Early colorectal cancers refer to invasive cancers that have infiltrated into the submucosa without invading muscularis propria, and approximately 10% of these patients have lymph node metastases that cannot be detected by conventional imaging. According to the guidelines of Chinese Society of Clinical Oncology (CSCO) Colorectal Cancer, early colorectal cancer cases with risk factors for lymph node metastasis (poor tumor differentiation, lymphovascular invasion, deep submucosal invasion and high-grade tumor budding) should receive salvage radical surgical resection; however, the specificity of this risk-stratification is inadequate, making most patients undergo unnecessary surgery. Firstly, this review focuses on the definition, oncological impact importance and controversy of the above "risk factors". Then, we introduce the progress of the risk stratification system for lymph node metastasis in early colorectal cancer, including the identification of new pathological risk factors, the construction of new risk quantitative models based on pathological risk factors, artificial intelligence and machine learning technology and the discovery of novel molecular markers associated with lymph node metastasis based on gene test or liquid biopsy. Aim to enhance clinicians' understanding of the risk assessment of lymph node metastasis in early colorectal cancer; we suggest to take the patient's personal situation, tumor location, anti-cancer intention and other factors into account to make individualized treatment strategies.
Humans ; Lymphatic Metastasis/pathology* ; Artificial Intelligence ; Colorectal Neoplasms/surgery* ; Risk Factors ; Risk Assessment ; Neoplasm Invasiveness ; Lymph Nodes/pathology*

Objective: To analyzed perioperative safety of cytoreductive surgery (CRS) for patients with colorectal cancer peritoneal metastasis (CRPM) and to construct a predictive model for serious advese events (SAE). Methods: A descriptive case-series study was conducted to retrospectively collect the clinicopathological data and treatment status (operation time, number of organ resection, number of peritoneal resection, and blood loss, etc.) of 100 patients with peritoneal metastases from colorectal cancer or appendix mucinous adenocarcinoma who underwent CRS at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to August 2021. There were 53 males and 47 females. The median age was 52.0 (39.0-61.8) years old. Fifty-two patients had synchronous peritoneal metastasis and 48 had metachronous peritoneal metastasis. Fifty-two patients received preoperative neoadjuvant therapy. Primary tumor was located in the left colon, the right colon and the rectum in 43, 28 and 14 cases, respectively. Fifteen patients had appendix mucinous adenocarcinoma. Measures of skewed distribution are expressed as M (range). Perioperative safety was analyzed, perioperative grade III or higher was defined as SAE. Risk factors associated with the occurrence of SAEs were analyzed using multivariate logistic regression. A nomogram was plotted by R software to predict SAE, the efficacy of which was evaluated using the area under the ROC curve (AUC) and correction curves. Results: The median peritoneal cancer index (PCI) score was 16 (1-39). Sixty-eight (68.0%) patients achieved complete tumor reduction (tumor reduction score: 0-1). Sixty-two patients were treated with intraperitoneal hyperthermic perfusion chemotherapy (HIPEC). Twenty-one (21.0%) patients developed 37 SAEs of grade III-IV, including 2 cases of ureteral injury, 6 cases of perioperative massive hemorrhage or anemia, 7 cases of digestive system, 15 cases of respiratory system, 4 cases of cardiovascular system, 1 case of skin incision dehiscence, and 2 cases of abdominal infection. No grade V SAE was found. Multivariate logistic regression analysis showed that CEA (OR: 8.980, 95%CI: 1.428-56.457, P=0.019), PCI score (OR: 7.924, 95%CI: 1.486-42.259, P=0.015), intraoperative albumin infusion (OR: 48.959, 95%CI: 2.115-1133.289, P=0.015) and total volume of infusion (OR: 24.729, 95%CI: 3.956-154.562, P=0.001) were independent risk factors for perioperative SAE in CRS (all P<0.05). Based on the result of multivariate regression models, a predictive nomogram was constructed. Internal verification showed that the AUC of the nomogram was 0.926 (95%CI: 0.872-0.980), indicating good prediction accuracy and consistency. Conclusions: CRS is a safe and effective method to treat CRPM. Strict screening of patients and perioperative fluid management are important guarantees for reducing the morbidity of SAE.
Adenocarcinoma, Mucinous/therapy* ; Adult ; Antineoplastic Combined Chemotherapy Protocols/therapeutic use* ; Appendiceal Neoplasms/surgery* ; Colorectal Neoplasms/pathology* ; Combined Modality Therapy ; Cytoreduction Surgical Procedures/methods* ; Female ; Humans ; Hyperthermia, Induced/methods* ; Male ; Middle Aged ; Peritoneal Neoplasms/secondary* ; Retrospective Studies ; Survival Rate

Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.
Adenoma/surgery* ; Colonic Neoplasms/surgery* ; Colonic Polyps/surgery* ; Colonoscopy/methods* ; Colorectal Neoplasms/pathology* ; Humans ; Singapore ; United States

To compare the safety and efficacy between endoscopic submucosal dissection (ESD) and radical surgery (RS) for the treatment of large colorectal laterally spreading tumors (LST) larger than 50 mm in diameter. 
 Methods: From January 2011 to January 2016, a total of 82 patients were diagnosed as large LST without deep submucosal invasion (T1 SM2, ≥1 000 µm) in the Second Xiangya Hospital of Central South University. Among them, 52 patients were treated by ESD and the other 30 patients were treated by RS [laparoscopic-assisted colectomy (LAC)/open colectomy (OC)]. The clinic data were retrospectively analyzed and the en-bloc resection rate, en-bloc R0 resection rate, local recurrence, complication, procedure time and hospital stay were collected and analyzed.
 Results: The lesion sizes were (5.80±1.20) cm and (5.53±0.69) cm in diameter for ESD and RS groups, respectively (P>0.05). En-bloc resection rates, en-bloc R0 resection rates and recurrence rates showed no significant difference between the ESD group and RS group (P>0.05). Complication rate of the ESD group (7.69%, 4/52) was much lower than that in the RS group (33.33%, 10/30; P<0.01). The ESD group also had a shorter hospital stay and operation time than the RS group (P<0.05).
 Conclusion: ESD appears to be a safe, minimal invasive and effective strategy for treating large LST and it is obviously better than RS in the aspects of hospital stay, operation time and short-term complication.
Colorectal Neoplasms ; pathology ; surgery ; Dissection ; Endoscopic Mucosal Resection ; standards ; Humans ; Intestinal Mucosa ; pathology ; surgery ; Neoplasm Recurrence, Local ; pathology ; surgery ; Retrospective Studies ; Treatment Outcome

Elderly patients with colorectal cancer have different clincopathological characteristics from younger patients. Colorectal cancers tend to localize in the proximal colon, from cecum to the splenic flexure in the elderly patients. Changes in the stools, rectal bleeding or black stool, abdominal pain, fatigue, weight loss and anemia are the common symptoms. Analysis showed that age is one of independent risk factors for lower completion rates of colonoscopy. Therefore, the choice of diagnosis methods in elderly patients should be careful. Achieving a clear diagnosis and avoiding complications should be considered at the same time. Most colorectal cancers in elderly are highly and moderately differentiated adenocarcinomas and locally advanced, and have less lymphatic and blood metastasis. The proportion of poorly differentiated adenocarcinoma increases with the increase of age, which should be concerned. Multiple colorectal cancers and colorectal cancer with extra-colorectal malignancy are not rare in the elderly patients. The common extra-colorectal tumors consist of gastric cancer, lung cancer, biliary carcinoma, pancreas cancer and malignancy from blood system. Molecular events, such as mutations of KARS, BRAF, TP53 and deficiency of DNA mismatch repair, are more frequent in elderly colorectal cancer patients. Many factors have impact on treatment decision in elderly patients with colorectal cancer, including age, comorbidities, physiological functions of organs and willingness of patients and their relatives. Although surgery is still the main treatment, the proportion of radical surgery is lower and emergency surgery is higher as compared to younger patients. With the development of minimally invasive surgical techniques and advances in anesthesia and perioperative management, laparoscopic surgery has become widespread in elderly patients with colorectal cancer. In addition, more attention should be paid to adjuvant therapy. Comprehensive individualized treatment plan should be taken to improve outcomes.
Adenocarcinoma ; pathology ; Aged ; Colonoscopy ; Colorectal Neoplasms ; diagnosis ; genetics ; pathology ; surgery ; Humans ; Laparoscopy ; Mutation ; Risk Factors

OBJECTIVETo explore the correlation between signs of living body in abdominal and pelvic cavities and syndrome typing of Chinese medicine (CM) in colorectal cancer patients.

METHODSTotally 112 colorectal cancer patients undergoing open abdominal surgery or laporoscopic surgery were syndrome typed as five types, i.e., inner-accumulation of damp and heat, blockage of stasis and toxin, Pi-Shen yang deficiency, blood-qi deficiency, Gan-Shen yin deficiency. Signs of living body in abdominal and pelvic cavities were collected. The correlation between signs of living body in abdominal and pelvic cavities and syndrome typing of CM were analyzed.

RESULTSRed colorectal canals or mass were dominated in colorectal cancer patients with inner-accumulation of damp and heat syndrome. Dark purple colorectal canals or mass were dominated in colorectal cancer patients with blockage of stasis and toxin syndrome. Reddish colorectal canals or mass were dominated in colorectal cancer patients with blood-qi deficiency syndrome. Pale colorectal canals or mass were dominated in colorectal cancer patients with Pi-Shen yang deficiency syndrome. Whitish or red-white stripes were dominated in colorectal cancer patients with Gan-Shen yin deficiency syndrome. Dropsy colorectal canal was associated with Pi-Shen yang deficiency syndrome. Intracavitary effusion was often seen in colorectal cancer patients with inner-accumulation of damp and heat syndrome. The effusion was yellowish in less amount. Intracavitary adhesion was often seen in colorectal cancer patients with blockage of stasis and toxin syndrome. There was no correlation between the maximum diameter of mass or each syndrome type of CM.

CONCLUSIONThere existed correlation between signs of living body in abdominal and pelvic cavities and syndrome typing of CM, which could be taken as one of references for syndrome typing of colorectal cancer patients.

Abdominal Cavity ; pathology ; Colorectal Neoplasms ; diagnosis ; surgery ; Humans ; Medicine, Chinese Traditional ; Pelvis ; pathology ; Yang Deficiency ; diagnosis ; Yin Deficiency ; diagnosis

The treatments of resectable colorectal liver metastases (CRLM) are controversial. This study aimed to evaluate the relative efficacy and safety of hepatic resection (HR) and radiofrequency ablation (RFA) for treating resectable CRLM. Between January 2004 and May 2010, the enrolled patients were given hepatic resection (HR group; n=32) or percutaneous RFA (RFA group; n=21) as a first-line treatment for CRLM. All the tumors had a maximum diameter of 3.5 cm and all patients had five or less tumors. The patient background, tumor characteristics, cumulative survival rate and recurrence-free survival rate were assessed in both groups. There were significantly more patients with comorbidities in the RFA group than those in the HR group (17 in RFA group vs. 10 in HR group; P<0.000). The mean maximum tumor diameter in the HR group and RFA group was 2.25±0.68 and 1.89±0.62 cm (P=0.054), and the mean number of tumors was 2.28±1.05 and 2.38±1.12 (P=0.744), respectively. The 1-, 3- and 5-year cumulative survival rates in the HR group were 87.5%, 53.1% and 31.3%, respectively, and those in the RFA group were 85.7%, 38.1% and 14.2%, respectively with the differences being not significant between the two groups (P=0.062). The 1-, 3- and 5-year recurrence-free survival rates in the HR group were 90.6%, 56.3% and 28.1%, respectively, and those in the RFA group were 76.1%, 23.8% and 4.8%, respectively, with the differences being significant between the two groups (P=0.036). In conclusion, as HR has greater efficacy than RFA in the treatment of resectable CRLM, we recommend it as the first option for this malignancy.
Aged ; Catheter Ablation ; methods ; Colorectal Neoplasms ; pathology ; radiotherapy ; surgery ; Female ; Hepatectomy ; methods ; Humans ; Liver ; pathology ; surgery ; Liver Neoplasms ; pathology ; radiotherapy ; secondary ; surgery ; Male ; Middle Aged ; Neoplasm Metastasis ; Treatment Outcome

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.
Adult ; Aged ; Colectomy/*methods ; Colon/blood supply/pathology/radiography ; Colonography, Computed Tomographic/*methods ; Colorectal Neoplasms/pathology/*radiography/*surgery ; Contrast Media ; Female ; Humans ; Laparoscopy/*methods ; Lymph Node Excision/methods ; Male ; Middle Aged ; Neoplasm Staging/methods

BACKGROUND/AIMS: Colorectal adenomas that are > or =10 mm have villous histology or high-grade dysplasia, or that are associated with > or =3 adenomas are considered high-risk for metachronous advanced neoplasia. We evaluated the cumulative incidence of metachronous advanced neoplasia according to the total number of high-risk findings detected on baseline colonoscopy. METHODS: This was a retrospective cohort study performed in 862 patients who underwent removal of colorectal adenomas between 2005 and 2009. At least one surveillance colonoscopy had been conducted at Konkuk University Medical Center, Seoul, Korea. RESULTS: The cumulative incidence of metachronous advanced neoplasia in patients with 0, 1, 2, and 3-4 high-risk findings at 1 year were 0.7%, 1.3%, 2.8%, and 8.0%; at 3 years, those were 5.9%, 11.9%, 15.5%, and 24.7%; and at 5 years, those were 8.5%, 18.7%, 26.3%, and 37.2%, respectively. In a multivariate model, the risk of metachronous advanced neoplasia was significantly higher for the multiple high-risk findings group when compared with the 0 high-risk findings group (1 high-risk (+): hazard ratio, 1.86 [95% confidence interval, 1.00-3.44]; 2 high-risk (+): 1.84 [0.88-3.84]; and 3-4 high-risk (+): 3.29 [1.54-7.01]; ptrend=0.020). CONCLUSIONS: The presence of overlapping multiple high-risk findings was associated with an increased risk of advanced neoplasia during surveillance.
Adenoma/epidemiology/*etiology/pathology ; Aged ; Colonic Polyps/complications/surgery ; *Colonoscopy ; Colorectal Neoplasms/epidemiology/*etiology/pathology ; Early Detection of Cancer/methods ; Female ; Humans ; Incidence ; Male ; Middle Aged ; Neoplasm Grading ; Neoplasms, Second Primary/epidemiology/*etiology/pathology ; Population Surveillance/methods ; Proportional Hazards Models ; Republic of Korea/epidemiology ; Retrospective Studies ; Risk Factors ; Time Factors ; Tumor Burden

OBJECTIVETo analyze long-term outcomes and related risk factors in patients undergoing simultaneous resection of synchronous colorectal liver metastasis.

METHODSClinicopathological, short- and long-term outcome data of 154 consecutive synchronous colorectal liver metastasis patients who underwent simultaneous resection between July 2003 and July 2013 were collected and analyzed with Cox multivariate methods retrospectively.

RESULTSNo perioperative death was found. A total of 46 patients (29.9%) had complications, which were all successfully treated medically or by percutaneous drainage. The 5-year overall survival rate was 46%, and the 5-year disease-free survival rate was 35%. Four factors were found to be independent predictors of poor overall survival by multivariate analysis: positive lymph node status (P=0.000), number of metastasis focus (≥4) (P=0.017), bilobar liver metastasis distribution (P=0.004) and non-R0 resection of liver metastasis (P=0.001). Three factors were found to be independent predictors of poor disease-free survival by multivariate analysis: positive lymph node status (P=0.031), bilobar liver metastasis distribution (P=0.001) and extrahepatic metastases (P=0.020).

CONCLUSIONSSimultaneous resection of synchronous colorectal liver metastasis is safe and its short- and long-term outcomes are quite good. Positive lymph node status, number of metastasis focus (≥4), bilobar liver metastasis distribution, non-R0 resection of liver metastasis and extrahepatic metastasis are risk factors of poor long-term prognosis.

Colorectal Neoplasms ; pathology ; Disease-Free Survival ; Hepatectomy ; Humans ; Liver Neoplasms ; secondary ; surgery ; Multivariate Analysis ; Retrospective Studies ; Risk Factors ; Survival Rate