Right-sided Colon Cancer Research Articles

ROS1 genomic rearrangements are rare actionable drivers in microsatellite stable colorectal cancer.

c-Ros oncogene 1, receptor tyrosine kinase (ROS1) genomic rearrangements have been reported previously in rare cases of colorectal cancer (CRC), yet little is known about the frequency, molecular characteristics, and therapeutic vulnerabilities of ROS1-driven CRC. We analyzed a clinical dataset of 40 589 patients with CRC for ROS1 genomic rearrangements and their associated genomic characteristics (Foundation Medicine, Inc [FMI]). We moreover report the disease course and treatment response of an index patient with ROS1-rearranged metastatic CRC. ROS1 genomic rearrangements were identified in 34 (0.08%) CRC samples. GOPC-ROS1 was the most common ROS1 fusion identified (11 samples), followed by TTC28-ROS1 (3 samples). Four novel 5' gene partners of ROS1 were identified (MCM9, SRPK1, EPHA6, P4HA1). Contrary to previous reports on fusion-positive CRC, ROS1-rearrangements were found exclusively in microsatellite stable (MSS) CRCs. KRAS mutations were significantly less abundant in ROS1-rearranged vs ROS1 wild type cases. The index patient presented with chemotherapy-refractory metastatic right-sided colon cancer harboring GOPC-ROS1. Molecularly targeted treatment with crizotinib induced a rapid and sustained partial response. After 15 months on crizotinib disseminated tumor progression occurred and KRAS Q61H emerged in tissue and liquid biopsies. ROS1 rearrangements define a small, yet therapeutically actionable molecular subgroup of MSS CRC. In summary, the high prevalence of GOPC-ROS1 and noncanonical ROS1 fusions pose diagnostic challenges. We advocate NGS-based comprehensive molecular profiling of MSS CRCs that are wild type for RAS and BRAF and patient enrollment in precision trials.

Comparing 5-Year Survival Rates Before and After Re-stratification of Stage I–III Right-Sided Colon Cancer Patients by Establishing the Presence/Absence of Occult Tumor Cells and Lymph Node Metastases in the Different Levels of Surgical Dissection

BackgroundTo establish the impact of re-stratification on the outcomes of patients (stage I–III right-sided colon cancer) based on the presence/absence of occult tumor cells (OTC) and/or metastatic lymph nodes in the different levels of surgical dissection. MethodsConsecutive patients were drawn from a multicenter prospective trial. After surgery, the surgical specimen was divided into the D1/D2 and D3 volumes before being further analyzed separately. All lymph nodes were examined with cytokeratin CAM 5.2 immunohistochemically. Lymph nodes containing metastases and OTC (micrometastases; isolated tumor cells) were identified. Re-stratification was as follows: RS1, stages I/II, no OTC in D1/D2 and D3 volumes; RS2, stages I/II, OTC in D1/D2 and/or D3; RS3, stage III, lymph node metastases in D1/D2, with/without OTC in D3; RS4, stage III, lymph node metastases in D3, with/without OTC in D3. ResultsEighty-seven patients (39 men, 68.4 + 9.9 years) were included. The standard stratified (SS) group contained the following: stages I/II (SS1) 57 patients; stage III (SS2) 30 patients. Re-stratified (RS) contained RS1 (38), RS2 (19), RS3 (24), and RS4 (6) patients. Lymph node ratio (OTC) RS2: 0.157 D1/D2; 0.035 D3 and 0.092 complete specimens. Lymph node ratio RS3: 0.113 D1/D2; complete specimen 0.056. Overall survival and disease-free survival were p = 0.875 and p = 0.049 for SS and p = 0.144 and p = 0.001 for RS groups, respectively. ConclusionThis re-stratification identifies a patient group with poor prognosis (RS4). Removing this group from SS2 eliminates all the differences in survival between RS2 and RS3 groups. The level of dissection of the affected nodes may have an impact on survival. Clinical Trial“Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography” registered at http://clinicaltrials.gov/ct2/show/NCT01351714

Robot-assisted versus laparoscopic short- and long-term outcomes in complete mesocolic excision for right-sided colonic cancer: a systematic review and meta-analysis.

Complete mesocolic excision (CME) surgery is increasingly implemented for the resection of right-sided colonic cancer, possibly resulting in improved 5-year overall and disease-free survival compared to non-CME surgery. However, it is not clear what surgical platform should be used. The aim of this study was to compare the following outcomes between robot-assisted and laparoscopic CME-surgery for right-sided colonic cancer: (i) short-term clinical outcomes, (ii) pathological specimen quality, and (iii) long-term oncological outcomes. Medline, Embase, and Cochrane Database of Systematic Reviews were searched from inception until August 2021. Pooled proportions were calculated by applying the inverse variance method. Heterogeneity was explored by I-square and supplemented by sensitivity- and meta-regression analyses. The risk of bias was evaluated by either MINORS or Cochrane's risk-of-bias tool (RoB 2). Fifty-five studies with 5.357 patients (740 robot-assisted and 4617 laparoscopic) were included in the meta-analysis. Overall postoperative morbidity was 17% [95% CI (14-20%)] in the robot-assisted group and 13% [95%CI (12-13%)] in the laparoscopic group. Robot-assisted CME was associated with a shorter hospital stay, lower intraoperative blood loss, a higher amount of harvested lymph nodes, and better 3-year oerall and disease-free survival. MINORS and RoB2 indicated a serious risk of bias across studies included. This review which includes predominantly non-randomized studies suggests a possible advantage of the robot-assisted CME compared with a laparoscopic technique for several short-term outcomes.

Propensity-score-matched analysis of D2 and D3 right hemicolectomy for colon cancer.

Complete mesocolic excision with D3 lymph node dissection in right-sided colon cancer is associated with improved oncological outcomes, but can potentially be associated with higher rates of complications compared to conventional D2 right hemicolectomy. This study aims to evaluate the oncological and perioperative outcomes of patients who underwent D3 right hemicolectomy, comparing to conventional right hemicolectomy. From 2015 to 2020, 360 patients underwent right hemicolectomy for colonic malignancies. Data was retrospectively analysed from a prospectively collected database. A propensity-score-matched analysis was performed between the two groups to evaluate their outcomes. About 88(24.4%) patients underwent D3 right hemicolectomy, with the rest undergoing D2 right hemicolectomy. After propensity-matched analysis, D3 right hemicolectomy had a higher lymph node yield (median of 26 versus 23, p= 0.005), lower overall recurrence rate (11.7% versus 25.7%, p= 0.03), and lower overall mortality rate (14.5% versus 30.1%, p= 0.02) There were no significant differences in the complication rates. There were no anastomotic leaks. D3 right hemicolectomy was associated with an improved 3-year disease-free survival (DFS) with a hazard ratio of 0.63 (P= 0.21), and also an improved 3-year overall survival (OS) with a hazard ratio of 0.68 (P= 0.31). D3 right hemicolectomy is associated with a higher lymph node yield, without increasing morbidity or mortality. It is also associated with significantly lower recurrence and overall mortality rates in this study. Short term 3-year DFS and OS also trend towards favouring D3 right hemicolectomy. However, this study is limited by the small sample size and retrospective nature.

Clinical implication of the advanced lung cancer inflammation index in patients with right-sided colon cancer after complete mesocolic excision: a propensity score-matched analysis

BackgroundThis study aimed to assess the clinical implications of the advanced lung cancer inflammation index (ALI) in patients with right-sided colon cancer (RCC) after complete mesocolic excision (CME).MethodsA total of 441 patients with RCC who underwent CME were included. The optimal cut-off value for the ALI was determined using the X-tile software. Logistic and Cox regression analyses were used to identify risk factors for postoperative complications and long-term outcomes. Predictive nomograms for overall survival (OS) and disease-free survival (DFS) were constructed after propensity score matching (PSM), and their performance was assessed using the net reclassification improvement index (NRI), integrated discrimination improvement index (IDI), and time-dependent receiver operating characteristic (time-ROC) curve analysis.ResultsThe optimal preoperative ALI cut-off value was 36.3. After PSM, ASA classification 3/4, operative duration, and a low ALI were independently associated with postoperative complications in the multivariate analysis (all P<0.05). Cox regression analysis revealed that an age >60 years, a carbohydrate antigen 19-9 (CA19-9) level >37 U/mL, pathological N+ stage, and a low ALI were independently correlated with OS (all P<0.05). A CA19-9 level >37 U/mL, pathological N+ stage, lymphovascular invasion, and a low ALI were independent predictors of DFS (all P<0.05). Predictive nomograms for OS and DFS were constructed using PSM. Furthermore, a nomogram combined with the ALI was consistently superior to a non-ALI nomogram or the pathological tumor-node-metastasis classification based on the NRI, IDI, and time-ROC curve analysis after PSM (all P<0.05).ConclusionThe ALI was an effective indicator for predicting short- and long-term outcomes in patients with RCC.

Outcome and Evaluation of Intestinal Obstruction Due to Bands in Virgin Abdomen: A Prospective Study

Introduction: Some major hospitals and clinics still insist on exploratory surgery when they evaluate a case of Intestinal obstruction in a patient with an otherwise virgin abdomen. Objective: The purpose of this research is to identify the causes of SBO in people who have never performed abdominal surgery. Materials and Methods: Multicentered based nonrandomized quasi experimental prospective study was performed in Northern International Medical College, Dhaka, Bangladesh from January 2018 to December 2021.Total number of patients n=60 treated for Intestinal obstruction due to bands in virgin abdomen. Follow up data, operative and pathologic findings were examined to determine the etiology of SBO. Results: Sixty patients met inclusion criteria; abdominal exploration was performed in 50 patients (83%) and 10 patients (17%) were managed non-operatively. Exploration was therapeutic in 29 (58%), negative in 20 (40%) and non-therapeutic in one patient (2%). Overall, 8 patients (13%) were diagnosed with a malignancy: right-sided colon cancer (n=3), small bowel (SB) neuroendocrine tumor (n=2), SB lymphoma (n=2) and carcinomatosis peritonei (n=1); six patients were diagnosed at the time of the initial exploration and two patients were diagnosed during follow up. Upon Prospective Study, both SB neuroendocrine tumors and one SB lymphoma were visible on the initial imaging. Leukocytosis (p=.03) and no recent weight loss (p=.04) were associated with negative exploration. Conclusion: Patients with a "virgin abdomen" generally have a non-threatening form of Intestinal obstruction in its earliest stages. Careful evaluation of imaging investigations is required for spotting early warning symptoms of a more serious illness. If the patient prefers non-surgical treatment, they will need to have a recent colonoscopy and give relevant examination findings history.

A Clinical Risk Analysis of Postoperative Nausea and Vomiting After Colorectal Cancer Surgery

Abstract Objective Postoperative nausea and vomiting (PONV) is a frequent complication following colorectal surgery. The present study investigated the risk factors for PONV after colorectal cancer surgery. Methods A retrospective study of 204 patients who underwent surgery for colorectal cancer was conducted. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with PONV. Results The overall incidence of postoperative nausea (PON) and postoperative vomit (POV) was 26.5% (54/204), and 12.3% (25/204), respectively. The univariate analysis showed that female gender (p &lt; 0.001), no current alcohol drinking habit (p = 0.003), and no stoma creation (p = 0.023) were associated with PON. Postoperative vomit was significantly correlated with female gender (p = 0.009), high body mass index (p = 0.017), and right-sided colon cancer (p = 0.001). The multivariate logistic regression analysis revealed that female gender (odds ratio [OR]: 4.225; 95% confidence interval [CI]: 2.170–8.226; p &lt; 0.001) was an independent risk factor for PON. A high body mass index (OR: 1.148; 95%CI: 1.018–1.295; p = 0.025), and right-sided colon cancer (OR: 3.337; 95%CI: 1.287–8.652; p = 0.013) were independent risk factors for POV. Conclusion Our findings suggest that female gender for PON and a high body mass index and right-sided colon cancer for POV are risk factors after colorectal cancer surgery. An assessment using these factors might be helpful for predicting PONV.

American Indian/Alaska Native and black colon cancer patients have poorer cause-specific survival based on disease stage and anatomic site of diagnosis

ObjectivesStudies of race-specific colon cancer (CC) survival differences between right- vs. left-sided CC typically focus on Black and White persons and often consider all CC stages as one group. To more completely examine potential racial and ethnic disparities in side- and stage-specific survival, we evaluated 5-year CC cause-specific survival probabilities for five racial/ethnic groups by anatomic site (right or left colon) and stage (local, regional, distant). MethodsWe obtained cause-specific survival probability estimates from National Cancer Institute’s population-based Surveillance, Epidemiology, and End Results (SEER) for CC patients grouped by five racial/ethnic groups (Non-Hispanic American Indian/Alaska Native [AIAN], Non-Hispanic Asian/Pacific Islander [API], Hispanic, Non-Hispanic Black [NHB], and Non-Hispanic White [NHW]), anatomic site, stage, and other patient and SEER registry characteristics. We used meta-regression approaches to identify factors that explained differences in cause-specific survival. ResultsDiagnoses of distant-stage CC were more common among NHB and AIAN persons (>22 %) than among NHW and API persons (< 20 %). Large disparities in anatomic site-specific survival were not apparent. Those with right-sided distant-stage CC had a one-year cause-specific survival probability that was 16.4 % points lower (99 % CI: 12.2–20.6) than those with left-sided distant-stage CC; this difference decreased over follow-up. Cause-specific survival probabilities were highest for API, and lowest for NHB, persons, though these differences varied substantially by stage at diagnosis. AIAN persons with localized-stage CC, and NHB persons with regional- and distant-stage CC, had significantly lower survival probabilities across follow-up. ConclusionsThere are differences in CC presentation according to anatomic site and disease stage among patients of distinct racial and ethnic backgrounds. This, coupled with the reality that there are persistent survival disparities, with NHB and AIAN persons experiencing worse prognosis, suggests that there are social or structural determinants of these disparities. Further research is needed to confirm whether these CC cause-specific survival disparities are due to differences in risk factors, screening patterns, cancer treatment, or surveillance, in order to overcome the existing differences in outcome.

Short-term outcomes of intracorporeal versus extracorporeal anastomosis in laparoscopic surgery for right-sided colon cancer: A propensity score-matched study.

Recently, intracorporeal anastomosis (IA) has been attracting attention. We aimed to compare the short-term outcomes of IA and extracorporeal anastomosis (EA) in laparoscopic surgery for right-sided colon cancer, after propensity score matching. We retrospectively reviewed 404 consecutive patients with right-sided primary colon cancer between January 2019 and July 2021, 359 of whom underwent laparoscopic surgery. We classified them into IA (n=72) and EA (n=287) groups. Propensity score matching analysis was performed, and the matched groups were compared. The IA group had a longer operation time and shorter time to first flatus, passage of stool, and oral intake. There were no differences in blood loss, postoperative complications, and postoperative hospital stay between the groups. The IA group had a higher inflammatory response in the laboratory data on postoperative day 1 compared to the EA group; however, there were no differences in the incidence of abdominal or surgical site infection (SSI). The IA group had a longer distal resection margin, and there were no peritoneal recurrences in either group. In the IA group, patients had earlier bowel recovery and a longer distal resection margin; however, other postoperative clinical outcomes were comparable. Although there was a higher postoperative inflammatory response in IA, there was no significant difference in postoperative complications, including SSI and intra-abdominal infection. Although long-term outcomes are not yet available, IA could be a useful procedure.

Lymph node yield in the pathological staging of resected nonmetastatic colon cancer: The more the better?

IntroductionGuidelines recommend regional lymphadenectomy with a lymph node yield (LNY) of at least 12 lymph nodes (LN) for adequate colon cancer (CC) staging. LNY ≥22LN may improve survival, especially in right-sided CC [Lee et al., Surg Oncol, 27(3), 2018]. This multicentric retrospective cohort study evaluated the impact of LNY and tumor laterality on CC staging and survival. Materials and methodsPatients with stage I-III CC that underwent surgery from 2012 to 2018 were grouped according to LNY: <22 and ≥ 22. Primary outcomes were LN positivity (N+ rate) and disease-free survival (DFS). Overall survival (OS) was the secondary outcome. Exploratory analyses were performed for laterality and stage. ResultsWe included 795 patients (417 < 22LN, 378 ≥ 22LN); 53% had left-sided CC and 29%/37%/38% had stage I/II/III tumors. There was no association between LNY ≥22LN and N+ rate after adjustment for grade, T stage, lymphovascular invasion (LVI) and perineural invasion; a trend for a higher N+ rate in left-sided CC was identified (interaction p = 0.033). With a median follow-up of 63.6 months for DFS and 73.2 months for OS, 254 patients (31.9%) relapsed and 207 (26.0%) died. In multivariate analysis adjusted for age, ASA score, laparoscopic approach, T/N stage, mucinous histology, LVI and adjuvant chemotherapy, LNY ≥22LN was significantly associated with both DFS (HR 0.75, p = 0.031) and OS (HR 0.71, p = 0.025). Restricted cubic spline analysis showed a more significant benefit for right-sided CC. ConclusionLNY ≥22LN was associated with longer DFS and OS in patients with operable CC, especially for right-sided CC.

Outcomes of right-sided and left-sided colon cancer after curative resection

The right and left side of the colon derived from the midgut and hindgut, respectively. Previous studies have reported different characteristics of right-sided colon cancer (RCC) and left-sided colon cancer (LCC), but oncological outcomes remain unclear. This study compared the outcomes of RCC and LCC. This retrospective study included 1017 patients who received curative colectomy for stage I-III colon cancer at a single institute between August 2008 and December 2019. Overall survival (OS) and time to recurrence (TTR) were analyzed as outcome measurements. No significant difference in the OS or TTR of patients with RCC and LCC were observed. In subgroup analysis, RCC was associated with shorter TTR than LCC in stage II colon cancer (HR 2.36, 95% confidence interval 1.24–4.48, p < 0.01). Multivariate analysis demonstrated that right sidedness, R1 resection, low body mass index (BMI) and adjuvant chemotherapy were independent factors for poor prognosis for stage II colon cancer. Low BMI, perineural invasion, higher T stage and N2 stage were independent factors for poor prognosis for stage III colon cancer. The results were confirmed by multivariate analysis after propensity score matching. Our study revealed that RCC was an independent risk factor for recurrence in stage II colon cancer.

Consensus statements on complete mesocolic excision for right-sided colon cancer—technical steps and training implications

BackgroundCME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways.MethodsGuidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus.ResultsTwenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme.ConclusionsConsensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies.

Pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy?

BackgroundConventional Right Colectomy with D2 lymphadenectomy (RC-D2) currently represent the most common surgical treatment of right-sided colon cancer (RCC). However, whether it should be still considered a standard of care, or replaced by a routine more extended D3 lymphadenectomy remains unclear. In the present study, we aim to critically review the patterns of relapse and the survival outcomes obtained from our 11-year experience of RC-D2.MethodsClinical data of 489 patients who underwent RC-D2 for RCC at two centres, from January 2009 to January 2020, were retrospectively reviewed. Patients with synchronous distant metastases and/or widespread nodal involvement at diagnosis were excluded. Post-operative clinical–pathological characteristics and survival outcomes were evaluated including the pattern of disease relapse.ResultsWe enrolled a total of 400 patients with information follow-up. Postoperative morbidity was 14%. The median follow-up was 62 months. Cancer recurrence was observed in 55 patients (13.8%). Among them, 40 patients (72.7%) developed systemic metastases, and lymph-node involvement was found in 7 cases (12.8%). None developed isolated central lymph-node metastasis (CLM), in the D3 site. The estimated 3- and 5-year relapse-free survival were 86.1% and 84.4%, respectively. The estimated 3- and 5-year cancer-specific OS were 94.5% and 92.2%, respectively.ConclusionsThe absence of isolated CLM, as well as the cancer-specific OS reported in our series, support the routine use of RC-D2 for RCC. However, D3 lymphadenectomy may be recommended in selected patients, such as those with pre-operatively known CLM, or with lymph-node metastases close to the origin of the ileocolic vessels.

Is a cutoff value of 12 still useful in stage II right-sided colon cancer without risk factors?

Various clinical practice guidelines recommend at least 12 regional lymph nodes should be removed for resected colon cancer. According to a recent study, the lymph node yield (LNY) in colon cancer surgery in the last 20 years has tended to increase from 14.91 to 21.30. However, it is unclear whether these guidelines adequately reflect recent findings on the number of harvested lymph nodes in colon cancer surgery. The aim of this study is to assess the impact of an LNY of more than 25 on survival in right-sided colon cancer. We included 285 patients who underwent a right hemicolectomy during the period from January 2010 through December 2015. Patients were divided into two groups (<25 nodes and ≥25 nodes). Primary endpoints included 5-year and 10-year survival including disease-free and overall. We found that survival outcomes of patients with a harvest of ≥25 nodes were not significantly different compared with a <25 group. Large tumor size (5 cm) is significantly associated with poor 5-year and 10-year overall survival. Survival outcomes of patients with a harvest of ≥25 nodes were not significantly different compared with the <25 group in stage II colon cancer with no risk.

The gut microbiota composition in patients with right- and left-sided colorectal cancer and after curative colectomy, as analyzed by 16S rRNA gene amplicon sequencing

BackgroundGut pathological microbial imbalance or dysbiosis is closely associated with colorectal cancer. Although there are observable differences in molecular and clinical characteristics between patients with right- and left-sided colon cancer, differences in their gut microbiomes have not been thoroughly investigated. Furthermore, subsequent changes in microbiota status after partial colectomy remain unknown. We examined the human gut microbiota composition to determine its relationship with colon cancer and partial colon resection according to location.MethodsStool samples from forty-one subjects (10 in the control group, 10 in the right-sided colon cancer [RCC] group, 6 in the sigmoid colon cancer [SCC] group, 9 in the right colon resection [RCR] group and 6 in the sigmoid colon resection [SCR] group) were collected, and DNA was extracted. After terminal restriction fragment length polymorphism (T-RFLP) analysis, the samples were subjected to 16S rRNA gene amplicon sequencing, and the metabolic function of the microbiota was predicted using PICRUSt2.ResultsT-RFLP analysis showed a reduced ratio of clostridial cluster XIVa in the SCC patients and clostridial cluster IX in the RCC patients, although these changes were not evident in the RCR or SCR patients. 16S rRNA gene amplicon sequencing demonstrated that the diversity of the gut microbiota in the RCC group was higher than that in the control group, and the diversity in the SCR group was significantly higher than that in the RCR group. Principal coordinate analysis (PCoA) revealed significant differences according to the group. Analyses of the microbiota revealed that Firmicutes was significantly dominant in the RCC group and that the SCC group had a higher abundance of Verrucomicrobia. At the genus level, linear discriminant analysis effect size (LEfSe) revealed several bacteria, such as Ruminococcaceae, Streptococcaceae, Clostridiaceae, Gemellaceae, and Desulfovibrio, in the RCC group and several oral microbiomes in the SCC group. Metabolic function prediction revealed that cholesterol transport- and metabolism-related enzymes were specifically upregulated in the RCC group and that cobalamin metabolism-related enzymes were downregulated in the SCC group.ConclusionGut microbial properties differ between RCC and SCC patients and between right hemicolectomy and sigmoidectomy patients and may contribute to clinical manifestations.

Blood-Cell-Based Inflammatory Markers as a Useful Tool for Early Diagnosis in Colorectal Cancer.

BackgroundSystemic inflammation seems to be involved in the pathogenetic pathways of colorectal cancer (CRC). Analytical markers that reflect the inflammatory status, such as neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) or systemic immune-inflammation index (SII), have been proposed as tools for the prognosis of CRC. Nevertheless, their use for diagnosis has been scarcely investigated.AimsTo analyze the ability of these markers and of a new marker combining SII and hemoglobin concentration, named NP/LHb = [neutrophils x platelets]/[lymphocytes x hemoglobin], as tools for CRC diagnosis. Furthermore, we studied their association with CRC-related variables.MethodsCase-control study including 214 CRC patients and 214 controls without CRC, matched by age (±5 years) and sex. We collected demographic, CRC-related and laboratory variables to calculate NLR, PLR, SII, and NP/LHb. In the case group, the laboratory variables were collected at two different period times, 6 months (IQR 4–8) before the CRC diagnosis and at the time of the diagnosis. ROC analysis was performed to evaluate the discriminatory accuracy of each index and we calculated Se, Sp, PPV, NPV, and OR to identify the diagnostic performance of each positive marker.ResultsNP/LHb showed high Sp (92.06%) and PPV (87.50%) to diagnose patients with CRC. This index exhibited an OR of 14.52 (8.26–25.52) and the best area under the curve (AUC: 0.78) for a positive CRC diagnosis. We found significant differences in all indices according to the presence of CRC, observing the highest values in CRC patients at time of diagnosis, in comparison with the analysis performed in the previous months to diagnosis or with control patients. There were significant differences in all ratios according to TNM stages (p < 0.05). PLR, SII and NP/LHb (but not NLR) showed significant differences according to tumor location (p < 0.05). Right-sided colon cancers presented the highest values, in comparison with left-sided and rectal cancers.ConclusionsSystemic inflammatory cell ratios (especially NP/LHb) change over time with the development of CRC, so they could be useful in its early diagnosis. We suggest that they could be routinely measured in patients with suspicion of CRC, to identify those ones with a higher risk of cancer, considering the high positive predictive value they have shown in our study.

Oncological impact of vascular invasion in colon cancer might differ depending on tumor sidedness.

PurposeVascular invasion is a well-known independent prognostic factor in colon cancer and tumor sidedness is also being considered a prognostic factor. The aim of this study was to compare the oncological impact of vascular invasion depending on the tumor location in stages I to III colon cancer.MethodsA retrospective analysis was performed using data from patients who underwent curative resection between 2004 and 2015. Patients were divided into right-sided colon cancer (RCC) and left-sided colon cancer (LCC) groups according to the tumor location. Disease-free survival (DFS) and overall survival (OS) were compared between the RCC and LCC groups, depending on the presence of vascular invasion.ResultsA total of 793 patients were included, of which 304 (38.3%) had RCC and 489 (61.7%) had LCC. DFS and OS did not differ significantly between the RCC and LCC groups. Vascular invasion was a poor prognostic factor for DFS in both RCC (hazard ratio [HR], 2.291; 95% confidence interval [CI], 1.186–4.425; p = 0.010) and LCC (HR, 1.848; 95% CI, 1.139–2.998; p = 0.011). Additionally, it was associated with significantly worse OS in the RCC (HR, 3.503; 95% CI, 1.681–7.300; p < 0.001), but not in the LCC group (HR, 1.676; 95% CI, 0.885–3.175; p = 0.109). Multivariate analysis revealed that vascular invasion was independently poor prognostic factor for OS in the RCC (HR, 3.186; 95% CI, 1.391–7.300; p = 0.006).ConclusionThis study demonstrated that RCC with vascular invasion had worse OS than LCC with vascular invasion.

Laparoscopic right hemicolectomy with a cranial-first approach for right-sided colon cancer.

Laparoscopic right hemicolectomy with a cranial-first approach for right-sided colon cancer.

Hide and Seek: Dysplasia Camouflage in a Patient With Barrett’s Esophagus

Question: An 84-year-old man presenting with fatigue was referred for endoscopy owing to anemia. On his esophagogastroduodenoscopy, a segment of Barrett’s esophagus (BE) was seen (Prague classification C2M4). Random biopsies were obtained as per the Seattle protocol. Histology revealed at least one specimen harboring high-grade dysplasia. He had ascending colon adenocarcinoma on colonoscopy. The BE segment was subsequently reassessed using white light, narrow band imaging (NBI), acetic acid chromoendoscopy, and high magnification. In a proximal tongue, there was an area appeared to have an irregular microvasculature. This was presumed to be the dysplastic lesion (Figure A; NBI). A clear demarcation line was noted between the distal nondysplastic segment and the irregular microvasculature of the proximal dysplastic area (Figure B; NBI and near focus). A decision was made to initially resect the BE segment using the endoscopic submucosal dissection (ESD) technique and operate the right-sided colon cancer at the same season in the following weeks. He continued his proton pump inhibitor (PPI) in the interim. While reassessing the lesion before performing ESD 0 month later, the previously identified dysplastic lesion was no longer identified (Figure C; white light). What is the most likely explanation and what is the best way to manage the case? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Further careful examination with NBI and magnification revealed an area of brownish discoloration below re-epithelialized mucosa (Figure D). The area to resect could not be ascertained, but the NBI and magnification images combined with the previously known location of the dysplastic area were used as landmarks to proceed with an ESD (Figure E, F). On histology, the dysplastic BE was buried underneath normal appearing squamous cell epithelium (Figure G; stain: hematoxylin and eosin). The dysplastic glandular proliferation showed focally fused glands formed by atypical, mitotically active epithelial cells without goblet cells. The dysplastic elements did not involve the muscularis mucosae nor the submucosa. This unique case demonstrates that re-epithelialization of a Barrett’s mucosa can occur within a short time interval. While managing BE, endoscopists should be aware of the acceleration of re-epithelization and the potential concealing of dysplastic cells under normal-appearing epithelial tissue such as presented here. Some evidence has shown that acid suppression can lead to this occurrence. A study of 26 patients examining the effect of high-dose lansoprazole on BE found that squamous islands were developed in 77% of the patients by the final visit.1Sampliner R.E. Effect of up to 3 years of high-dose lansoprazole on Barrett’s esophagus.Am J Gastroenterol. 1994; 89: 1844-1848PubMed Google Scholar In the study, squamous re-epithelization and subsequent burying of the dysplasia below the surface could be attributed to high-dose PPI use. It is, thus, paramount to carefully inspect the whole BE segment and beyond its obvious extent, especially in patients on a PPI. Likewise, this observation highlights the utmost importance of careful inspection and precise documentation of the location of dysplasia in BE during endoscopy. Applying advanced imaging techniques in addition to the white light may facilitate the visibility and improve the diagnostic and interventional precision.2Qumseya B. Sultan S. Bain P. et al.ASGE guideline on screening and surveillance of Barrett’s esophagus.GIE Journal. 2019; : 335-359Google Scholar

P-229 Comparison of clinicopathological and survival features of right and left colon cancers: Experience of the medical oncology department of Fez

Right-sided colon cancers (RCC) and left-sided colon cancers (LCC) have different epidemiological, physiological, pathological, genetic, and clinical characteristics, which result in differences in the course, prognosis, and outcome of disease. The objective of our study is to compare right-sided colon cancers and left-sided colon cancers regarding clinicopathological and survival characteristics. This is a retrospective study of 664 patients with colon cancer treated at the medical oncology department of Fez over a period from December 2009 to September 2020. Rectosigmoid, descending colon, and splenic flexure tumors were considered left-sided colon cancers, whereas ascending colon tumors were considered right-sided colon cancers. The Kaplan Meier method was used to estimate median survival. The study included 664 patients (female, 47 %) having colon cancer with a median age of 60years [23-83]. Of the patients, 78.5% (n=519) had LCC and 19.36 % (n=128) had RCC. The rate of patients aged ≥65 years and the rate of patients with a family history of colon cancer were higher in the LCC patients. The proportion of poorly differentiated adenocarcinomas represented 3%, of which 63% had cancer of the right colon. There was a significantly higher proportion of higher T stage (T3-4 :62%vs 38 %) in right sided tumors as compared to left sided tumors. The rate of metastatic patients was 64.1% in the RCC group and 43% in the LCC group. The median follow-up period was 14 months in the RCC group and 19 months in the LCC group with a higher median overall survival in the LCC group (32 vs 21 months). We found histopathological differences between right and left sided colon cancer. Tumors on the right colon were found to be more aggressive, as expressed by poorer differentiation, higher T stage associated with a median overall survival better in left colon cancer.