The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

The burden of incontinence in a real-world data environment—insights from a digital patient companion

Introduction and hypothesis!#!Urinary incontinence (UI) has a potentially devastating effect on women's quality of life (QoL). Conservative treatment by means of pelvic floor muscle training is the first-choice treatment modality. Nowadays, this can be supported by digital apps like pelvina©-a digital health companion pelvic floor course.!##!Methods!#!Using pelvina©, UI symptoms and QoL are regularly examined through the questionnaires QUID and SF-6D. Subsequently, we analyzed the incidence and degree of UI and its impact on QoL in 293 users in a real-world environment.!##!Results!#!The 293 patients included in this study had a median age of 36 years and a median of two children. Patients were slightly to moderately affected by UI with a QUID of 6 (2-11, maximum 24). Age and number of children were independently associated with the incidence of UI with an adjusted odds ratio (aOR) of 1.06 (95% CI 1.01-1.12) and aOR of 1.86 (95% CI 1.12-3.08). The severity of UI strongly correlated with impairment of QoL (ρ = 0.866, P &amp;lt; 0.001).!##!Conclusions!#!The use of real-world data generated by digital health solutions offers the opportunity to gain insight into the reality of patients' lives. In this article, we corroborate the known associations between number of children and UI as well as the great influence UI has on QoL. This study shows that, in the future, the use of digital apps can make an important contribution to scientific data acquisition and, for example, therapy monitoring

Analyzing non-sentinel axillary metastases in patients with T3–T4 cN0 early breast cancer and tumor-involved sentinel lymph nodes undergoing breast-conserving therapy or mastectomy

Purpose!#!In the ACOSOG Z0011 trial, completing axillary lymph node dissection (cALND) did not benefit patients with T1-T2 cN0 early breast cancer and 1-2 positive sentinel lymph nodes (SLN) undergoing breast-conserving surgery (BCT). This paper reports cALND rates in the clinical routine for patients who had higher (T3-T4) tumor stages and/or underwent mastectomy but otherwise met the ACOSOG Z0011 eligibility criteria. Aim of this study is to determine cALND time trends and non-sentinel axillary metastases (NSAM) rates to estimate occult axillary tumor burden.!##!Methods!#!Data were included from patients treated in 179 German breast cancer centers between 2008 and 2015. Time-trend rates were analyzed for cALND of patients with T3-T4 tumors separated for BCT and mastectomy and regarding presence of axillary macrometastases or micrometastases.!##!Results!#!Data were available for 188,909 patients, of whom 19,009 were identified with 1-2 positive SLN. Those 19,009 patients were separated into 4 cohorts: (1) Patients with T1-T2 tumors receiving BCT (ACOSOG Z0011 eligible; n = 13,741), (2) T1-T2 with mastectomy (n = 4093), (3) T3-T4 with BCT (n = 269), (4) T3-T4 with mastectomy (n = 906). Among patients with T3-T4 tumors, cALND rates declined from 2008 to 2015: from 88.2 to 62.6% for patients receiving mastectomy and from 96.6 to 58.1% in patients receiving BCT. Overall rates for any NSAM after cALND for cohorts 1-4 were 33.4%, 42.3%, 46.9%, 58.8%, respectively.!##!Conclusions!#!The cALND rates have decreased substantially in routine care in patients with 'extended' ACOSOG Z0011 eligibility criteria. Axillary tumor burden is higher in these patients than in the ACOSOG Z0011 trial

Internalization of Met Requires the Co-Receptor CD44v6 and Its Link to ERM Proteins

<div><p>Receptor Tyrosine Kinases (RTKs) are involved in many cellular processes and play a major role in the control of cell fate. For these reasons, RTK activation is maintained under tight control. Met is an essential RTK that induces proliferation, differentiation, migration, survival and branching morphogenesis. Deregulation of Met by overexpression, amplification or lack of effective degradation leads to cancer and metastasis. We have shown that Met relies on CD44v6 for its activation and for signaling in several cancer cell lines and also in primary cells. In this paper, we show that internalization of Met is dependent on CD44v6 and the binding of Ezrin to the CD44v6 cytoplasmic domain. Both CD44v6 and Met are co-internalized upon Hepatocyte Growth Factor induction suggesting that Met-induced signaling from the endosomes relies on its collaboration with CD44v6 and the link to the cytoskeleton provided by ERM proteins.</p></div

Colocalization of Met and CD44v6 in Rab5 positive endosomes upon HGF stimulation.

<p>(<b>A</b>) HeLa cells were transfected with mRFP-Rab5 wild type and human CD44v6. After 24 hours the cells were serum starved and treated with 50 µM cycloheximide for 2 hours. Cells were stimulated with 25 ng/ml HGF for 1hour on ice (cold start) and subsequently shifted to 37°C for the indicated time. Cells were fixed, permeabilized, and stained for Met (green) and CD44v6 (cyan) with specific antibodies (Materials and Methods). Nuclei were stained with Dapi (blue) and images were taken with a confocal microscope (Leica SPE) using a 63× objective. The last image is an enlargement of the square indicated in the middle image. Intensity profiles of the respective emission wavelengths of the mRFP-Rab5, Met, and CD44v6 signals were measured along lines drawn across the plasma membrane (a) or across vesicles (b,c). (<b>B</b>) HeLa cells were transfected with a constitutive active Rab5-GFP construct (Rab5 Q79L-GFP) and a human CD44v6 construct (see Materials and Methods) and treated as in A. Rab5 Q79L-GFP (green), Met (red), CD44v6 (cyan), Dapi (blue). Intensity profiles of the respective emission wavelengths of Rab5 Q79L-GFP, Met and CD44v6 are shown on the right side for the indicated endosomes at 15 minutes. Intensity profiles corresponding to the plasma membrane (a) and to an endosome (b) are included for the 0 minute time point (below).</p

The link between CD44v6 and the cytoskeleton through Ezrin is required for Met internalization.

<p>(<b>A</b>) HeLa cells were transfected with a rat CD44v4-7 construct deleted from the cytoplasmic domain (CD44v4-7Δcyt) or a control vector. The kinetic of Met internalization upon HGF induction was measured in a MESNA experiment (Material and Methods). In the first sample cells were kept at 4°C. –M refers to a sample obtained from cells that were not treated with MESNA. The Western Blot analysis was performed with a Met specific antibody and the rat specific CD44v6 antibody 1.1ASML (Material and Methods). (<b>B</b>) HeLa cells were transfected either with human CD44v6 wild type or with human CD44v6 tailless constructs as indicated. After 24 hours cells were serum starved, treated with 50 µM cycloheximide for 2 hours prior to HGF-induction, stimulated with 25 ng/ml HGF for 1 hour on ice (cold start) and incubated at 37°C for the indicated time periods. Cells were then fixed, stained, and imaged using a confocal microscope (Leica SPE) with a 63× objective. Met (red), CD44v6 wild type (green), CD44v6 tailless (green), Dapi (blue). Scale bar = 15 µm. The quantification of three independent experiments (n = 20) is shown. The percentage of transfected cells with Met exclusively located on endosomes or exclusively at the plasma membrane or on both was calculated for each time point. Values are the means of three independent experiments. Student´s t test: *p<0,05 and **p<0,01. (<b>C</b>) HeLa cells were transfected with an Ezrin construct deleted from the actin-binding domain (EzrinΔABD) or a control vector. The cells were serum starved for 24 hours followed by biotinylation (0,5 mg/ml), induced with HGF (50 ng/ml) and treated with MESNA. Upon cell lysis proteins were pulled down by NeutrAvidin beads. The precipitates were subjected to Western Blot analysis for Met and CD44v6. For the first sample the cell were kept at 4°C. –M: cells were not treated with MESNA. The experiment was repeated at least three times.</p

Co-localization of Met and CD44v6 in internal compartments after HGF stimulation.

<p>(<b>A</b>) Confocal images of endogenous Met and CD44v6 at different time points after HGF-induction. HeLa cells were serum starved, treated for 2 hours with 50 µM cycloheximide, incubated at 4°C for 1 hour with HGF (25 ng/ml) (cold start) and then shifted to 37°C for the indicated times. After fixation cells were stained for Met (red, AF276) and CD44v6 (green, VFF18) and nuclei (blue, Draq5) and imaged with the confocal microscope (LSM510) with a 63× objective (Material and Methods). For each time point, the mean Pearson Coefficient of 4–6 images was calculated using the Imaris software. Scale bar = 15 µm (<b>B</b>) Intensity profiles of the emission wavelengths of the Met and CD44v6 signals along lines drawn across the plasma membrane or vesicles containing both Met and CD44v6. The intensity of the respective wavelengths is plotted against the distance in µm. (<b>C</b>) Co-immunoprecipitation of CD44v6 and Met upon HGF induction. Serum-starved HeLa cells were induced with HGF (50 ng/ml) for the indicated time periods and Met was immunoprecipitated. The precipitate was subjected to Western Blot analysis and the membrane was blotted for Met, phospho-Met and CD44v6. The experiment was repeated at least three times.</p