Impact of endoscopic stent insertion on detection of viable circulating tumor cells from obstructive colorectal cancer

Abstract

Abstract. The placement of a self-expanding metallic stent (SEMS) in obstructive colorectal cancer (OCRC) is acknowledged to be a safe and effective procedure for the relief of obstruction. However, there is concern that shear forces acting on the tumor during stent expansion may release cancer cells into the circulation, resulting in a poor prognosis. The aim of the present study was to determine whether colonic stent insertion increases viable circulating tumor cells (v-CTCs). A telomerase-specific replication-selective adenovirus-expressing GFP (TelomeScanF35) detection system was used to detect v-CTCs in 8 OCRC patients with a SEMS before and after stent insertion and after surgical resection. In 7 patients, a SEMS was inserted as a bridge to surgery (BTS), and in one patient, a SEMS was inserted for palliation. Surgical resection (R0) was performed in 7 patients. Four patients had no v-CTCs before SEMS placement, two of four measurable patients had an increased number of v-CTCs after SEMS placement (1-3 v-CTCs), and one of two patients with increased v-CTCs developed distant lymphatic metastasis despite curative resection. Four patients had v-CTCs (1-19 cells) before SEMS placement, and two of these four patients had an increase in the number of v-CTCs (20-21 cells) after SEMS placement, while one of the four patients died early with distant metastasis. The present study demonstrated that endoscopic stent insertion for OCRC may result in tumor cell dissemination into the peripheral circulation and may induce distant metastases. IntroductionAt the time of the initial diagnosis of colorectal cancer, 8-13% of patients have obstructive symptoms (1,2). The treatment of choice for these patients has traditionally been emergency surgery. However, most studies have found that the morbidity and mortality rates are higher for emergency colorectal surgery than for elective surgery, and a temporary colostomy, which decreases patients' quality of life, is needed in many patients, which, in 10-40% of cases, becomes permanent (3). The purpose of stenting as a bridge to surgery (BTS) is to relieve the acute situation without emergency surgery, allowing elective surgery to be performed and thus improve surgical outcomes, determine the correct tumor stage, detect synchronous lesions, stabilize comorbidities, and carry out laparoscopic surgery. Immediate results in higher surgical risk patients who were stented were better for primary anastomosis, permanent stoma, wound infection, and overall morbidity, resulting in greater benefit. However, stent insertion was recently reported to have a high risk of perforation, re-obstruction, or stent migration (4,5). Moreover, perforations can lead to peritoneal dissemination. Sabbagh et al (6) reported worse overall survival and higher 5-year cancer-specific mortality of left-sided obstructive colorectal cancer (OCRC) patients with self-expanding metallic stent (SEMS) insertion than emergency surgery due to perforation induced by stent insertion. Furthermore, SEMS insertion as a BTS is ...

Determining the difference in the efficacy and safety of self-expandable metallic stents as a bridge to surgery for obstructive colon cancer among patients in the CROSS 0 group and those in the CROSS 1 or 2 group: a pooled analysis of data from two Japanese prospective multicenter trials

“…In addition, stent insertion for obstructive CRC may result in an increase in CK20 mRNA [21], cell-free DNA, circulating tumor DNA [24], and viable circulating tumor cells (v-CTCs) [25]. To accurately evaluate the effect of tumor manipulation by the radial force generated when a SEMS expands, the influence of additional surgery, such as colostomy, should be avoided as much as possible.…”

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction

“…Of all patients with colonic cancer, [9][10][11][12][13] per cent present initially with an acute obstruction, which accounts for 85 per cent of colonic emergencies 1,2 . Traditionally, left-sided obstructing colonic cancer (LSOCC) has been managed with emergency resection 3 .…”

Comparison of safety between self-expanding metal stents as a bridge to surgery and emergency surgery based on pathology: a meta-analysis

“…Since the rst reported use of SEMS in 1991, SEMS as a bridge of surgery has been widely developed because of its good short-term results, but its longterm oncology results are worrying (31). Several studies (32)(33)(34)(35) have found that SEMS implantation can cause tumor cells to release into the circulatory system, but Ishibashi (32) believes that these tumor cells are not cancer stem-like cells, which can be quickly removed by the body, so they will not cause distant metastasis of the tumor.…”