Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE) : a multicentre, randomised, parallel, single-blinded trial

Background Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context. Methods In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1: 1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials. gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants. Findings Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1 . 65, 95% CI 0 . 80-3 . 40; p= 0 . 17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days. Interpretation MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered. Copyright (c) 2019 Elsevier Ltd. All rights reserved.Peer reviewe

Inflammation and invasive margin in colorectal cancer

Abstract Prognostic features of colorectal cancer (CRC) are important for determining the optimal treatment for an individual patient. This study was carried out to evaluate the significance of the prognostic significance of inflammatory cell reaction and tumour budding at the invasive front of the tumour in CRC patients, to study the pattern of alterations in the serum cytokine levels of CRC patients compared to healthy controls, and to evaluate whether the patterns of the cytokine levels alter according to the stage of disease. Study material consists of a series of CRC patients operated in Oulu University Hospital (N=466, studies I-II, and N=148, study III). The intensities of inflammatory cell reaction and tumour budding were estimated and the association of these features with survival was analysed (I-II). Preoperative serum samples were collected from patients and age- and sex-matched controls, and concentrations of 13 cytokines and chemokines were analysed (III). Inflammatory cell reaction and tumour budding at the tumour invasive margin were independent prognostic markers in CRC. In patients with stage I-II disease, high-grade inflammation was associated with better 5-year survival (87.6%) than low-grade inflammation (47.0%). Tumour budding was present in 24.0% of cases and predicted worse 5-year survival (15.4% in contrast to 63.5%). Serum levels of PDGF, IL-6, IL-7, and IL-8 were higher, and levels of MCP-1 were lower in CRC patients compared to controls. A pattern of five most predictive cytokines reached an excellent capacity in discriminating patients from healthy controls and reached an AUC of 0.890 in the ROC analysis. High-stage CRC was associated with increased levels of IL-6, IL-8 and IL-1ra, and metastasised disease was accompanied by an orientation to Th2 cytokine milieu. According to this study, patients with CRC can be stratified into different prognostic groups by assessing inflammatory cell reaction and tumour budding at the invasive front of the tumour. Evaluation of these features may give additional information for making treatment decisions. Serum cytokine profile was shown to change during cancer progression and seems promising in separating CRC patients from healthy controls, but its clinical value is yet to be confirmed.Tiivistelmä Kasvaimen ennusteeseen vaikuttavien tekijöiden tunteminen on tärkeää syöpäpotilaan yksilöllisen hoidon suunnittelussa. Tässä tutkimuksessa selvitettiin kasvaimen tulehdusreaktion ja kasvaimen reunan silmuilevan kasvutavan merkitystä kolorektaalisyöpäpotilaiden ennusteeseen. Lisäksi tutkimuksessa mitattiin tulehdusreaktion välittäjäaineiden, seerumin sytokiinien, pitoisuuksia potilailla ja verrokeilla sekä näiden pitoisuuksien vaihtelua suhteessa syövän levinneisyyteen. Tutkimusaineisto koostui Oulun yliopistollisessa sairaalassa leikatuista kolorektaalisyöpäpotilaista (N=466, tutkimukset I–II, N=148, tutkimus III). Kasvainnäytteistä tutkittiin kasvaimen tulehdusreaktion ja silmuilevan kasvutavan voimakkuutta ja arvioitiin näitä piirteitä suhteessa potilaiden elinaikatietoihin (tutkimukset I–II). Potilaiden ja verrokkihenkilöiden seeruminäytteistä mitattiin 13 sytokiinin pitoisuudet (tutkimus III). Kasvaimen tulehdusreaktio ja silmuileva kasvutapa osoittautuivat itsenäisiksi ennustetekijöiksi. Potilailla oli parempi 5-vuotisennuste (87.6 %), jos kasvaimen tulehdusreaktio oli voimakas verrattuna tapauksiin, joissa tulehdusreaktio oli heikko (47.0 %). 24 %:ssa kasvaimista kasvutapa oli silmuileva, ja näillä 5-vuotisennuste oli huonompi kuin ei-silmuilevissa (15.4 % vs. 63.5 %). Potilailla todettiin korkeammat seerumin PDGF, IL-6, IL-7, ja IL-8 -pitoisuudet ja matalammat MCP-1 -pitoisuudet kuin verrokeilla. Mittaamalla viiden ennustearvoltaan merkitsevimmän sytokiinin pitoisuudet voitiin potilaat luotettavasti erottaa verrokeista ROC-analyysin avulla, kun ROC-käyrän alle jäävä pinta-ala oli 0.890 %. Pidemmälle levinneissä taudeissa todettiin korkeampia IL-6, IL-8 ja IL-1ra -pitoisuuksia, ja etäpesäkkeisissä taudeissa sytokiinipitoisuudet muuttuivat Th2 -profiilin suuntaiseksi. Tutkimuksen mukaan kasvaimen tulehdusreaktion ja silmuilevan kasvutavan arvioinnilla kolorektaalisyöpäpotilaat voidaan jakaa ennusteellisiin ryhmiin, mitä on mahdollista hyödyntää hoidon suunnittelussa. Seerumin sytokiiniprofiilin osoitettiin muuttuvan taudin edetessä, ja sytokiinien pitoisuudet poikkeavat kolorektaalisyöpäpotilailla verrattuna terveiltä verrokeilta mitattuihin arvoihin

Annual hospital volume and colorectal cancer survival in a population-based nationwide cohort study in Finland

Abstract Purpose: To examine the annual hospital volume of surgery in relation to survival in colorectal cancer. Previous studies on hospital volume and survival following colorectal cancer surgery are conflicting. Methods: All 49 032 patients who underwent resection for colorectal cancer in 1987–2016 in Finland were included, with complete follow-up until December 31, 2019. Primary outcome was 5-year mortality. Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) for quartiles of annual hospital volume for colorectal surgery, adjusted for calendar period, age, sex, comorbidity, stage, tumor location and oncological therapy. Additionally, colon and rectal cancer surgery were assessed separately. Sensitivity analysis of patients with confirmed curative intent was conducted. Results: Compared to highest quartile (≥108 resections annually), lowest hospital volume (≤37 resections annually) was associated with slightly increased 5-year all-cause mortality (adjusted HR 1.07, 95% CI 1.02–1.12). A pre-planned subgroup-analysis suggested a slightly improved 5-year survival in high-volume institutions for rectal cancer, but not colon cancer surgery. Sensitivity analysis including only those operated with confirmed curative intent suggested no differences between hospital volume groups in colorectal, colon or rectal cancer for 5-year all-cause mortality. Conclusions: Higher hospital volume is associated with slightly improved all-cause 5-year mortality in colorectal cancer surgery, but this effect may be limited to rectal cancer surgery only. Volume-outcome relationship in rectal cancer surgery should be investigated further using large datasets. These results do not support centralization of colon cancer surgery based on hospital volume only

Divergent expression of bacterial wall sensing toll-like receptors 2 and 4 in colorectal cancer

Abstract Aim: To characterize the expression of toll-like receptors (TLR) 2 and 4 in colorectal cancer (CRC) and in normal colorectal mucosa. Methods: We analysed tissue samples from a prospective series of 118 unselected surgically treated patients with CRC. Sections from formalin fixed, paraffin embedded specimens were analysed for TLR2 and TLR4 expression by immunohistochemistry. Two independent assessors evaluated separately expression at the normal mucosa, at the invasive front and the bulk of the carcinoma, and in the lymph node metastases when present. Expression levels in different locations were compared and their associations with clinicopathological features including TNM-stage and the grade of the tumour and 5-year follow-up observations were analysed. Results: Normal colorectal epithelium showed a gradient of expression of both TLR2 and TLR4 with low levels in the crypt bases and high levels in the surface. In CRC, expression of both TLRs was present in all cases and in the major proportion of tumour cells. Compared to normal epithelium, TLR4 expression was significantly weaker but TLR2 expression stronger in carcinoma cells. Weak TLR4 expression in the invasive front was associated with distant metastases and worse cancer-specific survival at 5 years. In tumours of the proximal colon the cancer-specific survival at 5 years was 36.9% better with strong TLR4 expression as compared with those with weak expression (P = 0.044). In contrast, TLR2 expression levels were not associated with prognosis. Tumour cells in the lymph node metastases showed higher TLR4 expression and lower TLR2 expression than cells in primary tumours. Conclusion: Tumour cells in CRC show downregulation of TLR4 and upregulation of TLR2. Low expression of TLR4 in the invasive front predicts poor prognosis and metastatic disease

Decreased serum apolipoprotein A1 levels are associated with poor survival and systemic inflammatory response in colorectal cancer

Abstract Recent studies have reported of an association between high serum apolipoprotein A1 (APOA1) levels and favorable prognosis in several malignancies, while the significance of apolipoprotein B (APOB) in cancer is less well-known. In this study, we analyzed the correlation between serum APOA1 and APOB levels, and APOB/APOA1 ratio, and their associations with clinicopathologic parameters, the levels of twenty systemic inflammatory markers, and survival in 144 colorectal cancer (CRC) patients. We demonstrated that low serum APOA1 levels associated with advanced T-class and TNM-stage but low serum APOB levels did not significantly correlate with tumor characteristics. Serum APOA1 levels showed strong negative correlation with the markers of systemic inflammation including serum CRP and interleukin (IL)-8 levels and blood neutrophil count, whereas high serum APOB levels associated with high serum CCL2 levels. High APOA1 and APOB levels and low APOB/APOA1 ratio associated with improved cancer specific and overall survival. APOA1 had independent prognostic value in Cox regression analysis. In conclusion, low serum APOA1 levels are associated with advanced stage and systemic inflammation, while serum APOB does not significantly correlate with tumor stage. Serum APOA1 represents a promising additional prognostic parameter in CRC

Putative anoikis‐resistant subpopulations in colorectal carcinoma:a marker of adverse prognosis

Abstract Anoikis is a form of apoptosis induced when a cell loses contact with the extracellular matrix (ECM). Anoikis resistance is essential for metastasis formation, yet only detectable by in vitro experiments. We present a method for quantitation of putative anoikis‐resistant (AR) subpopulations in colorectal carcinoma (CRC) and evaluate their prognostic significance. We studied 137 CRC cases and identified cell subpopulations with and without stromal or extracellular matrix (ECM) contact with hematoxylin‐and‐eosin‐stained sections and immunohistochemistry for laminin and type IV collagen. Suprabasal cells of micropapillary structures and inner cells of cribriform and solid structures lacked both stromal contact and contact with ECM proteins. Apoptosis rate (M30) was lower in these subpopulations than in the other carcinoma cells, consistent with putative AR subpopulation. We determined the areal density of these subpopulations (number/mm² tumor tissue), and their high areal density independently indicates low cancer‐specific survival. In conclusion, we show evidence that subpopulations of carcinoma cells in micropapillary, cribriform, and solid structures are resistant to anoikis as shown by lack of ECM contact and low apoptosis rate. Abundance of these subpopulations is a new independent indicator of poor prognosis in CRC, consistent with the importance of anoikis resistance in the formation of metastasis

Sarcopenia and Myosteatosis Are Associated with Neutrophil to Lymphocyte Ratio but Not Glasgow Prognostic Score in Colorectal Cancer Patients

Cancer patients commonly present sarcopenia, myosteatosis, and systemic inflammation, which are risk factors of poor survival. In this study, sarcopenia and myosteatosis were defined from preoperative body computed tomography scans of 222 colorectal cancer (CRC) patients and analyzed in relation to tumor and patient characteristics, markers of systemic inflammation (modified Glasgow prognostic score (mGPS), neutrophil–lymphocyte ratio (NLR), serum levels of C-reactive protein (CRP), albumin, and 13 cytokines, and survival. Of the systemic inflammation markers, sarcopenia and/or myosteatosis associated with elevated NLR (p = 0.005) and low albumin levels (≤35 g/L) (p = 0.018), but not with mGPS or serum cytokine levels. In addition, myosteatosis was associated with a proximal tumor location (p = 0.039), serrated tumor subtype (p < 0.001), and severe comorbidities (p = 0.004). Multivariable analyses revealed that severe comorbidities and serrated histology were independent predictors of myosteatosis, and older age and elevated NLR were independent indicators of sarcopenia. Myosteatosis associated with shorter overall survival in univariable analysis (HR 1.959, 95% CI 1.24–3.10, p = 0.004) but not in multivariable analysis (p = 0.075). We conclude that sarcopenia and myosteatosis were associated with inflammatory marker NLR, but not with mGPS. Moreover, patients with serrated CRC may have an increased risk of myosteatosis. Myosteatosis or sarcopenia were not independent predictors of patient survival

Preoperative anemia in colorectal cancer:relationships with tumor characteristics, systemic inflammation, and survival

Abstract Anemia is common in colorectal cancer (CRC) but its relationships with tumor characteristics, systemic inflammation, and survival have not been well characterized. In this study, blood hemoglobin levels and erythrocyte mean corpuscular volume (MCV) levels were measured in two independent cohorts of 148 CRC patients and 208 CRC patients, and their correlation with patient and tumor characteristics, systemic inflammatory markers (modified Glasgow Prognostic Score: mGPS; serum levels of thirteen cytokines, C-reactive protein, albumin), and survival were analyzed. We found that anemia, most frequently normocytic, followed by microcytic, was present in 43% of the patients. Microcytic anemia was most commonly associated with proximal colon tumor location. Average MCV and blood hemoglobin levels were lower in tumors with high T-class. Low blood hemoglobin associated with systemic inflammation, including high mGPS and high serum levels of C-reactive protein and IL-8. Particularly, normocytic anemia associated with higher mGPS. Normocytic anemia associated with a tendency towards worse overall survival (multivariate hazard ratio 1.61, 95% confidence interval 1.07–2.42, p = 0.023; borderline statistical significance considering multiple hypothesis testing). In conclusion, anemia in CRC patients is most frequently normocytic. Proximal tumor location is associated with predominantly microcytic anemia and systemic inflammation is associated with normocytic anemia

Putative anoikis resistant subpopulations are enriched in lymph node metastases and indicate adverse prognosis in colorectal carcinoma

Abstract Anoikis refers to apoptosis induced by the loss of contact with the extracellular matrix. Anoikis resistance is essential for metastasis. We have recently shown that it is possible to quantitatively evaluate putative anoikis resistant (AR) subpopulations in colorectal carcinoma (CRC). Abundance of these multi-cell structures is an independent marker of adverse prognosis. Here, we have quantified putative AR subpopulations in lymph node (LN) metastases of CRC and evaluated their prognostic value and relationship with the characteristics of primary tumors. A case series included 137 unselected CRC patients, 54 with LN metastases. Areal densities (structures/mm²) of putative AR structures in primary tumors had been analyzed previously and now were determined from all nodal metastases (n = 183). Areal density of putative AR structures was higher in LN metastases than in primary tumors. Variation of the areal density within different LN metastases of a single patient was lower than between metastases of different patients. Abundance of putative AR structures in LN metastases was associated with shorter cancer specific survival (p = 0.013), and this association was independent of T and N stages. Abundance of putative AR structures in primary tumors and LN metastases had a cumulative adverse effect on prognosis. Enrichment of putative AR subpopulations in LN metastases suggest that in metastasis formation, there is a selection favoring cells capable of forming these structures. Higher intra-case constancy relative to inter-case variation suggests that such selection is stable in metastasis development. Our findings indirectly support the biological validity of our concept of putative AR structures