한국인 대장암 2기 환자에서 정량적 12-다중유전자 검사(Oncotype DXⓇ Colon Cancer Assay)의 유효성 분석 : 유전자 발현 차이에 기여하는 인종적 차이의 의미

Dept. of Medicine/석사Purpose: To evaluate the Recurrence Score® of the quantitative 12-multigene expression assay and to determine risk groups based on the continuous Recurrence Score® in Korean patients. Method: A total of 95 patients with pathological T3N0 tumors and mismatch repair-proficient tumors were enrolled. The Recurrence Score® was used to classify risk groups (low risk, <30; intermediate risk, 30–40; high risk, ≥41). Results: Fifty-four patients (56.8%) were aged over 70 years. There were 49 men (51.6%) and 56 cases of right-sided colon cancer (58.9%). Eight cases (8.4%) had well-differentiated tumors, and 86 cases (90.5%) showed moderate differentiation. Only one case (1.1%) had a poorly differentiated tumor. Three patients (3.2%) had lymphovascular invasion. Sixty-one patients were identified as low risk (64.2%) and 34 patients as intermediate risk (35.8%). There were no high-risk patients. Although not significant, the 3-year recurrence risk increased with the Recurrence Score®. Conclusion: Distribution patterns of risk groups based on the Recurrence Score®, particularly the absence of a high-risk group, were different from the prior validation studies. These findings suggest that ethnic differences between Koreans and Western patients are potential contributing factors for different gene expressions in the quantitative 12-multigene expression assay. 목적: 한국인 대장암 2기 환자에서 정량적 12-다중유전자 검사의 재발점수에 대한 평가와 재발점수에 따른 재발 위험군을 선별하고자 한다. 방법: MMR-p 이면서 병리학적으로 T3N0인 95명의 환자를 대상하였으며, 재발 점수에 따라 30점 이하는 저위험군, 30-40점은 중간위험군, 40점 이상은 고위험군으로 분류하였다. 결과: 54명(56.8%)의 환자는 70세 이상이었으며, 49명(51.6%)는 남성이었으며, 56명(58.9%)는 우측대장암이었다. 8명(8.4%)이 고분화암이었고, 86명(90.5%)은 중간분화암, 1명(1.1%)만이 저분화암이었다. 3명(3.2%)에서 림프혈관강전이가 있었다. 재발점수에 따른 위험도 분류상 61명(64.2%)은 저위험군, 나머지 34명(35.8%)은 중간위험군이었으며 고위험군 환자는 없었다. 통계학적 유의성은 없었으나, 재발점수가 증가할수록 3년 재발율이 증가하는 추세를 보였다. 결론: 재발점수에 따른 위험군 분류상 고위험군이 존재하지 않는 것은 다른 이전의 유사한 검증 연구에서와는 다른 결과이다. 이러한 결과는 한국인과 서양인 환자 사이의 인종적 차이가 정량적 12-다중유전자 검사에서 서로 다른 유전자 발현을 하게 만드는 잠재적 기여 요인이 될 수도 있다는 것을 암시한다.ope

Laparoscopic right hemicolectomy with complete mesocolic excision provides acceptable perioperative outcomes but is lengthy - analysis of learning curves for a novice minimally invasive surgeon.

BACKGROUND: Associated with reduced trauma, laparoscopic colon surgery is an alternative to open surgery. Furthermore, complete mesocolic excision (CME) has been shown to provide superior nodal yield and offers the prospect of better oncological outcomes. METHODS: All oncologic laparoscopic right colon resections with CME performed by a single surgeon since the beginning of his surgical practice were retrospectively analyzed for operative duration and perioperative outcomes. RESULTS: The study included 81 patients. The average duration of surgery was 220.0 (range 206-233) minutes. The initial durations of about 250 minutes gradually decreased to less than 200 minutes in an inverse linear relationship (y = -0.58x × 248). The major complication rate was 3.6% ± 4.2% and the average nodal yield was 31.3 ± 4.1. CumulativeSum analysis showed acceptable complication rates and oncological results from the beginning of surgeon's laparoscopic career. CONCLUSION: Developing laparoscopic skills can provide acceptable outcomes in advanced right hemicolectomy for a surgeon who primarily trained in open colorectal surgery. Operative duration is nearly triple that reported for conventional laparoscopic right hemicolectomy. The slow operative duration learning curve without a plateau reflects complex anatomy and the need for careful dissection around critical structures. Should one wish to adopt this strategy either based on some available evidence of superiority or with intention to participate in research, one has to change the view of right hemicolectomy being a rather simple case to being a complex, lengthy laparoscopic surgery.ope

Impact of Diabetes on Oncologic Outcome of Colorectal Cancer Patients: Colon vs. Rectal Cancer

BACKGROUND: To evaluate the impact of diabetes on outcomes in colorectal cancer patients and to examine whether this association varies by the location of tumor (colon vs. rectum). PATIENTS AND METHODS: This study includes 4,131 stage I-III colorectal cancer patients, treated between 1995 and 2007 (12.5% diabetic, 53% colon, 47% rectal) in South Korea. Cox proportional hazards modeling was used to determine the prognostic influence of DM on survival endpoints. RESULTS: Colorectal cancer patients with DM had significantly worse disease-free survival (DFS) [hazard ratio (HR) 1.17, 95% confidence interval (CI): 1.00-1.37] compared with patients without DM. When considering colon and rectal cancer independently, DM was significantly associated with worse overall survival (OS) (HR: 1.46, 95% CI: 1.11-1.92), DFS (HR: 1.45, 95% CI: 1.15-1.84) and recurrence-free survival (RFS) (HR: 1.32, 95% CI: 0.98-1.76) in colon cancer patients. No association for OS, DFS or RFS was observed in rectal cancer patients. There was significant interaction of location of tumor (colon vs. rectal cancer) with DM on OS (P = 0.009) and DFS (P = 0.007). CONCLUSIONS: This study suggests that DM negatively impacts survival outcomes of patients with colon cancer but not rectal cancer.ope

Patterns of physical activity participation across the cancer trajectory in colorectal cancer survivors

PURPOSE: The purpose of the present study was to explore the participation in physical activity (PA) by colorectal cancer survivors across cancer trajectories and based on selected demographic and medical variables. METHODS: A total of 431 participants were surveyed individually at the Shinchon Severance Hospital, Seoul, Korea, to determine their PA levels before diagnosis, during treatment and after completion of cancer treatment. RESULTS: Percentage of survivors meeting American College of Sports Medicine guideline significantly reduced from 27% before diagnosis to 10% during treatment due to reduced strenuous intensity PA (28.8 ± 106.2 vs. 11.8 ± 95.9 min, p = 0.042), while total PA and mild intensity PA did not change. Total (187.2 ± 257.7 vs. 282.6 ± 282.0 min, p < 0.001) and mild (99.1 ± 191.5 vs. 175.1 ± 231.2 min, p < 0.001) intensity PA significantly increased after the completion of treatments compared with their PA level before diagnosis. Further analyses showed that age (more vs. equal or less than 60 years) and chemotherapy (chemotherapy vs. no chemotherapy) significantly influenced the level of physical activity (p = 0.004). Survivors who were older or received chemotherapy increased their total PA and mild intensity PA after the completion of treatment more than those who did not receive chemotherapy. CONCLUSIONS: The level and the pattern of physical activity by colorectal cancer survivors differed across cancer trajectories, which were significantly influenced by age and adjuvant chemotherapy.ope

The effects of inpatient exercise therapy on the length of hospital stay in stages I-III colon cancer patients: randomized controlled trial

PURPOSE: This study aimed to examine the effects of a postsurgical, inpatient exercise program on postoperative recovery in operable colon cancer patients METHODS: We conducted the randomized controlled trial with two arms: postoperative exercise vs. usual care. Patients with stages I-III colon cancer who underwent colectomy between January and December 2011 from the Colorectal Cancer Clinic, were recruited for the study. Subjects in the intervention group participated in the postoperative inpatient exercise program consisted of twice daily exercise, including stretching, core, balance, and low-intensity resistance exercises. The usual care group was not prescribed a structured exercise program. The primary endpoint was the length of hospital stay. Secondary endpoints were time to flatus, time to first liquid diet, anthropometric measurements, and physical function measurements. RESULTS: A total of 31 (86.1 %) patients completed the trial, with adherence to exercise interventions at 84.5 %. The mean length of hospital stay was 7.82 ± 1.07 days in the exercise group compared with 9.86 ± 2.66 days in usual care (mean difference, 2.03 days; 95 % confidence interval (CI), -3.47 to -0.60 days; p = 0.005) in per-protocol analysis. The mean time to flatus was 52.18 ± 21.55 h in the exercise group compared with 71.86 ± 29.2 h in the usual care group (mean difference, 19.69 h; 95 % CI, -38.33 to -1.04 h; p = 0.036). CONCLUSIONS: Low-to-moderate-intensity postsurgical exercise reduces length of hospital stay and improves bowel motility after colectomy procedure in patients with stages I-III colon cancer.ope

Effects of a 12-week home-based exercise program on the level of physical activity, insulin, and cytokines in colorectal cancer survivors: a pilot study

PURPOSE: The purposes of this study are to examine (1) the feasibility and efficacy of two different home-based exercise protocols on the level of physical activity (PA), and (2) the effect of increased PA via home-based exercise program on biomarkers of colorectal cancer. METHODS: Seventeen patients (age 55.18 ± 13.3 years) with stage II-III colorectal cancer completed the 12-week home-based exercise program. Subjects were randomized into either casually intervened home-based exercise group (CIHE) or intensely intervened home-based exercise group (IIHE). The primary outcome was the level of PA. Furthermore, insulin, homeostasis model assessment of insulin resistance, insulin-like growth factor axis, and adipocytokines were measured. RESULTS: Both CIHE and IIHE program significantly increased the level of PA at 12 weeks compared to its level at baseline (CIHE, 10.00 ± 8.49 vs. 46.07 ± 45.59; IIHE, 12.08 ± 11.04 vs. 35.42 ± 27.42 MET hours per week). Since there was no difference in PA change between groups (p = 0.511), the data was combined in analyzing the effects of increased PA on biomarkers. Increase in PA significantly reduced insulin (6.66 ± 4.58 vs. 4.86 ± 3.48 μU/ml, p = 0.006), HOMA-IR (1.66 ± 1.23 vs. 1.25 ± 1.04, p = 0.017), and tumor necrosis alpha-α (TNF-α 4.85 ± 7.88 vs. 2.95 ± 5.38 pg/ml, p = 0.004), and significantly increased IGF-1 (135.39 ± 60.15 vs. 159.53 ng/ml, p = 0.007), IGF binding protein (IGFBP)-3 (2.67 ± 1.48 vs. 3.48 ± 1.00 ng/ml, p = 0.013), and adiponectin (6.73 ± 3.07 vs. 7.54 ± 3.96 μg/ml, p = 0.015). CONCLUSION: CIHE program was as effective as IIHE program in increasing the level of PA, and the increase in PA resulted in significant change in HOMA-IR, IGF-1 axis, TNF-α, and adiponectin levels in stage II-III colorectal cancer survivors.ope

Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer

Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients' short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case-control cohort studies with longer follow-up periods are required.ope