Jy-Ming Chiang

Effect of preoperative neutrophil–lymphocyte ratio on the surgical outcomes of stage II colon cancer patients who do not receive adjuvant chemotherapy

Background and aimsSelection of appropriate stage II colon cancer patients for adjuvant chemotherapy is critical for improving survival outcome. With the aim of identifying more high risk factors for stage II colon cancer, this study aimed to determine whether the neutrophil–lymphocyte ratio (NLR) is a predictor of surgical outcomes in patients with stage II colon cancer who do not receive adjuvant chemotherapy.Materials and methodsWe enrolled 1,040 stage II colon cancer patients who had undergone colectomy at a single institution between January 1995 and December 2005 and did not receive adjuvant chemotherapy.ResultsOf these 1,040 patients, 785 (75.5%) patients had a normal NLR and 255 (24.5%) had an elevated NLR. Those with an elevated NLR included patients ≥65xa0years, T4b cancer, carcinoembryonic antigen ≥5xa0ng/mL, and tumor obstruction or perforation. Patients with an elevated NLR had a significantly worse overall survival (OS) and worse disease-free survival (DFS) than did patients with a normal NLR. Cox regression analysis revealed that elevated NLR was an independent predictor of OS (P=0.012) but not DFS (P=0.255).ConclusionAn elevated NLR is an independent predictor of OS but not DFS in stage II colon cancer patients who did not receive adjuvant chemotherapy. Preoperative NLR measurement in stage II colon cancer patients may be a simple method for identifying patients with a poor prognosis who can be enrolled in further trials of adjuvant chemotherapy.

Favorable influence of age on tumor characteristics of sporadic colorectal adenocarcinoma: patients 30 years of age or younger may be a distinct patient group.

AbstractPURPOSE: Age is reported as a risk factor for carcinogenesis, even though age can affect cancer behavior both positively and negatively. Young patients with colorectal cancer reveal different tumor characteristics than average-age and older-age groups, although few studies report the influence of age among the entire range of patient ages. The influence of age on clinicopathologic characteristics of sporadic colorectal cancer was analyzed. Whether an age group with distinct tumor characteristics was present was determined. nMETHODS: A total of 5,436 patients who underwent colectomy in a single institute within a seven-year period were studied. Data on clinical and histopathologic features of colorectal cancer were collected from the cancer registry and medical records. These characteristics were analyzed according to ten-year age groups. nRESULTS: Eighty-three patients (1.6 percent) were 30 years of age or younger, whereas 285 (5.5 percent) were 31 to 40 years of age. Most patients (74.6 percent) were 51 to 80 years of age. The proportion of localized tumors (Dukes A and Dukes B) significantly increased as age increased, from 31.3 percent in the 30 years or younger age group to 49 percent in the 80 years or older group (P < 0.001). The proportion of poorly differentiated tumors tended to decreased as age increased (from 16.9 percent in the 30 years or younger group to 6.2 percent in the 80 years or older group; P = 0.009). A similar trend in the proportion of mucin-producing tumors was also observed (36 percent in the younger group vs. 7.5 percent in the older group; P < 0.001). There was no significantly different distribution of tumor locations among the different age groups. nCONCLUSIONS: Age appears to favorably influence the clinicopathological characteristics of sporadic colorectal cancer. As age increased, the characteristics of tumor stage at diagnosis, tumor differentiation, and mucin production improved.

Risk Factors for Lymph Node Metastasis in pT1 and pT2 Rectal Cancer: A Single-Institute Experience in 943 Patients and Literature Review

BackgroundLocal excision has become an alternative for radical resection in rectal cancer for selected patients. The purpose of this study was to assess the clinicopathologic factors determining lymph node metastasis (LNM) in patients with T1–2 rectal cancer.MethodsBetween January 1995 and December 2009, a total of 943 patients with pT1 or pT2 rectal adenocarcinoma received radical resection at a single institution. Clinicopathologic factors were evaluated by univariate and multivariate analyses to identify risk factors for LNM.ResultsA total of 943 patients (544 men and 399 women) treated for T1–2 rectal cancer were included in this study. LNM was found in 188 patients (19.9%). In multivariate analysis, lymphovascular invasion (LVI; Pxa0<xa00.001, hazard ratio 11.472), poor differentiation (PD; Pxa0=xa00.007, hazard ratio 3.218), and depth of invasion (presence of pT2; Pxa0=xa00.032, hazard ratio 1.694) were significantly related to nodal involvement. The incidence for LNM lesions in the presence of LVI, PD, and pT2 was 68.8, 50.0, and 23.1%, respectively, while that for pT1 carcinomas with no LVI or PD was 7.5%.ConclusionsLVI, PD, and pT2 are independent risk factors predicting LNM in pT1–2 rectal carcinoma.

Outcomes of resection for colorectal cancer hepatic metastases stratified by evolving eras of treatment

Background and purposeThe outcomes and management of colorectal cancer (CRC) hepatic metastasis have undergone many evolutionary changes. In this study, we aimed to analyze the outcomes of patients with CRC hepatic metastasis in terms of the era of treatment.MethodsWe conducted a retrospective review of 279 patients who underwent liver resection (LR) for CRC hepatic metastases. The prognoses of patients treated pre-2003 (era 1) and post-2003 (era 2) were examined.ResultsOf the patients included in the study, 210 (75.3%) had CRC recurrence after LR. There was a significant difference in the ratio of CRC recurrence between the 2 eras (82.0% in era 1 vs. 69.5% in era 2; p = 0.008). Analysis of recurrence-free and overall survival rates also showed that the patient outcome was significantly better in the post-2003 era than in the pre-2003 era. Further analysis showed that a significantly higher percentage of patients in era 2 had received modern chemotherapeutic regimens including irinotecan and oxaliplatin, while patients in era 1 were mainly administered fluorouracil and leucovorin for adjuvant chemotherapy. Among patients with CRC recurrence, a significant ratio of those in era 2 underwent surgical resection for recurrent lesions, and these patients had a better survival curve than did patients without resection (34.1% vs. 2.2% for 5-year survival; p < 0.0001).ConclusionThe incidence of CRC recurrence after LR for hepatic metastasis remains very high. However, the management and outcomes of patients with CRC hepatic metastasis have greatly improved with time, suggesting that the current use of aggressive multimodality treatments including surgical resection combined with modern chemotherapeutic regimens effectively prolongs the life expectancy of these patients.

Prognostic significance of the number of tumors and aggressive surgical approach in colorectal cancer hepatic metastasis

BackgroundAlthough liver resection (LR) for colorectal cancer (CRC) hepatic metastasis is the best strategy to improve patient outcomes, there are considerable concerns regarding the recurrence of CRC after LR. In this study, we investigated the prognostic indicators associated with CRC recurrence after LR for hepatic metastasis.MethodsThis is a retrospective review of patients who underwent curative LR for CRC hepatic metastasis between January 2008 and December 2012. The clinicopathological features and outcome parameters affecting prognosis were analyzed.ResultsA total of 332 LRs with curative intent were performed in 278 patients, of whom 168 (60.4%) experienced CRC recurrence after the first LR, and 206 of the 332 LRs (62.0%) developed CRC recurrence. A preoperative serum carcinoembryonic antigen level greater than 100 ng/mL and four or more metastatic tumor nodules were independent prognostic factors for CRC recurrence after LR. The disease-free survival rate after LR was significantly associated with the number of metastatic nodules. The patients who underwent surgical resection for recurrent CRC had favorable outcomes, with a five-year overall survival rate of 65.2%.ConclusionThe number of metastatic tumors significantly affects the outcomes of patients who undergo LR for CRC hepatic metastasis, indicating that a novel therapeutic strategy for patients at high risk may be required. However, favorable long-term outcomes are achievable through aggressive treatment with surgical resection of the recurrent CRC.

Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy

The quantitative relationship between serum albumin level and surgical outcomes has not been clearly established. This study included 3732 patients with colon cancer who underwent a potentially curative colectomy. Post-operative mortality and morbidity were analysed according to the patients demographic data, pre-operative comorbidities, and tumour-related factors. Age, asthma, renal impairment, and albumin level were significantly associated with post-operative morbidity and mortality in the multivariate analyses. Logistic regression analysis revealed linear relationships of post-operative morbidity and mortality with albumin level. The morbidity and mortality rates decreased by 7.3% and 15.6%, respectively, for each 0.1xa0g/dL increase in albumin level. This finding remained significant in the hypoalbuminaemia subgroup but not in the normoalbuminaemia subgroup. That is, the morbidity and mortality rates significantly decreased by 8.7% and 17.7%, respectively (both Pxa0<xa00.001), in the former group and decreased by 2.7% (Pxa0=xa00.112) and 11.6% (Pxa0=xa00.092), respectively, in the latter group. This study demonstrated that serum albumin level linearly predicted the post-operative morbidity and mortality among the colorectal cancer patients. Pre-operative serum albumin level may therefore be used as a continuous rather than a categorical marker of disease severity, especially among patients with hypoalbuminaemia.

Clinical features and prognosis in hepatectomy for colorectal cancer with centrally located liver metastasis.

BackgroundHepatic metastasectomy for patients with primary colorectal cancer offers better long-term outcome, and chemotherapy can increase the rate of hepatic resectability for patients with initially inoperable disease. The pattern of liver metastasis and status of the primary tumor are rarely discussed in the analysis of long-term outcome. In this report, we evaluate the influence of the pattern of metastasis on clinical features and prognosis.MethodsOne hundred and fifty-nine patients who underwent hepatic metastasectomy with curative intent for liver metastasis of colorectal cancer between October 1991 and December 2006 were enrolled. Patients were grouped according to whether liver metastasis was centrally or peripherally located, based on imaging and operative findings. Patient demographics, characteristics of the primary and metastatic tumors, and surgical outcomes were analyzed for long-term survival.ResultsA greater proportion of patients with centrally located metastases were male, as compared with those with peripherally located metastases. Compared with patients with peripherally located metastases, patients with centrally located metastases were more likely to have multiple lesions (P = 0.016), involvement of multiple segments (P = 0.006), large metastases (P < 0.001), and bilobar distribution of metastases (P < 0.001). The estimated 5-year recurrence-free and overall survival rates were 22.4% and 34.2%, respectively. Univariate analysis revealed that centrally located metastasis, primary tumor in the transverse colon, metastasis in regional lymph nodes, initial extrahepatic metastasis, synchronous liver metastasis, multiple lesions, poorly differentiated tumor, and resection margin <10 mm were significant poor prognostic factors for recurrence-free survival and overall survival. Cox regression analysis showed that inadequate resection margin and centrally located liver metastasis were significant predictors of shorter overall survival.ConclusionsIn colorectal cancer, centrally located liver metastasis represents a poor prognostic factor after hepatectomy, and is associated with early recurrence. Neoadjuvant chemotherapy may be used to downstage centrally located liver metastases to improve outcome.

Surgical resection of locally advanced primary transverse colon cancer--not a worse outcome in stage II tumor.

Background and aimsIn locally advanced primary transverse colon cancer, a tumor may cause perforation or invade adjacent organs. Extensive resection is the best choice of treatment, but such procedures must be weighed against the potential survival benefits. This study was performed to identify the clinicopathological features and treatment outcomes of such tumors.Materials and methodsWe retrospectively reviewed the database of the Colorectal Cancer Registry of Chang Gung Memorial Hospital between February 1995 and December 2005. Patients with colon cancer sited between the hepatic and splenic flexure that involved an adjacent organ without distant metastasis were defined as having locally advanced transverse colon cancer.ResultsA total of 827 patients who underwent surgery for transverse primary colon cancer were enrolled in the study. Stage II and stage III colon cancer were diagnosed in 548 patients. Thirty-two (5.8%) patients were diagnosed with locally advanced tumors. Multivariate analysis revealed that stage III, preoperative carcinoembryonic antigen ≥5xa0ng/mL, a tumor with perforation or obstruction, and the presence of a locally advanced tumor were significant prognostic factors for both overall and cancer-specific survival. Postoperative morbidity rates differed significantly between the locally advanced and non-locally advanced tumor groups (22.7% vs. 12.3%, Pu2009<u20090.01). No significant overall survival difference was observed among the stage II transverse colon tumors (Pu2009=u20090.21).ConclusionSurgical resection of locally advanced transverse colon tumors resulted in a higher morbidity and mortality than that of non-locally advanced tumors, but the benefit of extensive surgery in the case of locally advanced tumors cannot be underestimated. Furthermore, this benefit is more pronounced in the case of stage II tumors.

Preoperative alkaline phosphatase elevation was associated with poor survival in colorectal cancer patients

PurposePurpose To assess preoperative serum alkaline phosphatase (ALP) levels in colon adenocarcinomapatients with various clinical features and determine its prognostic value.MethodsBetween 2000 and 2013, 10,800 stage I-IV colon cancer patients who underwent surgery wereretrospectively enrolled. The relationship between ALP level and variables, including age, gender,carcinoembryonic Antigen (CEA) levels, aspartate aminotransferase (AST) level, bilirubin level, tumor size,liver cirrhosis, hepatitis, albumin level, histological type, and TNM-stage, were evaluated. The impact of ALP level elevation on survival was evaluated.ResultsSignificant elevations in ALP level were found in patients with CEA ≥5 ng/ml (p<0.001); AST |≥43 U/L (p<0.001); total bilirubin ≥1.5 U/L (p<0.001); liver cirrhosis (p<0.001); albumin; <3.5g/dL (p <0.001); and stage IV disease (p=0.03).Patients with elevated ALP levels had significantly worse 5-year overall survival (OS) for colon (5-year OSrate: 71.5% vs. 78.3%, p<0.001; Fig. 1a) and rectal (5-year OS rate: 64.5% vs. 72.3%, p<0.001; Fig. 1b)cancer than patients with normal ALP levels.ConclusionsElevated preoperative ALP levels was not only associated with liver disease, but it was alsorelated with advanced tumor status, and indicated a poor survival in colon and rectal cancer patients.

Clinical relevance of oncologic prognostic factors in the decision-making of pre-hepatectomy chemotherapy for colorectal cancer hepatic metastasis: the priority of hepatectomy

BackgroundAlthough liver resection (LR) provides the best chance of long-term survival for patients with colorectal cancer (CRC) hepatic metastasis, concerns regarding chemotherapy before liver resection remain unresolved.MethodsA retrospective review of patients who underwent curative LR for CRC hepatic metastasis between January 2008 and February 2016 was performed. Outcome relevance based on oncologic prognostic factors and chemotherapy prior to liver resection was assessed.ResultsPatients who had received pre-hepatectomy chemotherapy for CRC hepatic metastasis and delayed liver resection had a worse outcome in terms of CRC recurrence following liver resection. The hazard ratio (HR) of pre-hepatectomy chemotherapy in patients with minor oncologic prognostic factors was 1.55 (confidence interval, CIu2009=u20091.07–2.26, pu2009=u20090.021) for CRC recurrence after liver resection for hepatic metastasis, whereas the HR of pre-hepatectomy chemotherapy was 1.34 (CIu2009=u20090.99–1.81, pu2009=u20090.062) for CRC recurrence in patients with multiple oncologic prognostic factors.ConclusionThe administration of pre-hepatectomy chemotherapy and delaying liver resection seems not to be an optimal strategy to provide a clinical benefit for patients with CRC hepatic metastasis. Hence, liver resection should be attempted without delay at the initial detection of CRC hepatic metastasis whenever possible.