colonoscopies. We aimed to determine the clinicopathological, biological, and genomic characteristics of post-colonoscopy CRCs (PCCRCs).METHODS:Of the 1,619 consecutive patients with 1,765 CRCs detected between 2008 and 2016, 63 patients with 67 PCCRCs, when colonoscopies were performed 6–60 months before diagnosis, were recruited. After excluding patients with inflammatory bowel disease, familial polyposis syndrome, CRCs that developed from diminutive adenomatous polyps, and recurrent CRCs after endoscopic resection, 32 patients with 34 PCCRCs were enrolled. The lesions' clinicopathological features, mismatch repair proteins (MMRs), and genomic alterations were investigated.RESULTS:The overall PCCRC-5y rate, rate of intramucosal (Tis) lesions, and rate of T1 or more deeply invasive cancers were 3.7% (66/1,764), 3.9% (32/820), and 3.6% (34/944), respectively. Thirty-three patients' MMRs were investigated; 7 (21%) exhibited deficient MMRs (dMMRs), comprising 4 with T2 or more deeply invasive cancers and 5 whose lesions were in the proximal colon. Twenty-three tumors' genomic mutations were investigated; PIK3CA had mutated in 5 of 6 T2 or more deeply invasive cancers, of which, 4 were located in the proximal colon. Two patients with dMMRs and BRAFV600E mutations had poor prognoses. Sixty-one percent (17/28) of the macroscopic type 0 lesions were superficial. All superficial Tis and T1 PCCRCs were detected <24 months after the negative colonoscopies. They were distributed throughout the colon and rectum.DISCUSSION:PCCRCs may be invasive cancers in the proximal colon that exhibit dMMRs and/or PIK3CA mutations or missed early CRCs especially superficial lesions.

COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing—A New Paradigm Shift

ABSTRACT Colorectal cancer is the third leading cause of cancer related deaths and to date, the COVID-19 pandemic has led to major disruptions of the diagnosis and treatment pathways of this cancer, which may adversely affect survival outcomes for many years. Colorectal cancer pathways must be maintained at a near normal throughput with urgent attention to the backlog of patients to avoid a potential crisis of avoidable cancer deaths. A radical review and revamping of endoscopy services to improve efficiency during COVID-19 is urgently required. To date most endoscopy units have severely restricted their activity, except for time-critical diagnostic and therapeutic procedures. In the post- COVID-19 recovery phase, access to endoscopy services will increase but capacity will be reduced compared to before the pandemic, due to infection control measures. A pragmatic and safe strategy is urgently needed to clear the backlog of endoscopic procedures and for managing the new symptomatic referrals. We propose the use of non-invasive tests, such as FIT and mSEPT9 combined with “safety netting” to “rule out” colorectal cancer and to reduce the utilization of colonoscopy by up to 80% and limit the procedure to those patients at high risk of cancer.

Abstract C044: Inter-ethnic differential gene expression in stage II recurrent colorectal cancers

Abstract Inter-ethnic differential gene expression in stage II recurrent colorectal cancers Prachi Bajpai1, Amr Elholy1, Michael Behring1, Dongquan Chen2, 3, Kevin Hale1, Sumit Agrawal1, Hyung-Gyoon Kim1, Trafina Jadhav1, Temegsen Samuel4, Upender Manne1, 3 1Department of Pathology, 2Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA, 3O’Neal Comprehensive Cancer Center of UAB, Birmingham; 4Department of Pathobiology, College of Veterinary Medicine, Tuskegee University, Tuskegee, Alabama, USA Background and Objective: For colorectal cancer (CRC), the second most common cause of cancer-related death in the US, there are racial/ethnic disparities in incidence and mortality. Of these patients, 25-35% with pathologic Stage II CRCs exhibit recurrence after surgery with curative intent. Relative to Caucasian (CA) patients, African American (AA) patients with CRC have a 20% higher stage-specific mortality. The present study delineates a distinct gene expression profile, specific for Stage II CRCs, based on disease recurrence and patient race/ethnicity. Methods: We obtained gene expression profiles for Stage II CRCs from 16 AA and 30 CA patients by the use of Affymetrix GeneChip microarrays. Samples from patients with recurrent disease, within 5 years post-surgery, were compared to those with non-recurrent CRCs within 5 years post-surgery. For comparison between AA with CA patients, gene expression was assessed. Results: For recurrent CRCs, there were nine genes common to AA and CA patients, suggesting a common gene signature specific for Stage II disease. For tumors, relative to their corresponding normal tissues, there was higher expression of five of these genes; the direction of association with disease recurrence was distinct with race/ethnicity. GFM2, DCAF17, and GEN1 had a positive association with recurrence in CAs and a negative association with recurrence in AAs. Additionally, for recurrent patients, TAPBP and FEZ were upregulated in AAs and downregulated in CAs (False Discovery Rate &amp;lt;0.05 for all genes). BCL2L2, OXA1L, AHNAK2, and MEGF6 were consistently overexpressed in CRCs of both race/ethnicity groups. Currently, we are validating these findings in a prospective Stage II CRC cohort to correlate observations with time to recurrence. Conclusion: The present study identifies molecular signatures, specific for Stage II CRCs, for patients of two ethnic backgrounds, and contribute to a better understanding of the CRC health disparities for AAs and CA. This work was supported by a NIH/NCI grant (U54CA118948). Citation Format: Prachi Bajpai, Amr Elholy, Michael Behring, Dongquan Chen, Kevin Hale, Sumit Agrawal, Hyung-Gyoon Kim, Trafina Jadhav, Temegsen Samuel, Upender Manne. Inter-ethnic differential gene expression in stage II recurrent colorectal cancers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C044.

Outcomes from A Dedicated Complex Cancer Service for Locally Advanced and Recurrent Colorectal and Anal Cancers

Outcomes from A Dedicated Complex Cancer Service for Locally Advanced and Recurrent Colorectal and Anal Cancers

An 18-Year Experience in Diagnostic Laparoscopy of Peritoneal Carcinomatosis: Results from 744 Patients

BackgroundDespite accurate preoperative imaging assessment, optimal cytoreductive surgery with hyperthermic intraperitoneal chemotherapy remains unfeasible in many patients with peritoneal carcinomatosis at the time of surgery. The aim of this study was to evaluate the role of diagnostic laparoscopy in the selection of candidates. MethodsProspectively collected data of all patients undergoing diagnostic laparoscopy in our Department were retrospectively analyzed. Demographics and perioperative features as well as operative details and outcome were evaluated. ResultsThe study included 744 consecutive patients. Primary ovarian tumors were the most common indications, followed by gastric tumors and recurrent colorectal cancers. The procedure was successfully completed in 99.73% of cases. Approximately two thirds of them (68%) had undergone previous surgical procedures. The presence of ascites was recorded in 482 patients (64.78%). A total of 374 (50.3%) patients were excluded from surgical exploration. Among those who eventually underwent surgery, CC0 resection was obtained in 64.6% (239) of cases. Understaging of peritoneal carcinomatosis was observed in 11 patients (1.48%). Postoperative mortality was null and 5 (0.8%) complications were observed. Three (0.4%) port-site metastases were recorded at the beginning of the experience. ConclusionDiagnostic laparosocopy is a safe and feasible tool able to improve the selection of patients eligible for cytoreduction with hyperthermic intraperitoneal chemotherapy, at the same time allowing avoiding a significant number of unnecessary laparotomies.

New and Recurrent Colorectal Cancers After Resection: a Systematic Review and Meta-analysis of Endoscopic Surveillance Studies

Outcomes of endoscopic surveillance after surgery for colorectal cancer (CRC) vary with the incidence and timing of CRC detection at anastomoses or non-anastomoses in the colorectum. We performed a systematic review and meta-analysis to evaluate the incidence of CRCs identified during surveillance colonoscopies of patients who have already undergone surgery for this cancer. We searched PubMed, EMBASE, SCOPUS, and the Cochrane Central Register of Clinical Trials through January 1, 2018 to identify studies investigating rates of CRCs at anastomoses or other locations in the colorectum after curative surgery for primary CRC. We collected data from published randomized controlled, prospective, and retrospective cohort studies. Data were analyzed by multivariate meta-analytic models. From 2373 citations, we selected 27 studies with data on 15,803 index CRCs for analysis (89% of patients with stage I-III CRC). Overall, 296 CRCs at non-anastomotic locations were reported over time periods of more than 16 years (cumulative incidence, 2.2% of CRCs; 95% confidence interval [CI], 1.8%-2.9%). The risk of CRC at a non-anastomotic location was significantly reduced more than 36 months after resection compared with before this time point (odds ratio for non-anastomotic CRCs at 36-48 months vs 6-12 months after surgery, 0.61; 95% CI, 0.37-0.98; P= .031); 53.7% of all non-anastomotic CRCs were detected within 36 months of surgery. One hundred and fifty-eight CRCs were detected at anastomoses (cumulative incidence of 2.7%; 95% CI, 1.9%-3.9%). The risk of CRCs at anastomoses was significantly lower 24months after resection than before (odds ratio for CRCs atanastomoses at 25-36 months after surgery vs 6-12 months, 0.56; 95% CI, 0.32-0.98; P= .036); 90.8% of all CRCsat anastomoses were detected within 36 months of surgery. After surgery for CRC, the highest risk of CRCsat anastomoses and at other locations in the colorectum is highest during 36 months after surgery-risk decreases thereafter. Patients who have undergone CRC resection shouldbe evaluated by colonoscopy more closely during thistime period. Longer intervals may be considered thereafter.

Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis.

To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients. Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington. We identified patients aged ≥21 with de novo or recurrent breast (ndenovo =352; nrecurrent =765), colorectal (nde novo =1,072; nrecurrent =542), and lung (nde novo =4,041; nrecurrent =340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12months preceding, month of, and 12months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity. In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65. Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.

Intraoperative radiotherapy: review of techniques and results.

Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community.Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise.IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers).This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.

Differences in medical care costs for recurrent versus de novo stage IV cancer by age at diagnosis.

6611 Background: To address the paucity of data on costs of cancer recurrence, this study estimated medical care costs of patients diagnosed with recurrent breast, colorectal or lung cancer, and compared costs to patients diagnosed with de novo stage IV disease. Methods: Data from patients enrolled in three health plans who were diagnosed with de novo stage IV or recurrent breast (nstage IV = 352; nrecurrent= 765), colorectal (nstage IV = 1072 and nrecurrent= 542) and lung (nstage IV = 4042 and nrecurrent= 339) cancers between 2000-2012 were used to estimate total medical care costs in the 12 months preceding (pre-index), month of index, and 12 months following (post-index) diagnosis/recurrence date. Cancer patients were identified using tumor registry data. Recurrent cancers were validated by medical record abstraction and the RECUR algorithms –innovative tools to detect recurrence using claims and electronic health record data. We used generalized linear repeated measures regression models controlling for demographic and comorbidity variables to estimate costs (2012 US$), stratified by age at diagnosis (ages &lt; 65, ≥65). Results: Medical care cost differences in the pre-index period indicate higher costs for recurrent cancer patients than for stage IV breast (Age &lt; 65:+$2550; Age ≥65: +$1254), colorectal (Age &lt; 65:+$3295; Age ≥65: +$1653), and lung cancer patients (Age &lt; 65:+$3232; Age ≥65: +$2340). Conversely, in the index and post-index periods, costs for stage IV cancers were higher than recurrent cancer costs. Specifically, post-index period cost differences indicate higher costs for stage IV patients than for recurrent breast (Age &lt; 65:+$683; Age ≥65: +$1172), colorectal (Age &lt; 65:+$3104; Age ≥65: +$1557), and lung cancer patients (Age &lt; 65:+$1136; Age ≥65: +$1103). Conclusions: Our study provides medical care cost estimates of recurrent and de novo stage IV cancers. Cost differences between recurrent and stage IV cancers reveal heterogeneity in care patterns that merits further investigation. The reported study costs, measured in capitated care systems using standardized fee-for-service reimbursement coefficients, may serve as a benchmark for stage-specific phase-of-care oncology episode payment models.

Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study

ObjectivesRadical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team. MethodA retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model. ResultsThirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years. ConclusionLong-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.

Influence of intraoperative radiation therapy on locally advanced and recurrent colorectal tumors: A 16-year experience

BackgroundIntraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. MethodsA retrospective review (1999–2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. ResultsThere were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. ConclusionIORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.