Published online Feb 15, 2018. doi: 10.4291/wjgp.v9.i1.8
Peer-review started: March 24, 2017
First decision: May 4, 2017
Revised: November 25, 2017
Accepted: December 4, 2017
Article in press: December 5, 2017
Published online: February 15, 2018
Processing time: 323 Days and 5.7 Hours
Colorectal cancer is the fourth most common cancer in the United Kingdom with over 40000 cases diagnosed each year. Despite the widespread use of screening programs, a large number of cases are diagnosed in the acute or urgent setting with adverse post-operative mortality, disease-free and overall long-term survival.
A large proportion of patients with colorectal cancer are diagnosed in the acute setting with an emergency presentation (26%) or following an urgent 2-wk referral (27%). Compared to elective resection, emergency surgery is associated with adverse postoperative outcomes (post-operative mortality 4.6% vs 16%), disease-free and overall long-term survival. The basis for this is multifactorial and may include altered physiology, immune-suppression, adverse tumour biology, advanced disease, peri-operative complications and lower progression to adjuvant therapies.
Adverse predictive factors for survival in colorectal cancer include emergency presentation with obstruction or perforation and histo-pathological features such as T4 disease, advanced nodal disease. Lymph node ratio offers to a new representation of nodal disease. Although it is affected directly but the lymph node yield, its utility as a predictive tool for recurrent disease has not been evaluated. We aimed to identify clinical and histological predictive factors for early recurrence disease and pattern to inform surveillance strategies and aid in early detection.
Following institutional approval, a retrospective study of clinical and histo-pathological parameters was carried out to study patterns of recurrence and survival in consecutive patients undergoing elective and emergency resection for colorectal cancer over an eight-year study period.
Outcomes were evaluated in 266 consecutive patients following curative surgery with a median follow-up of 7.9 years. The proportion of patients undergoing emergency resection was 13.2%. Recurrent disease was detected in 67 patients (25.2%) during follow-up with the majority identified early within 3 years (82.1%). Liver was the predominant site of metastatic disease (73.1%). Emergency resection (OR = 3.60, P = 0.001), T4 stage (OR = 4.33, P < 0.001) and lymphovascular invasion (LVI) (OR = 2.37, P = 0.032) were associated with higher risk of recurrent disease. Emergency resection, T4 disease and a high lymph node ratio (LNR) were strong independent predictors of adverse long-term survival.
Our study reaffirms the independent predictive potential of histological and clinical features for recurrent disease in patients undergoing emergency resection for colorectal cancer. Furthermore, it introduces the independent utility of lymph node ratio (LNR) alongside T stage and lympho-vascular invasion in identifying patients with high risk of recurrent disease.
Modified surveillance strategies should be evaluated in presence of adverse clinical and histological factors to improve early detection of recurrent disease in high-risk patients to offset adverse disease-free and overall long-term survival.