Multicenter real-world study on safety and efficacy of neoadjuvant therapy in combination with immunotherapy for colorectal cancer / 中华胃肠外科杂志

Objective: To provide reference and evidence for clinical application of neoadjuvant immunotherapy in patients with colorectal cancer through multicenter large-scale analysis based on real-world data in China. Methods: This was a retrospective multicenter case series study. From January 2017 to October 2021, data of 94 patients with colorectal cancer who received neoadjuvant immunotherapy in Peking University Cancer Hospital (55 cases), Union Hospital of Tongji Medical College of Huazhong University of Science and Technology (19 cases), Sun Yat-sen University Cancer Center (13 cases) and Changhai Hospital of Navy Medical University (7 cases) were retrospectively collected, including 48 males and 46 females. The median age was 58 years. Eighty-one cases were rectal cancer and 13 cases were colon cancer (2 cases of double primary colon cancer). Twelve cases were TNM staging II and 82 cases were stage III. Forty-six cases were well differentiated, 37 cases were moderately differentiated and 11 cases were poorly differentiated. Twenty-six patients (27.7%) with mismatch repair defects (dMMR) and microsatellite instability (MSI-H) were treated with immunotherapy alone, mainly programmed cell death protein-1 (PD-1); sixty-eight cases (72.3%) with mismatch repair proficient (pMMR) and microsatellite stability (MSS) were treated with immune combined with neoadjuvant therapy, mainly CapeOx (capecitabine+oxaliplatin) combined with PD-1 antibody plus long- or short-course radiotherapy, or PD-1 antibody combined with cytotoxic T lymphocyte associated antigen 4 (CTLA-4) antibody. Analysis and evaluation of adverse events during neoadjuvant immunotherapy were performed according to the National Cancer Institute Common Toxicity Standard version 3.0; the surgical complications were evaluated according to the Clavien-Dindo grading standard; the efficacy evaluation of neoadjuvant immunotherapy included the following indicators: major pathological remission (MPR) was defined as tumor regression induced by neoadjuvant therapy in pathology residual tumor ≤10%; pathological complete response (pCR) was defined as tumor regression induced by neoadjuvant therapy without residual tumor in pathology; the tumor response rate was disease control rate (DCR), namely the proportion of complete response (CR), partial response (PR) and stable disease (SD) in the whole group; the objective response rate (ORR) was CR+PR. Results: The median cycle of neoadjuvant immunotherapy was 4 (1-10) in whole group, and the incidence of immune-related adverse reactions was 37.2% (35/94), including 35 cases (37.2%) of skin-related adverse reactions, 21 cases (22.3%) of thyroid dysfunction and 8 cases (8.5%) of immune enteritis, of which grade III or above accounted for 1.1%. The median interval between completion of neoadjuvant therapy and surgery was 30 (21-55) days. There were 81 cases of radical resection of rectal cancer, 11 cases of radical resection of colon cancer, and 2 cases of colon cancer combined with other organ resection. The primary tumor resection of all the patients reached R0. The incidence of surgical-related complications was 22.3% (21/94), mainly anastomotic leakage (4 cases), pelvic infection (4 cases), abdominal effusion (3 cases), anastomotic stenosis (3 cases ) and abdominal and pelvic hemorrhage (2 cases). Grade I-II complications developed in 13 cases (13.8%), grade III and above complications developed in 8 cases (8.5%), no grade IV or above complications were found. During a median follow-up of 32 (1-46 ) months, DCR was 98.9% (93/94), ORR was 88.3 % (83/94), pCR was 41.5% (39/94), MPR was 60.6% (57/94). The pCR rate of 26 patients with dMMR and MSI-H undergoing simple immunotherapy was 57.7% (15/26), and MPR rate was 65.4% (17/26). The pCR rate of 68 pMMR and MSS patients undergoing combined immunotherapy was 35.3%(24/68), and MPR rate was 58.8% (40/68). Conclusions: Neoadjuvant immunotherapy has favorable tumor control rate and pathological remission rate for patients with initial resectable colorectal cancer. The incidences of perioperative adverse reactions and surgical complications are acceptable.

Short-term outcome of programmed cell death protein1 (PD-1) antibody combined with total neoadjuvant chemoradiotherapy in the treatment of locally advanced middle-low rectal cancer with high risk factors / 中华胃肠外科杂志

Objective: Total neoadjuvant chemoradiotherapy is one of the standard treatments for locally advanced rectal cancer. This study aims to investigate the safety and feasibility of programmed cell death protein 1 (PD-1) antibody combined with total neoadjuvant chemoradiotherapy in the treatment of locally advanced middle-low rectal cancer with high-risk factors. Methods: A descriptive cohort study was conducted. Clinicopathological data of 24 patients with locally advanced middle-low rectal cancer with high-risk factors receiving PD-1 antibody combined with neoadjuvant chemoradiotherapy in Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital between January 2019 and April 2021 were retrospectively analyzed. Inclusion criteria: (1) rectal adenocarcinoma confirmed by pathology; patient age of ≥ 18 years and ≤ 80 years; (2) the distance from low margin of tumor to anal verge ≤ 10 cm under sigmoidoscopy; (3) ECOG performance status score 0-1; (4) clinical stage T3c, T3d, T4a or T4b, or extramural venous invasion (EMVI) (+) or mrN2 (+) or mesorectal fasciae (MRF) (+) based on MRI; (5) no evidence of distant metastases; (6) no prior pelvic radiation therapy, no prior chemotherapy or surgery for rectal cancer; (7) no systemic infection requiring antibiotic treatment and no immune system disease. Exclusion criteria: (1) anticipated unresectable tumor after neoadjuvant treatment; (2) patients with a history of a prior malignancy within the past 5 years, or with a history of any arterial thrombotic event within the past 6 months; (3) patients received other types of antitumor or experimental therapy; (4) women who were pregnant or breast-feeding; (5) patients with any other concurrent medical or psychiatric condition or disease; (6) patients received immunotherapy (PD-1 antibody). The neoadjuvant therapy consisted of three stages: PD-1 antibody (sintilimab 200 mg, IV, Q3W) combined with CapeOx regimen for three cycles; long-course intensity modulated radiation therapy (IMRT) with gross tumor volume (GTV) 50.6 Gy/CTV 41.8 Gy/22f; CapeOx regimen for two cycles after radiotherapy. After oncological evaluation following the end of the third stage of treatment, surgery or watch and wait would be carried out. Surgical safety, histopathological changes and short-term oncological outcome were analyzed. Results: There were 15 males and 9 females with a median age of 65 (47-78) years. Median distance from the lower margin of the tumor to the anal verge was 4 (3-7) cm. The median maximal diameter of the tumor was 5.1 (2.1-7.5) cm. Twenty patients were cT3, 4 were cT4, 8 were cN1, 5 were cN2a, 11 were cN2b. Ten cases were MRF (+) and 10 were EMVI (+). All the patients were mismatch repair proficient (pMMR). During the neoadjuvant treatment period, 6 patients (25.0%) developed grade 1-2 treatment-related adverse events, including 3 immune-related adverse events. As of April 30, 2021, 20 patients (83.3%, 20/24) had received surgical resection, including 19 R0 resections and 16 sphincter-preservation operations. Morbidity of postoperative complication was 25.0% (5/20), including 2 cases of Clavien-Dindo grade II (1 of anastomotic bleeding and 1 of pseudomembranous enteritis), 3 cases of grade I anastomotic stenosis. Pathological complete response (pCR) rate was 30.0% (6/20) and major pathological response rate was 20.0% (4/20). None of Ras/Raf mutants had pCR or cCR (0/5), while 6 of 17 Ras/Raf wild-type patients had pCR and 3 had cCR, which was significantly higher than that of Ras/Raf mutants (P<0.01). Nine of 16 patients with Ras/Raf wild-type and differentiated adenocarcinoma had pCR or cCR. Among other 4 patients without surgery, 3 patients preferred watch and wait strategy because their tumors were assessed as clinical complete response (cCR), while another one patient refused surgery as the tumor remained stable. After a median follow-up of 11 (6-24) months, only 1 patient with signet ring cell carcinoma had recurrence. Conclusions: PD-1 antibody combined with total neoadjuvant chemoradiotherapy in the treatment of locally advanced rectal cancer has quite good safety and histopathological regression results. Combination of histology and genetic testing is helpful to screen potential beneficiaries.

Plant Identification of Different Growth Forms of Justicia procumbens and Comparison of Their Chemical Components Content / 中国实验方剂学杂志

Objective: To identify two different growth types vertical growth (V-class) and lateral growth (L-class)) of Justicia procumbens, and compare the contents of chemical compounds between upper part and different organs. Method: DNA was extracted from the leaves of two growth forms of J. procumbens. Internal transcriptional spacer 2 (ITS2) and psbA-trnH sequences were obtained by polymerase chain reaction (PCR) amplification and bidirectional sequencing. High performance liquid chromatography (HPLC) was used to determine the contents of justicidin B (JB) and chinensinaphthol methyl ether (CME) from the above-ground parts of V-class and L-class J. procumbens and their inflorescence,leaves,and stems. Independent sample T-test and Paired-sample T-test were used to compare the contents of JB and CME from two different growth forms of J. procumbens and their different organs. Result: The DNA sequences after shearing were shown to be identical between the V-class and L-class samples. Independent sample T-test showed no difference on the content of JB between the above-ground parts of V-class and L-class samples,but the content of CME was higher in V-class J. procumbens than L-class (PT-test showed that the content of JB and CME were different in the inflorescence,leaves,and stems of J. procumbens (PJ. procumbens was higher than that in L-class. Conclusion: DNA barcoding and comparison of JB and CME content indicated that the two different growth forms of J. procumbens belong to the same species. The contents of CME were different in J. procumbens between different growth forms,and was higher in V-class. Meanwhile,due to the little content of JB and CME in stems,the best picking time of J. procumbens is the flowering and fruiting period with more inflorescence and leaves.

Establishment of rat osteoarthritis model and the expression of MMP-13 and ADAMTS-5 in cartilage tissue / 局解手术学杂志

Objective To evaluate the feasibility of making the osteoarthritis (OA) model in the medial collateral ligament and the medial meniscus excision in rats,and to explore the mechanism of MMP-13 and ADAMTS-5 protein in the cartilage of rat osteoarthritis models.Methods Forty SD rats were randomly divided into model group(n =30) and sham operation group(n =10).The knee joint OA model was made from the medial collateral ligament of the knee and the medial meniscus,and the sham operation group was sutured after opening the capsule of the knee joint.Rats in the model group were killed at 4,6,and 8 weeks after the operation,and the sham operation group died of the rats at 8 weeks after the operation.The articular cartilage tissue of rats was taken.The expression level of MMP-13 and ADAMTS-5 protein in cartilage tissue was detected by Western blot and immunohistochemistry.Results Cartilage degeneration was observed in the model group 4 weeks after operation,and degeneration was further aggravated at 6 and 8 weeks.There was no significant degeneration in the sham operation group.There was a significant difference in the articular cartilage score between the two groups (P ＜ 0.05).The results of Western blot detection showed that the protein expression of MMP-13 and ADAMTS-5 was low in the sham operation group.The MMP-13 model began to rise for 4 weeks,and continued to rise in the 6th week,and the 8th week was lower than that of the previous one.The protein expression had significant difference in all groups at 4 weeks,6 weeks and 8 weeks (P ＜ 0.05).The ADAMTS-5 model began to rise for 6 weeks,and the expression level was maintained before the model was maintained for 8 weeks.The protein expression at 4 weeks compared to that at 6 weeks and 8 weeks had significant difference(P ＜0.05).The protein expression in rat articular cartilage tissue at 6 weeks and 8 weeks had no significant difference (P ＞ 0.05).The expression trend of immunohistochemical detection protein was consistent with that of Western blot.Conclusion The animal model of OA can be established by using the method of medial collateral ligament dissection and medial meniscectomy.The expression level of MMP-13 and ADAMTS-5 in different stages of OA has changed significantly.Further research is needed to explore its related signaling pathways.

Comparison of short-term postoperative outcomes between hand-assisted laparoscopic and conventional sigmoidectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the safety and efficacy perioperatively between hand-assisted laparoscopic surgery (HALS) and conventional open sigmoidectomy.</p><p><b>METHODS</b>Prospectively collected data on 115 patients with sigmoid colon cancer between January 2009 to June 2010 were analyzed. There were 62 patients in the HALS group and 53 in the conventional sigmoidectomy group (CS). Patient characteristics, operative parameters, and perioperative outcomes were compared.</p><p><b>RESULTS</b>HALS patients were similar to CS patients in age(60.2 yrs vs. 63.4 yrs, P=0.163), gender (53.2% vs. 60.4% male, P=0.441), tumor size (4.7 cm vs. 5.3 cm, P=0.114) and tumor stage. The two groups were comparable in operative time [(122.4±32.0) min vs.(126.7±37.4) min, P=0.510], lymph node harvest (15.1±4.6 vs. 16.8±6.4, P=0.163), free margin length [(4.1±1.8) cm vs.(4.3±1.7) cm, P=0.601], and postoperative complications. However, HALS group had less intraoperative bleeding [(62.6±35.4) ml vs. (168.9±137.1) ml, P=0.000], shorter time to flatus [(2.3±0.8) d vs. (3.3±1.1) d, P=0.000], and shorter hospital stay [(8.8±2.7) d vs.(12.6±8.0) d, P=0.001].</p><p><b>CONCLUSIONS</b>HALS results in similar short-term outcomes compared to conventional surgery. HALS is safe and minimally invasive.</p>

Application of hand-assisted laparoscopic surgery (HALS) in colectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of hand-assisted laparoscopic surgery (HALS) in colorectal tumors.</p><p><b>METHODS</b>Clinical data of 70 patients with colorectal tumors were retrospectively analyzed. All the patients had received HALS colectomy in the Beijing Cancer Hospital. Lapdisc was used for the hand port at the umbilicus. Two additional trocars were used.</p><p><b>RESULTS</b>There were 38 males and 32 females. The median age was 61(29-89) years. Diagnoses included sigmoid cancer(n=48), sigmoid adenoma(n=4), descending colon cancer (n=3), ascending colon cancer (n=1), rectal cancer (n=13), total colectomy(n=1). The operative time was (126.0±22.5) minutes. The intraoperative blood loss was (75.0±18.8) ml. The mean number of lymph node dissection was(16.8±4.2). The median postoperative hospital stay was 9.4 days. There were no perioperative deaths. One patient developed anastomotic stricture and two anastomotic leak, all of which were successfully managed with conservative treatment.</p><p><b>CONCLUSION</b>HALS is a safe and effective technique for colectomy.</p>

Effect of T-2 toxin on growth and development of rat knee epiphyseal plate and metaphyseal bone in normal and low nutritional status / 中国地方病学杂志

Objective To observe the effect of T-2 toxin on growth and development of rat epiphyseal plate of left knee and metaphyseal bone of femur and tibia in normal and low nutritional status, to find out possible pathogenic factors of Kashin-Beck disease and provide experimental basis for early intervention. Methods Ninety 3-week-old Wistar rats, weighing 60 - 70 g, were randomly divided into three groups: control group(general feed), T-2 toxin + general feed group, T-2 toxin + low nutrition feed group, thirty rats in each group with equally sex ratio. T-2 toxin (1.0 mg/kg) was administered orally 5 times a week via a gavage needle for 4 weeks. The change of hair, activity and body weight was observed. After 1, 2, 4 weeks, the epiphyseal plate of left knee and metaphyseal bone of femur and tibia (including distal femur and proximal tibia) were collected. Specimens were processed with HE and Masson staining. The morphology of chondrocytes and matrix collagen content in epiphyseal plate was observed. Trabecular bone volume fraction in tibial metaphyseal bone was analyzed by Image-Pro Plus 6.0 software. Results In the control group, rats were in good movement and hair with light, but in T-2 toxin + general feed group and T-2 toxin + low nutrition feed group, rats were found with reduced activities and hair with dark color. Body weights(g) of the control group, the T-2 toxin + general feed group and the T-2 toxin + low nutrition feed group were 81.0 ± 6.2, 79.0 ±5.1, 77.0 ± 7.5, respectively, by the end of first week; 101.8 ± 6.7, 97.0 ± 6.8, 93.0 ± 5.3, respectively, by the end of second week; 151.1 ± 15.7, 126.5 ± 11.9, 106.5 ± 11.5, respectively, by the end of fourth week. There was significant difference in groups by second week and the fourth week (F = 9.72, 41.65, all P ＜ 0.05 ). There was significant difference among multi-groups by the fourth week(all P ＜ 0.01 ). Under light microscope, at the second weeks, coagulative necrosis of chondrocytes was found in hypertrophic zone in the two groups with T-2 toxin; at the fourth weeks, cell necrosis increased. Masson staining showed collagen staining in the two groups with T-2 toxin significantly turned to clear pale coloration, indicating that the collagen matrix was significantly reduced. Image analysis showed there was significant difference in groups at the second and fourth week(F= 9.72, 41.65, all P＜ 0.05)in tibial metaphyseal trabecular bone volume fraction. There was significant difference between T-2 toxin + low nutrition feed group[(0.55 ± 0.12)％, (0.21 ± 0.0)％] and control group[(0.67 ± 0.09)％, (0.51 ± 0.14)％] by the second and fourth week(all P ＜ 0.01 ). Conclusions Under normal nutritional status, T-2 toxin can induce hypertrophic epiphyseal cartilage necrosis, collagen content decreased in epiphyseal plate, metaphyseal trabecular bone formation disorders; in the low nutritional status, T-2 toxin can lead to rat epiphyseal necrosis and significant metaphyseal bone disorder, but whether the performance is related to Kaschin-Beck disease needs to be studied further.

Occult lymph node metastasis in the middle and lower third rectal cancer after neoadjuvant radiotherapy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the occult lymph node metastasis in the middle and lower third rectal cancer after neoadjuvant radiotherapy.</p><p><b>METHODS</b>From June 2003 to December 2006, 74 rectal cancer patients received neoadjuvant radiotherapy (30 Gy/10 f/2 w, CACA-CRC-001) and underwent total mesorectal excision (TME) two weeks later. Fat clearance technique was used in all the samples. Occult lymph node metastasis was detected in the mesorectum using the anti-CK antibody.</p><p><b>RESULTS</b>In total 1883 retrieved lymph nodes, 172 metastasis lymph nodes were harvested by HE examination with the mean diameter [(4.9+/-2.6) mm] being larger than that (2.7+/-1.4) mm of the 1711 negative nodes (P<0.01). In HE negative nodes, occult metastasis was found in 40 lymph nodes (2.33%) from 24 patients. Most of these nodes were less than 5 mm (90.0%) with a mean diameter of (3.2+/-1.2)mm, smaller than those of HE-positive metastasis nodes (P<0.01). Occult metastasis was found in 23.1% (9/39) of HE-negative patients. Occult metastasis incidence was higher in patients with HE-positive nodes (42.8%,P<0.01). No correlation of lymph node occult metastasis with tumor differentiation, age, or surgical procedures was found. There was no significant difference in recurrence-free survival between ypN(0) patients with and without occult metastasis (P=0.157).</p><p><b>CONCLUSION</b>It is not necessary to include occult lymph node metastasis in the TNM staging in patients with ypN(0) rectal cancer.</p>

Comparison of pathologic and clinical characteristics of young and old patients with advanced rectal cancer after neoadjuvant radiotherapy / 中华外科杂志

<p><b>OBJECTIVES</b>To address the difference of pathologic and clinical characteristics of the young and the middle-aged and elderly patients with advanced rectal cancer after neoadjuvant radiotherapy.</p><p><b>METHODS</b>A total of 252 patients undergoing radical surgery from January 2000 to January 2005 were included in this study. The patients were divided into two groups according to the age at diagnosis:young-patient group (< 40 years) and old-patient group (≥ 40 years). The pathologic and clinical materials were collected and the oncologic outcome was compared between the two arms.</p><p><b>RESULTS</b>A total of 252 patients were included in this study, included 54 patients in young-patient group and 198 patients in old-patient group, respectively. There was no significant difference in gender, clinical stage and pretreatment serum carcinoembryonic antigen (CEA) between the two groups. However, the proportion of mucinous and signet-ring cell cancer was significantly higher in young-patient group (20.4% vs. 4.0%, P < 0.05), and furthermore, the proportion of pathologic stage later than IIIA was also significantly higher in the young-patient group (61.1% vs. 42.9%, P < 0.05). There was no significant difference in local recurrence rate between the patients who received neoadjuvant radiotherapy and those who did not in the young-patient group, whereas the difference was observed significant in the old-patient group (3.3% vs. 11.2%, P < 0.05). There was no significant difference in both the disease free survival and overall survival between the two arms (5y-DFS: 63.3% vs. 68.5%, P > 0.05; 5y-OS: 73.5% vs. 72.9%, P > 0.05).</p><p><b>CONCLUSIONS</b>Rectal cancer in young patients has poorer histologic differentiation and more advanced pathologic stage, but the long-term survival is similar to that in middle-aged and elderly patients. The local control effect of neoadjuvant radiotherapy on rectal cancer in young patients still need to be further investigated.</p>

Outcome of total mesorectal excision for lower rectal cancer: micrometastasis in the mesorectum / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the correlation between micrometastasis in mesorectum and pathological factors after total mesorectal excision(TME) in lower rectal cancer.</p><p><b>METHODS</b>All lymph nodes were obtained by fat clearance from 31 lower rectal cancer patients with TME. The lymph nodes which had previously been considered negative of metastasis by conventional examination were submitted to immunohistochemical examination to identify the micrometastases using anti-cytokeratin antibody. The correlation between micrometastasis and pathological factors were analyzed.</p><p><b>RESULTS</b>One thousand and seven LNs were collected from 31 patients. One hundred and five LNs were found positive by conventional examination, and the mean diameter was (5.5 +/- 3.1) mm. The mean diameter of conventional negative LNS was (2.8 +/- 1.5) mm. The diameter differed significantly between conventional positive and negative LNS (P < 0.05). In 902 conventional negative LNs, 26 contained micrometastasis (209%) and the mean diameter was (3.3 +/- 1.2) mm. The diameter of LNs with micrometastasis was significantly smaller than that of conventional positive LNs (P < 0.05). The diameter of most of the micrometastatic LNs(88.5%) was less than 5 mm. Fourteen patients (38.7%) contained micrometastasis. The pathological stage, serum carcinoembryonic antigen level and tumor differentiation were related to micrometastasis (P < 0.05).</p><p><b>CONCLUSIONS</b>With the detection of micrometastasis after fat clearance, we can estimate the LN metastasis status more accurately. It can be useful in clinical staging and individual treatment of rectal cancer.</p>