Randomized Controlled Trial of the Intraportal Chemotherapy Combined With Adjuvant Chemotherapy (mFOLFOX6) for Stage II and III Colon Cancer

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To the Editor:
We read this important study by Chang et al,1 comparing intraportal chemotherapy with adjuvant chemotherapy (mFOLFOX6) versus adjuvant chemotherapy (mFOLFOX6) alone in Stage II and III colon cancer with great interest.
The article explores new lands in this era of treating surgical colon cancer patients integrating intraportal chemotherapy with adjuvant chemotherapy and presents some interesting results that question the contemporary chemotherapy treatment. However, we feel that important factors regarding method of surgery and perioperative period are left unexplained.
The use of laparoscopic method has been introduced throughout the last 20 years and is associated with reduced morbidity, short term mortality,2 and in some articles improved survival in patients with Union for International Cancer Control stage III colorectal cancer.3–5 Type of surgery or if an enhanced recovery pathway was used was not described in the article. These factors, although they are usually not reported in studies focused on adjuvant therapies, may have a huge impact on treatment response. Thus, future studies should be performed in state of the art perioperative surgical treatment including minimally invasive surgery and enhanced recovery pathways. It is expected that the technique involving single shot intraportal chemotherapy may evolve in the future and based on the results by Chang et al be implemented in high risk patients, thus, it is important to report the feasibility of the technique. Did it prolong the surgical duration considerably, and if so for how long a time? Was there any procedure-related complications?
Another recent discovery in this field is the importance of anesthesia administered during surgery and the perioperative analgesic treatment.6 Xu et al7 recently demonstrated that cancer cell proliferation and invasiveness was reduced in vitro in serum from patients undergoing open colectomy and receiving an opioid reduced anesthesia because of the use of propofol and epidural analgesia compared with patients receiving sevoflurane anesthesia with opioid analgesia. They also presented data showing that the neutrophil/lymphocyte ratio was increased in the latter group that translates to a protumor inflammatory microenvironment. However, data on anesthesia administered during surgery is not provided by Chang et al,1 and possible differences between the groups is needed to further validate the results.
We believe the authors have provided an important step towards integrating oncological treatment in the operating room for a larger group of patients and believe that these results should be validated in larger scaled studies in patients with preoperative suspicion of stage III cancer.

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