<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03809403</url>
  </required_header>
  <id_info>
    <org_study_id>APHP180453</org_study_id>
    <nct_id>NCT03809403</nct_id>
  </id_info>
  <brief_title>Influence of the Surgical Technique Used for Colectomies on the Concentration of Circulating Tumor DNA and the Presence of Circulating Tumor Cells: Comparison of the &quot;no Touch&quot; Technic With Either First Clamping of the Mesenteric Vessels or First Mobilization of the Tumor Followed by Clamping.</brief_title>
  <acronym>ADNCHIR</acronym>
  <official_title>Influence of the Surgical Technique Used for Colectomies on the Concentration of Circulating Tumor DNA and the Presence of Circulating Tumor Cells: Comparison of the &quot;no Touch&quot; Technic With Either First Clamping of the Mesenteric Vessels or First Mobilization of the Tumor Followed by Clamping.</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Assistance Publique - Hôpitaux de Paris</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>Institut National de la Santé Et de la Recherche Médicale, France</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>Assistance Publique - Hôpitaux de Paris</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      Colectomy is the most commonly used therapeutic approach for the treatment of non-metastatic&#xD;
      colorectal cancer. This approach is generally very effective however the rate of recurrence&#xD;
      and the appearance of metachronous metastasis remains a major problem in the postoperative&#xD;
      period. One of the hypothesis that can explain this tumor progression is the dissemination of&#xD;
      tumor cells at the time of tumor mobilization. In this work, we wish to verify this&#xD;
      hypothesis by comparing two surgical technics used in our department for left or right&#xD;
      colectomies: respectively either first section of the mesenteric vessels followed by the&#xD;
      mobilization of the tumor or first mobilization of the tumor followed by the section of the&#xD;
      mesenteric vessels. To evaluate the dissemination, we will study two disseminations markers&#xD;
      that have shown their prognostic value: i) circulating tumor cells (which represent a direct&#xD;
      marker of dissemination) and ii) tumor circulating DNA (which is an indirect marker) but has&#xD;
      the advantage of being more representative of all tumor clones and therefore the tumor burden&#xD;
      released into the blood at the time of surgery).&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      A / Epidemiology of colorectal cancer&#xD;
&#xD;
      Colorectal cancer remains the third most common cancer in France in 2017 with an incidence of&#xD;
      about 44,000 new cases in 2017 and nearly 18,000 deaths each year. The ColoRectal Cancer&#xD;
      (CRC) ranks second among cancer deaths behind lung cancer and breast cancer. Thanks to&#xD;
      diagnostic and therapeutic progress, the mortality rate decrease of 1.5% in men and 1.1% in&#xD;
      women between 2005 and 2012.&#xD;
&#xD;
      Despite these numbers, colorectal cancer has a good prognosis when diagnosed at an early&#xD;
      stage. In fact, the 5-year relative survival is 91% for localized stages (stage I and II) and&#xD;
      70% for stages with locoregional and lymph nodes invasion (stage III). On the other hand,&#xD;
      about 25% of the patients at the time of diagnosis have metastasis (stage IV), with a&#xD;
      survival at 5 years of 11%. Those data explain that the mortality of this cancer is mainly&#xD;
      due to the spread of the primary tumor to secondary locations, mainly liver or lung.&#xD;
&#xD;
      The unstable microsatellite phenotype (ISM) is an important colonic carcinogenesis pathway,&#xD;
      find in approximately 15% of operable colorectal cancers (CRC) and may be of sporadic or&#xD;
      hereditary origin. Several studies have shown that patients with MSI tumors have a better&#xD;
      prognosis than patients with stable microsatellite tumors (SSM) due to a better response to&#xD;
      platinum-based chemotherapy. The determination of this status therefore determines the&#xD;
      adjuvant treatment of CRC and is determined in anatomopathology on the analysis of the&#xD;
      operative specimen.&#xD;
&#xD;
      B / The place of surgery in the care of the CCR:&#xD;
&#xD;
      Currently, the (tumor node metastasis (TNM) classification is used to establish therapeutic&#xD;
      management. Stages I are treated by surgery alone. Stages II are treated by surgery alone in&#xD;
      the absence of risk factors for recurrence and with adjuvant chemotherapy if not. Stages III&#xD;
      are treated by surgery and adjuvant chemotherapy within 8 weeks and for 6 months. For the&#xD;
      stages IV (metastatic), the management of those patients is discussed on a case-by-case basis&#xD;
      according to the symptomatic or non-symptomatic nature of the primary tumor and the&#xD;
      resectability or non-resectability of the metastasis. If there is no contraindication, most&#xD;
      of these patients are treated with first-line chemotherapy, then reassessed every 2 to 3&#xD;
      months.&#xD;
&#xD;
      C / Surgical technic:&#xD;
&#xD;
      Surgical treatment depends on tumor localisation:&#xD;
&#xD;
      In the case of a tumor located on the right colon, from the caecum to the middle of the&#xD;
      transverse colon, a right colectomy is performed associated with lymph node dissection along&#xD;
      the superior mesenteric vessels.&#xD;
&#xD;
      In the case of a tumor located on the left colon, from the middle of the transverse colon to&#xD;
      the rectum, a left colectomy is performed with a dissection centered on the inferior&#xD;
      mesenteric artery.&#xD;
&#xD;
      In current practice, there are different surgical technics for both types of left and right&#xD;
      colectomies. One of the main differences between those technics is the section of vessels&#xD;
      (superior or inferior mesenteric vessels):&#xD;
&#xD;
      The so-called &quot;no touch&quot; technic involves a ligation of the mesenteric vessels before any&#xD;
      tumor mobilization. This technic is the one used systematically at Saint Antoine Hospital for&#xD;
      left colectomy because of the easy dissection of the inferior mesenteric artery and vein in&#xD;
      the absence of mobilization of the left colon, those vessels being at a distance from other&#xD;
      elements (the left ureter is visualized before the ligation of the inferior mesenteric&#xD;
      artery).&#xD;
&#xD;
      An other technic is to first mobilize the tumor to have an optimal exposure of the vessels&#xD;
      before the ligation. This technic is the one routinely performed at Saint Antoine Hospital&#xD;
      for the right colectomies because of the anatomy of the ileocolic artery and the right colic&#xD;
      artery at the origin of which is performed the lymphadenectomy. Indeed the complete&#xD;
      mobilization of the right colon allows a section of the adhesions between the right mesocolon&#xD;
      (which contains the colonic vessels) and the duodenum and the right ureter. In this way, the&#xD;
      section of the right colic vessels can be made at the origin with good control of adjacent&#xD;
      structures. Moreover, the lymph node dissection is systematically performed by laparotomy:&#xD;
      indeed even for colectomies performed under laparoscopy it is necessary to make a&#xD;
      mini-laparotomy incision in order to extract the operative piece and to perform the&#xD;
      anastomosis.&#xD;
&#xD;
      Currently, no difference has been demonstrated in terms of survival without recurrence and&#xD;
      overall survival between those different technics.&#xD;
&#xD;
      Moreover, the choice of the approach, laparoscopic or by laparotomy, depends on the&#xD;
      comorbidities of the patient, severe respiratory failure may be a contraindication to&#xD;
      laparotomy and its history: one or more previous surgeries by laparotomy is considered as a&#xD;
      contraindication to laparoscopy.&#xD;
&#xD;
      D / Circulating tumor DNA (ctDNA) and Circulating Tumor Cells (CTC) in colorectal cancer:&#xD;
&#xD;
      One of the metastatic extension factors of colorectal tumors treated at a localized stage&#xD;
      (stage II and III) is the dissemination of circulating tumor DNA and circulating tumor cells&#xD;
      in the peripheral blood.&#xD;
&#xD;
      Tumor cells witch migrate into the blood and lymphatic vessels from a tumor (primary or&#xD;
      metastasis) are called circulating tumor cells (CTCs). Some of these have a tumor inducing&#xD;
      potential (responsible for relapses) or the ability to form metastasis with time.&#xD;
&#xD;
      Advances in molecular biology technologies (high-throughput sequencing and digital polymerase&#xD;
      chain reaction (PCR), for example) have made possible to consider the exploration of&#xD;
      circulating tumor DNA, which is present in small quantities in plasma. The amount of ctDNA is&#xD;
      proportional to the tumor burden. Thus the mutations of the tumor's DNA (or somatic&#xD;
      mutations) can be identified from the ctDNA, the mutations having a theranostic impact on the&#xD;
      KRAS, NRAS and BRAF genes could be identified in the ctDNA of patients presenting colorectal&#xD;
      cancers. These mutations can thus serve as tracers, the amount of tumor DNA can also be&#xD;
      monitored and DNA methylation tests can also be specific for the tumor DNA. The presence of&#xD;
      these molecular abnormalities can therefore be used to detect CTCs and ctDNA in these&#xD;
      patients. Several studies, initially conducted in the context of breast cancer,have shown the&#xD;
      interest of these two parameters in the monitoring and follow-up of patients with CRC: indeed&#xD;
      their short half-life of a few minutes to a few hours allows a follow-up in real time their&#xD;
      kinetics in the peripheral blood, making it a predictor of earlier relapse than commonly&#xD;
      measured tumor markers (ACE and CA 19-9). In addition, their presence is associated with a&#xD;
      significant decrease in recurrence-free survival and overall survival. Studies in colorectal&#xD;
      cancer show similar results to those shown for breast cancer: In the retrospective study of&#xD;
      Linuma et al, multivariate analysis for relapse-free survival (SSR) and overall survival (SG)&#xD;
      found that patients with CTC expression and positive ctDNA had a worse prognosis than the&#xD;
      others: SG (hazard ratio [HR], 3.84, 95% CI, 2.41 to 6.22, P .001) and SSR ( HR, 3.02, 95%&#xD;
      CI, 1.83 to 5.00, P .001). These results are found in the prospective study by Roder et al,&#xD;
      where the detection of CTC in operated patients with colon cancer is associated with 5-year&#xD;
      Overall survival (OS)of 68% against 85% in patients without CTC detectable. In multivariate&#xD;
      analysis, the results are similar with a significant difference on SG (HR1.94, 95% CI&#xD;
      1.0-3.7, p = 0.04) and SSR (HR 1.94, 95% CI 1.1-3.7, p = 0.044).&#xD;
&#xD;
      E / Determination of microsatellite instability (MSI) status on ctDNA:&#xD;
&#xD;
      Patients with MSI tumors have a better prognosis than microsatellite stability (MSS) patients&#xD;
      and have different sensitivities to chemotherapy. The MSI status is currently determined on&#xD;
      the operative specimen in pathology by determining the expression of the MLH1-MSH2-MSH6 and&#xD;
      PMS2 proteins by immunohistochemistry and by a molecular test determining the instability of&#xD;
      microsatellite markers. The determination of the MSI status on the ctDNA is not carried out&#xD;
      in current practice but raises several questions: is it systematically detectable on the&#xD;
      ctDNA found on peripheral blood when this phenotype is present? Are the ctDNA levels&#xD;
      comparable according to the MSI and MSS status?&#xD;
&#xD;
      F / Influence of the surgical technic on the amount of ctDNA:&#xD;
&#xD;
      In order to limit the metastatic spread of CRC, studies have evaluated standard surgical&#xD;
      technics, particularly in order to limit the release of ctDNA or CTC.&#xD;
&#xD;
      Studies have compared laparoscopy versus laparotomy on the level of ctDNA and intraoperative&#xD;
      CTC in portal and peripheral blood. The results showed a significant decrease in the overall&#xD;
      cDNA level in laparoscopic patients. The randomized prospective study of Wind et al reports&#xD;
      CTC levels in the laparotomy and laparoscopic groups, respectively 44% vs. 5%. 9% (p = 0.046)&#xD;
      in portal blood after mobilization of the tumor. And after resection of the tumor&#xD;
      respectively 29% vs. 20% (p = 0.590) in the portal blood. One of the hypothesis of the&#xD;
      authors to explain this difference is that laparoscopic tumor mobilization is significantly&#xD;
      less important than the one performed during laparotomy.&#xD;
&#xD;
      This hypothesis led to the principle of the &quot;no touch&quot; technic: to achieve the minimum of&#xD;
      intraoperative tumor mobilization with an early ligation of mesenteric vessels.&#xD;
&#xD;
      A few low-level studies have compared ADNct and CTC levels in perioperative peripheral blood&#xD;
      comparing the &quot;no touch&quot; technic with those that mobilize the tumor first. The results show a&#xD;
      tendency to decrease the rates of both markers in the no-touch technic. In the prospective&#xD;
      study by Hayashi et al, 8 out of 11 patients (73%) operated according to the &quot;mobilization&#xD;
      first&quot; technique had detectable CTCs in portal and postoperative portal blood samples whereas&#xD;
      only 1 patient (14%) from the &quot;no touch&quot; group was detected.&#xD;
&#xD;
      G / Objective:&#xD;
&#xD;
      The objective of this work is to compare the amount of ctDNA and CTC in the peripheral blood&#xD;
      at D-1, D1 and D3 after colectomy for localized adenocarcinoma using the surgical &quot;no touch&quot;&#xD;
      technic against mobilization first and to determine the MSI status on ctDNA.&#xD;
&#xD;
      The standard procedure for hospitalization for patients requiring colectomy for CCR is as&#xD;
      follows:&#xD;
&#xD;
        -  A preoperative consultation with the surgeon and one with the anesthesiologist.&#xD;
&#xD;
        -  Hospitalization the day before the intervention with visit of the surgeon and the&#xD;
           anesthesiologist, blood sample of a complete preoperative assessment (D-1).&#xD;
&#xD;
        -  Intervention (D0): right or left colectomy depending on tumor localization.&#xD;
&#xD;
        -  Systematic blood test after surgery on D1, D3: samples of 4ml tubes for blood count&#xD;
           determination, blood Ionogram and assay of C-reactive protein.&#xD;
&#xD;
        -  Release on D4 depending on the clinical condition and the results of the blood tests.&#xD;
&#xD;
      As part of the research:&#xD;
&#xD;
        -  An information note is given to the subject the day before the intervention and a&#xD;
           written statement is collected before the J-1 levy&#xD;
&#xD;
        -  During the blood samples taken as part of the treatment, an additional volume is&#xD;
           collected 2 samples of 6mL at D-1 then at D1 and D3 to measure the levels of circulating&#xD;
           tumor cells and tumor circulating DNA by PCR and the MSI status. There is no blood&#xD;
           sample added by the research, the tubes are thus collected at the same time as the&#xD;
           standard blood samples of usual perioperative follow-up.&#xD;
&#xD;
      D / ctDNA Extraction, Molecular Tests, and CTC Detection:&#xD;
&#xD;
      The extraction of complementary deoxyribonucleic acid (cDNA) will be performed with an&#xD;
      extraction automaton (MaxwellTM) from 6 ml of plasma obtained from the blood sample. The cDNA&#xD;
      obtained will be quantified by fluorimetry and quantitative polymerase chain reaction (qPCR).&#xD;
      Molecular analyzes will be performed by high-throughput sequencing on targets of interest in&#xD;
      colorectal cancer and supplemented with digital PCR targeting mutations previously identified&#xD;
      by sequencing the primary tumor (from the operative specimen). A set up of DNA methylation&#xD;
      tests can also be done.&#xD;
&#xD;
      Due to the rarity of CTCs, it is necessary to proceed in two steps: i) enrichment followed&#xD;
      ii) ScreenCell® detection is a non-invasive technique that allows to enrich from the&#xD;
      peripheral blood a cell fraction containing circulating cells The ScreenCell® Molecular&#xD;
      Biology (MB) kit then makes it possible to carry out molecular analyzes such as PCRs in order&#xD;
      to sequence the gene of interest. This ScreenCell® MB kit allows DNAse free filtration.&#xD;
      Before filtration, 6 ml of blood are diluted in 1 ml of the buffer provided. Two minutes&#xD;
      after 1.6 ml of the culture medium adapted to the blood cells studied. After filtration, the&#xD;
      kit allows extraction of RNA directly from isolated cells in the filter. An adequate volume&#xD;
      of the lysis buffer is added directly to the filter capsule (closed in an eppendorf) to&#xD;
      extract RNA from the isolated cells in the filter. After centrifugation, the genetic material&#xD;
      will be analyzed. For this, a reverse transcriptase will be performed in order to obtain the&#xD;
      cDNA of interest.&#xD;
&#xD;
      Statistical analyzes will be performed to compare tumor cell and circulating DNA levels&#xD;
      according to non parametric Fisher or chi² tests. A value of p &lt;0.005 is considered&#xD;
      significant.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Unknown status</overall_status>
  <last_known_status>Recruiting</last_known_status>
  <start_date type="Actual">February 5, 2019</start_date>
  <completion_date type="Anticipated">August 2019</completion_date>
  <primary_completion_date type="Anticipated">August 2019</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Cohort</observational_model>
    <time_perspective>Prospective</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>Presence of ctDNA</measure>
    <time_frame>Day 1</time_frame>
    <description>Evaluate the presence of ctDNA on D1 postoperatively by comparing the two methods of surgery: &quot;no touch&quot; method and first mobilization of the tumor in patients with colon cancer</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Presence of ctDNA</measure>
    <time_frame>Day -1</time_frame>
    <description>Evaluate the presence of ctDNA on D-1 postoperatively by comparing the two methods of surgery: &quot;no touch&quot; method and first mobilization of the tumor in patients with colon cancer</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Presence of ctDNA</measure>
    <time_frame>Day 3</time_frame>
    <description>Evaluate the presence of ctDNA on D3 postoperatively by comparing the two methods of surgery: &quot;no touch&quot; method and first mobilization of the tumor in patients with colon cancer</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Presence of CTC</measure>
    <time_frame>Day -1, Day 1 and Day 3</time_frame>
    <description>Evaluate the presence of CTC at D-1, D1 and D3 in peripheral blood by comparing the two methods of surgery between the &quot;no touch&quot; method and first mobilization of the tumor in patients with colon cancer.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>MSI status</measure>
    <time_frame>Day -1, Day 1 and Day 3</time_frame>
    <description>Determine the MSI status on ctDNA in the postoperative period.</description>
  </secondary_outcome>
  <number_of_groups>2</number_of_groups>
  <enrollment type="Anticipated">40</enrollment>
  <condition>Colorectal Cancer</condition>
  <arm_group>
    <arm_group_label>&quot;No touch&quot; group:</arm_group_label>
    <description>Patients with left sided colic adenocarcinoma who underwent left colectomy with an early ligation of mesenteric vessels</description>
  </arm_group>
  <arm_group>
    <arm_group_label>&quot;Mobilisation first&quot; group</arm_group_label>
    <description>patients with right colic adenocarcinoma who underwent right colectomy with early mobilisation of the tumor followed by the ligation of the vessels.</description>
  </arm_group>
  <biospec_retention>Samples With DNA</biospec_retention>
  <biospec_descr>
    <textblock>
      2 samples of 6ml of peripherical blood&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        All patients, aged over 18 years old and more, undergoing colectomy for non-metastatic&#xD;
        adenocarcinoma (stage I, II, III) in the colorectal surgery department at St Antoine&#xD;
        Hospital from 01/01/2018 to 1/07/2019 are included in the study. Written consent is&#xD;
        obtained at the time of admission.&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Probability Sample</sampling_method>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  men and women, aged over18 years old and more&#xD;
&#xD;
          -  colectomy for localized colon adenocarcinoma&#xD;
&#xD;
          -  Adenocarcinoma of the colon stage 1,2,3&#xD;
&#xD;
          -  Patient having signed the consent&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  carcinomatosis&#xD;
&#xD;
          -  metastatic tumor&#xD;
&#xD;
          -  pregnancy and breast feeding&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
  </eligibility>
  <overall_official>
    <last_name>Yann Parc, PU-PH</last_name>
    <role>Principal Investigator</role>
    <affiliation>Assistance Publique - Hôpitaux de Paris</affiliation>
  </overall_official>
  <overall_contact>
    <last_name>Yann Parc, PU-PH</last_name>
    <phone>0149282540</phone>
    <email>yann.parc@aphp.fr</email>
  </overall_contact>
  <overall_contact_backup>
    <last_name>Jeremie Lefevre, MD, PhD</last_name>
    <phone>0149282540</phone>
    <email>jeremie.lefevre@aphp.fr</email>
  </overall_contact_backup>
  <location>
    <facility>
      <name>Department of Digestive Surgery, Hôpital Saint-Antoine</name>
      <address>
        <city>Paris</city>
        <zip>75012</zip>
        <country>France</country>
      </address>
    </facility>
    <status>Recruiting</status>
    <contact>
      <last_name>Yann PARC, PUPH, MD</last_name>
      <phone>00 33 1 49 28 25 47</phone>
      <email>yann.parc@sat.aphp.fr</email>
    </contact>
    <contact_backup>
      <last_name>Hélène HERMAND, Degree</last_name>
      <phone>00 33 1 49 28 66 80</phone>
      <email>alex.duval@inserm.fr</email>
    </contact_backup>
  </location>
  <location_countries>
    <country>France</country>
  </location_countries>
  <verification_date>February 2019</verification_date>
  <study_first_submitted>December 20, 2018</study_first_submitted>
  <study_first_submitted_qc>January 17, 2019</study_first_submitted_qc>
  <study_first_posted type="Actual">January 18, 2019</study_first_posted>
  <last_update_submitted>March 12, 2019</last_update_submitted>
  <last_update_submitted_qc>March 12, 2019</last_update_submitted_qc>
  <last_update_posted type="Actual">March 14, 2019</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor</responsible_party_type>
  </responsible_party>
  <keyword>Colorectal cancer</keyword>
  <keyword>Surgical Technic</keyword>
  <keyword>No touch technic</keyword>
  <keyword>Circulating Tumor DNA</keyword>
  <keyword>Circulating Tumor Cells</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Colorectal Neoplasms</mesh_term>
    <mesh_term>Neoplastic Cells, Circulating</mesh_term>
  </condition_browse>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03809403
org study id: APHP180453
nct id: NCT03809403
lead sponsor: 
collaborator: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
Colectomy is the most commonly used therapeutic approach for the treatment of non-metastatic
      colorectal cancer. This approach is generally very effective however the rate of recurrence
      and the appearance of metachronous metastasis remains a major problem in the postoperative
      period. One of the hypothesis that can explain this tumor progression is the dissemination of
      tumor cells at the time of tumor mobilization. In this work, we wish to verify this
      hypothesis by comparing two surgical technics used in our department for left or right
      colectomies: respectively either first section of the mesenteric vessels followed by the
      mobilization of the tumor or first mobilization of the tumor followed by the section of the
      mesenteric vessels. To evaluate the dissemination, we will study two disseminations markers
      that have shown their prognostic value: i) circulating tumor cells (which represent a direct
      marker of dissemination) and ii) tumor circulating DNA (which is an indirect marker) but has
      the advantage of being more representative of all tumor clones and therefore the tumor burden
      released into the blood at the time of surgery).
A / Epidemiology of colorectal cancer

      Colorectal cancer remains the third most common cancer in France in 2017 with an incidence of
      about 44,000 new cases in 2017 and nearly 18,000 deaths each year. The ColoRectal Cancer
      (CRC) ranks second among cancer deaths behind lung cancer and breast cancer. Thanks to
      diagnostic and therapeutic progress, the mortality rate decrease of 1.5% in men and 1.1% in
      women between 2005 and 2012.

      Despite these numbers, colorectal cancer has a good prognosis when diagnosed at an early
      stage. In fact, the 5-year relative survival is 91% for localized stages (stage I and II) and
      70% for stages with locoregional and lymph nodes invasion (stage III). On the other hand,
      about 25% of the patients at the time of diagnosis have metastasis (stage IV), with a
      survival at 5 years of 11%. Those data explain that the mortality of this cancer is mainly
      due to the spread of the primary tumor to secondary locations, mainly liver or lung.

      The unstable microsatellite phenotype (ISM) is an important colonic carcinogenesis pathway,
      find in approximately 15% of operable colorectal cancers (CRC) and may be of sporadic or
      hereditary origin. Several studies have shown that patients with MSI tumors have a better
      prognosis than patients with stable microsatellite tumors (SSM) due to a better response to
      platinum-based chemotherapy. The determination of this status therefore determines the
      adjuvant treatment of CRC and is determined in anatomopathology on the analysis of the
      operative specimen.

      B / The place of surgery in the care of the CCR:

      Currently, the (tumor node metastasis (TNM) classification is used to establish therapeutic
      management. Stages I are treated by surgery alone. Stages II are treated by surgery alone in
      the absence of risk factors for recurrence and with adjuvant chemotherapy if not. Stages III
      are treated by surgery and adjuvant chemotherapy within 8 weeks and for 6 months. For the
      stages IV (metastatic), the management of those patients is discussed on a case-by-case basis
      according to the symptomatic or non-symptomatic nature of the primary tumor and the
      resectability or non-resectability of the metastasis. If there is no contraindication, most
      of these patients are treated with first-line chemotherapy, then reassessed every 2 to 3
      months.

      C / Surgical technic:

      Surgical treatment depends on tumor localisation:

      In the case of a tumor located on the right colon, from the caecum to the middle of the
      transverse colon, a right colectomy is performed associated with lymph node dissection along
      the superior mesenteric vessels.

      In the case of a tumor located on the left colon, from the middle of the transverse colon to
      the rectum, a left colectomy is performed with a dissection centered on the inferior
      mesenteric artery.

      In current practice, there are different surgical technics for both types of left and right
      colectomies. One of the main differences between those technics is the section of vessels
      (superior or inferior mesenteric vessels):

      The so-called "no touch" technic involves a ligation of the mesenteric vessels before any
      tumor mobilization. This technic is the one used systematically at Saint Antoine Hospital for
      left colectomy because of the easy dissection of the inferior mesenteric artery and vein in
      the absence of mobilization of the left colon, those vessels being at a distance from other
      elements (the left ureter is visualized before the ligation of the inferior mesenteric
      artery).

      An other technic is to first mobilize the tumor to have an optimal exposure of the vessels
      before the ligation. This technic is the one routinely performed at Saint Antoine Hospital
      for the right colectomies because of the anatomy of the ileocolic artery and the right colic
      artery at the origin of which is performed the lymphadenectomy. Indeed the complete
      mobilization of the right colon allows a section of the adhesions between the right mesocolon
      (which contains the colonic vessels) and the duodenum and the right ureter. In this way, the
      section of the right colic vessels can be made at the origin with good control of adjacent
      structures. Moreover, the lymph node dissection is systematically performed by laparotomy:
      indeed even for colectomies performed under laparoscopy it is necessary to make a
      mini-laparotomy incision in order to extract the operative piece and to perform the
      anastomosis.

      Currently, no difference has been demonstrated in terms of survival without recurrence and
      overall survival between those different technics.

      Moreover, the choice of the approach, laparoscopic or by laparotomy, depends on the
      comorbidities of the patient, severe respiratory failure may be a contraindication to
      laparotomy and its history: one or more previous surgeries by laparotomy is considered as a
      contraindication to laparoscopy.

      D / Circulating tumor DNA (ctDNA) and Circulating Tumor Cells (CTC) in colorectal cancer:

      One of the metastatic extension factors of colorectal tumors treated at a localized stage
      (stage II and III) is the dissemination of circulating tumor DNA and circulating tumor cells
      in the peripheral blood.

      Tumor cells witch migrate into the blood and lymphatic vessels from a tumor (primary or
      metastasis) are called circulating tumor cells (CTCs). Some of these have a tumor inducing
      potential (responsible for relapses) or the ability to form metastasis with time.

      Advances in molecular biology technologies (high-throughput sequencing and digital polymerase
      chain reaction (PCR), for example) have made possible to consider the exploration of
      circulating tumor DNA, which is present in small quantities in plasma. The amount of ctDNA is
      proportional to the tumor burden. Thus the mutations of the tumor's DNA (or somatic
      mutations) can be identified from the ctDNA, the mutations having a theranostic impact on the
      KRAS, NRAS and BRAF genes could be identified in the ctDNA of patients presenting colorectal
      cancers. These mutations can thus serve as tracers, the amount of tumor DNA can also be
      monitored and DNA methylation tests can also be specific for the tumor DNA. The presence of
      these molecular abnormalities can therefore be used to detect CTCs and ctDNA in these
      patients. Several studies, initially conducted in the context of breast cancer,have shown the
      interest of these two parameters in the monitoring and follow-up of patients with CRC: indeed
      their short half-life of a few minutes to a few hours allows a follow-up in real time their
      kinetics in the peripheral blood, making it a predictor of earlier relapse than commonly
      measured tumor markers (ACE and CA 19-9). In addition, their presence is associated with a
      significant decrease in recurrence-free survival and overall survival. Studies in colorectal
      cancer show similar results to those shown for breast cancer: In the retrospective study of
      Linuma et al, multivariate analysis for relapse-free survival (SSR) and overall survival (SG)
      found that patients with CTC expression and positive ctDNA had a worse prognosis than the
      others: SG (hazard ratio [HR], 3.84, 95% CI, 2.41 to 6.22, P .001) and SSR ( HR, 3.02, 95%
      CI, 1.83 to 5.00, P .001). These results are found in the prospective study by Roder et al,
      where the detection of CTC in operated patients with colon cancer is associated with 5-year
      Overall survival (OS)of 68% against 85% in patients without CTC detectable. In multivariate
      analysis, the results are similar with a significant difference on SG (HR1.94, 95% CI
      1.0-3.7, p = 0.04) and SSR (HR 1.94, 95% CI 1.1-3.7, p = 0.044).

      E / Determination of microsatellite instability (MSI) status on ctDNA:

      Patients with MSI tumors have a better prognosis than microsatellite stability (MSS) patients
      and have different sensitivities to chemotherapy. The MSI status is currently determined on
      the operative specimen in pathology by determining the expression of the MLH1-MSH2-MSH6 and
      PMS2 proteins by immunohistochemistry and by a molecular test determining the instability of
      microsatellite markers. The determination of the MSI status on the ctDNA is not carried out
      in current practice but raises several questions: is it systematically detectable on the
      ctDNA found on peripheral blood when this phenotype is present? Are the ctDNA levels
      comparable according to the MSI and MSS status?

      F / Influence of the surgical technic on the amount of ctDNA:

      In order to limit the metastatic spread of CRC, studies have evaluated standard surgical
      technics, particularly in order to limit the release of ctDNA or CTC.

      Studies have compared laparoscopy versus laparotomy on the level of ctDNA and intraoperative
      CTC in portal and peripheral blood. The results showed a significant decrease in the overall
      cDNA level in laparoscopic patients. The randomized prospective study of Wind et al reports
      CTC levels in the laparotomy and laparoscopic groups, respectively 44% vs. 5%. 9% (p = 0.046)
      in portal blood after mobilization of the tumor. And after resection of the tumor
      respectively 29% vs. 20% (p = 0.590) in the portal blood. One of the hypothesis of the
      authors to explain this difference is that laparoscopic tumor mobilization is significantly
      less important than the one performed during laparotomy.

      This hypothesis led to the principle of the "no touch" technic: to achieve the minimum of
      intraoperative tumor mobilization with an early ligation of mesenteric vessels.

      A few low-level studies have compared ADNct and CTC levels in perioperative peripheral blood
      comparing the "no touch" technic with those that mobilize the tumor first. The results show a
      tendency to decrease the rates of both markers in the no-touch technic. In the prospective
      study by Hayashi et al, 8 out of 11 patients (73%) operated according to the "mobilization
      first" technique had detectable CTCs in portal and postoperative portal blood samples whereas
      only 1 patient (14%) from the "no touch" group was detected.

      G / Objective:

      The objective of this work is to compare the amount of ctDNA and CTC in the peripheral blood
      at D-1, D1 and D3 after colectomy for localized adenocarcinoma using the surgical "no touch"
      technic against mobilization first and to determine the MSI status on ctDNA.

      The standard procedure for hospitalization for patients requiring colectomy for CCR is as
      follows:

        -  A preoperative consultation with the surgeon and one with the anesthesiologist.

        -  Hospitalization the day before the intervention with visit of the surgeon and the
           anesthesiologist, blood sample of a complete preoperative assessment (D-1).

        -  Intervention (D0): right or left colectomy depending on tumor localization.

        -  Systematic blood test after surgery on D1, D3: samples of 4ml tubes for blood count
           determination, blood Ionogram and assay of C-reactive protein.

        -  Release on D4 depending on the clinical condition and the results of the blood tests.

      As part of the research:

        -  An information note is given to the subject the day before the intervention and a
           written statement is collected before the J-1 levy

        -  During the blood samples taken as part of the treatment, an additional volume is
           collected 2 samples of 6mL at D-1 then at D1 and D3 to measure the levels of circulating
           tumor cells and tumor circulating DNA by PCR and the MSI status. There is no blood
           sample added by the research, the tubes are thus collected at the same time as the
           standard blood samples of usual perioperative follow-up.

      D / ctDNA Extraction, Molecular Tests, and CTC Detection:

      The extraction of complementary deoxyribonucleic acid (cDNA) will be performed with an
      extraction automaton (MaxwellTM) from 6 ml of plasma obtained from the blood sample. The cDNA
      obtained will be quantified by fluorimetry and quantitative polymerase chain reaction (qPCR).
      Molecular analyzes will be performed by high-throughput sequencing on targets of interest in
      colorectal cancer and supplemented with digital PCR targeting mutations previously identified
      by sequencing the primary tumor (from the operative specimen). A set up of DNA methylation
      tests can also be done.

      Due to the rarity of CTCs, it is necessary to proceed in two steps: i) enrichment followed
      ii) ScreenCell® detection is a non-invasive technique that allows to enrich from the
      peripheral blood a cell fraction containing circulating cells The ScreenCell® Molecular
      Biology (MB) kit then makes it possible to carry out molecular analyzes such as PCRs in order
      to sequence the gene of interest. This ScreenCell® MB kit allows DNAse free filtration.
      Before filtration, 6 ml of blood are diluted in 1 ml of the buffer provided. Two minutes
      after 1.6 ml of the culture medium adapted to the blood cells studied. After filtration, the
      kit allows extraction of RNA directly from isolated cells in the filter. An adequate volume
      of the lysis buffer is added directly to the filter capsule (closed in an eppendorf) to
      extract RNA from the isolated cells in the filter. After centrifugation, the genetic material
      will be analyzed. For this, a reverse transcriptase will be performed in order to obtain the
      cDNA of interest.

      Statistical analyzes will be performed to compare tumor cell and circulating DNA levels
      according to non parametric Fisher or chi² tests. A value of p <0.005 is considered
      significant.
observational model: Cohort
time perspective: Prospective
measure: Presence of ctDNA
time frame: Day 1
description: Evaluate the presence of ctDNA on D1 postoperatively by comparing the two methods of surgery: "no touch" method and first mobilization of the tumor in patients with colon cancer
measure: Presence of ctDNA
time frame: Day -1
description: Evaluate the presence of ctDNA on D-1 postoperatively by comparing the two methods of surgery: "no touch" method and first mobilization of the tumor in patients with colon cancer
measure: Presence of ctDNA
time frame: Day 3
description: Evaluate the presence of ctDNA on D3 postoperatively by comparing the two methods of surgery: "no touch" method and first mobilization of the tumor in patients with colon cancer
measure: Presence of CTC
time frame: Day -1, Day 1 and Day 3
description: Evaluate the presence of CTC at D-1, D1 and D3 in peripheral blood by comparing the two methods of surgery between the "no touch" method and first mobilization of the tumor in patients with colon cancer.
measure: MSI status
time frame: Day -1, Day 1 and Day 3
description: Determine the MSI status on ctDNA in the postoperative period.
arm group label: "No touch" group:
description: Patients with left sided colic adenocarcinoma who underwent left colectomy with an early ligation of mesenteric vessels
arm group label: "Mobilisation first" group
description: patients with right colic adenocarcinoma who underwent right colectomy with early mobilisation of the tumor followed by the ligation of the vessels.
2 samples of 6ml of peripherical blood
study pop: 
sampling method: Probability Sample
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
last name: Yann Parc, PU-PH
role: Principal Investigator
affiliation: Assistance Publique - Hôpitaux de Paris
last name: Yann Parc, PU-PH
phone: 0149282540
email: yann.parc@aphp.fr
last name: Jeremie Lefevre, MD, PhD
phone: 0149282540
email: jeremie.lefevre@aphp.fr
facility: 
status: Recruiting
contact: 
contact backup: 
country: France
responsible party type: Sponsor
mesh term: Colorectal Neoplasms
mesh term: Neoplastic Cells, Circulating