[Recurrence of Jejunal Carcinoma in the Ileum and Ovary - A Case Report]

Small bowel carcinoma has poor prognosis. The basis of treatment is surgical resection. There are no established guidelines for chemotherapy. We report a case in which we performed surgical resection of recurrent jejunal carcinoma. A 62-year-old woman underwent laparoscopic partial resection of the small intestine for primary jejunal carcinoma. The final diagnosis was T3N0M0, fStage II A. After 16 months of follow-up, she developed abdominal pain and vomiting. We diagnosed recurrence of jejunal carcinoma in the ileum and right ovary. Single-port laparoscopic small intestinal resection and right ovariectomy were performed. The patient underwent curative resection for recurrent lesions. The type of tumor in the ileum and right ovary was consistent with primary jejunal carcinoma by histopathological examination, and was diagnosed as recurrence of jejunal carcinoma. She is now on adjuvant chemotherapy with XELOX.

The short-term outcomes of laparoscopic multivisceral resection for locally advanced colorectal cancer: our experience of 39 cases

PURPOSE

Laparoscopic surgery for locally advanced colorectal cancer suspected of direct invasion to adjacent organs or structures remains controversial because of its high conversion rate, inadequate oncologic clearance and surgical outcomes. This study retrospectively evaluated the short-term outcomes of laparoscopic multivisceral resection for colorectal cancer and investigated the factors influencing conversion to open surgery.

METHODS

Between 2010 and 2015, 39 patients who underwent laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures were included. The conversion rate, resection margin status, surgical results, and morbidity and mortality rates were evaluated. We also investigated the factors influencing conversion.

RESULTS

The conversion rate was 28 %. The resection margin was negative in all cases. The median operative time was 247 min, and the median blood loss was 80 ml. The postoperative mortality rate was 0 %, and the morbidity rate was 28 %; complications of Grade 3 or more were observed in 2 patients (5 %). The factors influencing conversion were ≥2 adherent organs (p = 0.028) and clinical suspicion of direct invasion to adjacent organs (cT4b) (p = 0.076).

CONCLUSION

Laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures is feasible in selected patients. Conversion is more likely with ≥2 adherent organs and cT4b.

Safety and efficacy of an "enhanced recovery after surgery" protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study

PURPOSE

The aim of this multi-institutional study was to prospectively evaluate the safety and efficacy of an enhanced recovery after surgery (ERAS) protocol for colonic surgery.

METHODS

The subjects of this study were 320 patients with an American Society of Anesthesiologists (ASA) grade I or II physical status. Patients underwent elective open or laparoscopic colonic resection or high anterior resection between April 2011 and January 2014 at one of six institutions. Three hospitals implemented an ERAS protocol (n = 159), and three administered conventional care (n = 161). The primary outcome measure was the surgical complication rate.

RESULTS

Most operations, irrespective of group, were performed laparoscopically. The incidence of a surgical complication was 17.0 % in the ERAS group vs. 16.1 % in the conventional group (P = 0.842), in which several non-surgical complications also arose. Oral food intake was implemented earlier for the ERAS group vs. the conventional group, after a median (range) of 1 (1-31) vs. 3 (1-9) days for the ERAS vs. conventional care groups, respectively (P < 0.001). The median length of postoperative hospital stay was reduced by 5.5 days for the ERAS group, being 8.5 (5-41) vs. 14 (7-56) days for the ERAS vs. conventional care groups, respectively (P < 0.001).

CONCLUSION

This multi-institutional controlled study clearly demonstrated that an ERAS protocol was efficient, without increasing the complication risk.

Long-term outcome of adrenalectomy for metastasis resulting from colorectal cancer with other metastatic sites: A report of 3 cases

Metastasis to the adrenal glands is a relatively frequent observation at autopsy of patients that have succumbed to cancer. Long-term disease-free survival has been reported in patients following the resection of solitary adrenal metastasis resulting from colorectal cancer. In addition, following primary resection for colorectal cancer, solitary metastasis to the adrenal glands is rare, even in outpatients at routine follow-ups. Therefore, adrenal metastasis is usually detected in combination with multiple synchronous metastases at other sites in the terminal stages of cancer. Between 1998 and 2002, 3 patients with adrenal metastasis and other synchronous metastatic sites underwent surgery for adrenal metastasis at the Department of Gastroenterological Surgery at Osaka University. The other synchronous metastatic sites observed in the 3 patients consisted of lung and para-aortic lymph nodes. In total, 2 out of the 3 patients experienced long-term disease-free survival for >5 years following surgery and 1 patient underwent curative resection for recurrence of metastases in the liver and right adrenal gland 79 months subsequent to the initial resection for adrenal metastasis. All 3 patients survived for >90 months. In conclusion, aggressive surgical resection for adrenal metastasis and other metastatic sites resulting from colorectal cancer may result in a survival benefit in selected patients.

Efficacy and Safety of Regorafenib or TAS-102 in Patients with Metastatic Colorectal Cancer Refractory to Standard Therapies

BACKGROUND

Regorafenib and TAS-102 are novel antitumor agents for patients with metastatic colorectal cancer (mCRC) whose disease has progressed after standard therapies. In randomized trials, regorafenib and TAS-102 prolonged survival in patients with mCRC. However, the appropriate selection of regorafenib or TAS-102 in treatment strategy has not yet been established.

PATIENTS AND METHODS

We performed a retrospective analysis, between March 2013 and July 2015, on the efficacy and safety of regorafenib or TAS-102.

RESULTS

Thirty-seven patients with mCRC treated with regorafenib or TAS-102 were included. Of these 37 patients, 23 first received regorafenib and 14 received TAS-102. The median progression-free survival and overall survival were 3.0 and 5.8 months, respectively, in the regorafenib group and 2.1 and 6.3 months, respectively, in the TAS-102 group. Drug-related adverse events (AEs) and grade ≥3 AEs were 23 (100%) and 10 (43.5%), respectively, in the regorafenib group and 13 (92.9%) and 2 (14.3%), respectively, in the TAS-102 group. The most frequent grade ≥3 AEs were hepatotoxicity (17.4%) and hand-foot syndrome (13.0%) in the regorafenib group, and neutropenia (14.3%) in the TAS-102 group. In subgroup analysis, the median overall survival was 11.5 months in patients receiving crossover treatment with regorafenib to TAS-102, and 7.6 months in those receiving crossover treatment with TAS-102 to regorafenib.

CONCLUSION

Our results showed that regorafenib and TAS-102 have comparable efficacy but different toxicity profiles in patients with mCRC. Both are considered new salvage treatment options. Differences in the toxicity profiles between the two treatments will help in choosing regorafenib or TAS-102.

First-line cetuximab-based chemotherapies for patients with advanced or metastatic KRAS wild-type colorectal cancer

Colorectal cancer (CRC) is one of the most commonly occurring cancers worldwide. A burgeoning number of studies have demonstrated that the addition of cetuximab to another standard first-line regimen markedly improves the outcome of CRC treatment. However, at present, the efficacy and safety of cetuximab-based combination chemotherapy has not been well described in Japan. The aim of the present study was to evaluate the efficacy and safety of first-line chemotherapies that included cetuximab for patients with advanced or metastatic Kirsten rat sarcoma viral oncogene homolog (KRAS) wild-type CRC in Japan. This prospective multicenter observational study was conducted at 13 affiliated medical institutions. A total of 64 patients were enrolled between 2010 and 2013. The patients met the following criteria for eligibility: i) histologically confirmed, advanced or metastatic KRAS wild-type CRC; and ii) cetuximab-based chemotherapies administered as a first-line treatment. First-line cetuximab-based treatments were administered as follows: 29 patients (45.3%) received a combination of infusional fluorouracil, leucovorin and oxaliplatin; 14 patients (21.9%) received a combination of capecitabine and oxaliplatin; and 10 patients (15.6%) received a combination of infusional fluorouracil, leucovorin and irinotecan. The overall response rate (including complete plus partial responses) was 50% (32/64 patients). Initially, 48 lesions were diagnosed as unresectable. Among those, 13 lesions (27.1%) were converted to a resectable status following cetuximab-based combination chemotherapy treatments. The median overall survival time and the progression-free survival time were 1,189 and 359 days, respectively. The most frequent grade 3/4 adverse event was neutropenia, which occurred in 20.3% of the patients. The incidence of grade 3/4 skin toxicity was 17.2% (11/64 patients). Cetuximab-based therapies may represent a promising first-line regimen for patients with advanced or metastatic KRAS wild-type CRC in Japan. In addition, this combination was associated with a low incidence of serious toxicities.

Identification of a human intestinal myeloid cell subset that regulates gut homeostasis

Inappropriate activation of T helper (Th) cells, such as Th1 and Th17 cells, is implicated in the pathogenesis of chronic inflammatory disorders including ulcerative colitis (UC). CX₃CR1^high macrophages contribute to intestinal homeostasis through various mechanisms in mice. However, whether mononuclear phagocytes with regulatory functions are present in the human colon is not clearly defined. We investigated whether innate myeloid cells that suppress activation of effector T cells exist in the human intestinal mucosa. Among intestinal lamina propria cells, Lin^- HLA-DR^high CD14⁺ CD163^high cells were subdivided into CD160^low and CD160^high cells. Both subsets produced high levels of IL-10. CD163^high CD160^high cells suppressed effector T cell proliferation, whereas CD163^high CD160^low cells induced Th17 differentiation. Patients with UC exhibited increased numbers of CD163^high CD160^low cells, while showing profoundly decreased numbers of CD163^high CD160^high cells. In this context, CD163^high CD160^high cells had higher CD80/CD86 expression and lower IL10RB expression, and these cells did not suppress effector T cell proliferation. The CD163^high CD160^high subset in normal intestinal mucosa inhibits inappropriate Th1/Th17 responses through suppression of their proliferation, and its number and suppressive activity are impaired in patients with UC. These findings indicate how human innate immune cells might prevent UC development.

Abstract 1718: Characteristics of carbonic anhydrase 9-expressing cells in the human intestinal crypt base

Background/Aims: In many tissues, stem cells are sequestered in hypoxic microenvironments. However, little is known about the relationship between hypoxia and the intestinal crypt base, the presumed location of intestinal stem cells. This study investigated the expression of carbonic anhydrase 9 (CA9), a hypoxia-inducible membrane-tethered protein, in normal intestinal crypt base cells and in adenoma and early colorectal cancer.

Methods: Using surgically resected human colorectal cancer specimens, we investigated the expression pattern and functional associations of CA9 in human adult normal intestinal epithelia and in adenoma and early colorectal cancer using immunofluorescence, immunohistochemical staining, flow cytometry, and quantitative real-time polymerase chain reaction.

Results: Almost all slender cells in the crypt base in the ileum were CA9+. In the right and left colon, 25% and 40% of all cells, respectively, were CA9+. Notably, CA9+ cells had eosinophilic structures in their basal cytoplasm. Adenomas and T1 colorectal cancer showed broad CA9 expression. Flow cytometry analysis indicated that CA9+ cells had increased mRNA levels of AXIN2, a Wnt signaling factor.

Conclusion: These observations indicate that CA9 expression in normal crypt base cells is associated with intestinal epithelial stemness. CA9 expression may be involved in the carcinogenesis of colorectal cancer.

Citation Format: Yozo Suzuki, Hidekazu Takahashi, Masahiro Tanemura, Junichi Nishimura, Naotsugu Haraguchi, Masahisa Ohtsuka, Susumu Miyazaki, Mamoru Uemura, Taishi Hata, Tsunekazu Mizushima, Hirofumi Yamamoto, Yuichiro Doki, Masaki Mori. Characteristics of carbonic anhydrase 9-expressing cells in the human intestinal crypt base. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1718.

Safety of Emulsifying Lipid Formulation Containing Omega-3 Polyunsaturated Fatty Acids for Patients with Crohn's Disease

BACKGROUND/AIM

The efficacy of omega-3 supplementation by oral capsule for patients with Crohn's disease (CD) remains controversial. We investigated the safety and efficacy of an omega-3 emulsified formulation.

PATIENTS AND METHODS

Six patients with CD in remission participated in this open-label clinical trial. Patients ingested one bottle (100 ml) of the test formulation (IMARK S®) daily for 28 days. After a 1-month washout period, patients ingested two bottles of the formulation daily for 28 days. Anthropometric and blood tests were performed before and after each intervention.

RESULTS

The omega-3 emulsifying formulation was safe with minimal side-effects. Body weight and body-mass index were not altered; however, CD activity index scores tended to decrease after ingested one bottle of formulation. Blood tests revealed no severe adverse effects.

CONCLUSION

Supplementation with an omega-3 emulsifying formulation can be safe and useful for maintaining remission in patients with CD and warrants further studies.

Prediction of Postoperative Complications Following Elective Surgery in Elderly Patients with Colorectal Cancer Using the Comprehensive Geriatric Assessment

AIMS

The study aims to determine whether the Comprehensive Geriatric Assessment (CGA) could predict complications of colorectal cancer (CRC) surgery and identify the problems. So we compared the prognostic value of the CGA with patient characteristics and determined predictive scores.

METHODS

A total of 156 patients aged 75 years and older, who underwent surgery for CRC at Osaka University Hospital, were enrolled. Each patient was examined by the CGA prospectively, and all postoperative complications were obtained from the medical records. The CGA included the Barthel Index (BI), Vitality Index, instrumental activities of daily living (iADL), Mini-Mental State Examination (MMSE) and Geriatric Depression Score (GDS). All elements were retrospectively compared in patients with or without postoperative complications, including delirium, surgical site infection and ileus.

RESULTS

Overall, postoperative complications developed in 76 patients (48.7%). The BI and MMSE were associated with the incidence of complications, and BI, iADL, MMSE and GDS were significantly related with delirium. Multivariate logistic analysis identified the MMSE as a significant determinant of postoperative complications after adjusting for other determined predictive scores including the prognostic nutritional index and performance status.

CONCLUSION

The CGA was a useful predictor of postoperative complications in elderly patients when administered before surgery for CRC.

Regeneration of peritoneal mesothelial cells after placement of hyaluronate carboxymethyl-cellulose (Seprafilm®)

PURPOSE

To examine the regeneration of mesothelium under a bioresorbable membrane.

METHODS

A 1 cm² piece of peritoneum was resected from both sides of the abdominal wall of retired female mice. A piece of hyaluronate and carboxymethyl-cellulose (Seprafilm^®) was placed over the wound on one side and the other side was left uncovered. We evaluated the degree of adhesion and regeneration of mesothelial cells macroscopically and histologically using immunohistochemistry at different times.

RESULTS

Macroscopically, the degree of postoperative adhesion in the treated site was significantly less than that in the untreated site. The membrane was left in place for 7 postoperative days (PODs). By POD 5, the regenerated peritoneum mesothelial cells covered part of the area and by POD 7, they had regenerated over almost all of that area in the abdominal wall.

CONCLUSION

The anti-adhesion membrane worked as a physical barrier to prevent postoperative adhesion until the mesothelial cells had regenerated completely. To our knowledge, this is the first study conducted to assess the regeneration of peritoneum mesothelial cells under a bioresorbable membrane using immunohistochemistry.

Risk factors for superficial incisional surgical site infection after gastrectomy: analysis of patients enrolled in a prospective randomized trial comparing skin closure methods

BACKGROUND

Surgical site infection is one of the commonest complications of gastrointestinal surgery. The nature of surgical procedures and wound closure methods may influence the incidence of superficial incisional surgical site infection. Patients enrolled in a prospective randomized controlled trial comparing skin closure methods are the best subjects for analyzing surgical site infection risk.

METHOD

From a cohort of 1080 patients who had been enrolled in our previous randomized controlled trial, data for 685 patients who had undergone elective open total gastrectomy or distal gastrectomy for gastric cancer were extracted. The incidences of superficial incisional surgical site infection after total gastrectomy and distal gastrectomy were compared and risk factors for superficial incisional surgical site infection were investigated by univariate analyses using logistic regression models.

RESULTS

In all, 42 patients (6.1 %) developed superficial incisional surgical site infections after gastrectomy; 15 of 288 patients (5.2 %) developed these infections after total gastrectomy, and 27 of 397 patients (6.8 %) developed these infections after distal gastrectomy-these differences are not significant. According to univariate analysis, age (75 years or older or younger than 75 years) was the only risk factor for superficial incisional surgical site infections (P = 0.049). There was a tendency for the incidence of superficial incisional surgical site infection to increase in parallel with age.

CONCLUSION

The incidence of superficial incisional surgical site infection did not differ between total gastrectomy and distal gastrectomy. Advanced age was the only identified risk factor for superficial incisional surgical site infections after gastrectomy.

Down-Regulation of microRNA-132 is Associated with Poor Prognosis of Colorectal Cancer

Background

Given the role of microRNA in colorectal cancer (CRC) progression, we explored the association between microRNA (miRNA) expression and CRC-related prognosis.

Methods

Three types of tissue samples (primary CRC lesions without liver metastasis, primary lesions with liver metastasis, and liver metastatic tissues) were used for miRNA profiling to identify differentially expressed miRNA. Quantitative real-time PCR was used to examine miRNA expression in CRC cells and in tumor tissues.

Results

MiR-132 was significantly down-regulated in primary CRC tissues with liver metastasis and liver metastatic lesions compared to primary lesions without liver metastasis. Multivariate analysis for overall survival indicated that low miR-132 expression was an independent prognostic factor for CRC patients (overall survival P = 0.040, disease-free survival P = 0.015). Ectopic expression of miR-132 significantly inhibited cell proliferation and cell invasion. The luciferase reporter assay revealed that anoctamin 1 (ANO1) was a direct target of miR-132. Kaplan–Meier survival curves showed that high ANO1 expression was a significant prognostic factor for overall survival of patients with CRC (P = 0.0344).

Conclusions

Down-regulation of miR-132 is associated with poor prognosis in CRC. ANO1 could be one of the crucial targets of miR-132 in CRC.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-016-5133-3) contains supplementary material, which is available to authorized users.

Comparison of bleeding risks related to venous thromboembolism prophylaxis in laparoscopic vs open colorectal cancer surgery: a multicenter study in Japanese patients

BACKGROUND

Venous thromboembolism is the most common preventable cause of hospital death. The objective of this study was to clarify risk factors for postoperative bleeding related to thromboprophylaxis after laparoscopic colorectal cancer surgery.

METHODS

The study was conducted at 23 Japanese institutions and included patients with colorectal cancer who underwent laparoscopic or open surgery followed by fondaparinux treatment. We performed a retrospective analysis from a prospectively maintained database. We used multivariate analyses to evaluate clinical risk factors for prophylaxis-related bleeding events.

RESULTS

After multivariate analysis, male gender, intraoperative blood loss of less than 25 mL, and a preoperative platelet count below 15 × 10⁴/μL were found to be independent risk factors in the laparoscopic surgery group. Only the preoperative platelet count was an independent risk factor in the open surgery group.

CONCLUSIONS

Different prophylactic treatments for postoperative venous thromboembolism may be necessary in laparoscopic vs open surgery for colorectal cancer.

Characteristics of carbonic anhydrase 9 expressing cells in human intestinal crypt base

Though recent studies have revealed that stem cells of many tissues are harbored in hypoxic microenvironment, little is known about the relationship between hypoxia and intestinal crypt base, where intestinal stem cells are supposed to exist. In this study, we focused on carbonic anhydrase IX (CA9), a hypoxia-inducible membrane-tethered protein, in normal intestinal crypt base, adenoma and early colorectal cancer. Using surgically resected human colorectal cancer specimen, we searched for the expression pattern and functional association of CA9 in human adult normal intestinal epithelia, adenoma and early colorectal cancer by immunofluorescent and immunohistochemical staining, flow cytometry, and quantitative real-time-polymerase chain reaction. We demonstrated that almost all crypt base slender cells in ileum and crypt base cells with eosinophilic structure in their basal cytoplasm in right and left colon were CA9+ with the ratio of 25 to 40%, and that adenoma and T1 colorectal cancer showed broad expression of CA9. Flow cytometrically sorted CA9+ population showed increased mRNA level of a Wnt signaling factor AXIN2. In conclusion, these observations indicate that CA9 expression in normal crypt base cells has association with intestinal epithelial stemness and CA9 may be involved in the carcinogenesis of colorectal cancer.

Platelet Activation Markers Are Associated with Crohn's Disease Activity in Patients with Low C-Reactive Protein

BACKGROUND

In assessing Crohn's disease (CD) activity, C-reactive protein (CRP) is an important indicator of inflammation; however, it is not necessarily associated with the Crohn's Disease Activity Index (CDAI), particularly in patients with low CRP. Recently, platelet activation factors have been recognized due to their importance in the inflammatory response. In this study, we examined associations between the CDAI and platelet factor 4 (PF-4), β-thromboglobulin (β-TG), and other coagulation and fibrinolysis factors.

AIMS

We aimed to find a new marker for evaluating disease activity in patients with CD and low CRP.

METHODS

Nine markers, including CRP, platelet count, white blood cell count, fibrin and fibrinogen degradation product, fibrinogen, thrombin-antithrombin complex, prothrombin fragments 1 + 2, PF-4, and β-TG were evaluated in 47 patients with CD and low CRP (<1.0 mg/dl). Patients were assigned to high or low disease activity groups, CDAI-H (CDAI ≥ 150) and CDAI-L (CDAI < 150), respectively.

RESULTS

CDAI-H exhibited significantly higher PF-4 and β-TG levels than CDAI-L (P < 0.01). Other markers were not significantly different between groups. CDAI was positively correlated with the levels of PF-4 and β-TG (P = 0.0033 and 0.0024; r = 0.4202 and 0.4321, respectively). Receiver operating characteristic curve analyses of PF-4 and β-TG showed high sensitivity (61.9 and 81%, respectively) and specificity (84.7 and 69.2%, respectively) for diagnosing active CD.

CONCLUSION

Among eight potential markers, PF-4 and β-TG were the most highly correlated with CDAI in patients with CD and low CRP. PF-4 and β-TG levels showed promise as new markers for assessing CD in patients with low CRP.

A clinical trial of autologous adipose-derived regenerative cell transplantation for a postoperative enterocutaneous fistula

PURPOSE

Adipose-derived stem cell (ADSC) transplantation is expected to be a minimally invasive, but effective, treatment for postoperative enterocutaneous fistulas associated with poor blood flow and chronic inflammation. The aim of this study was to assess the safety and efficacy of a novel ADSC therapy for this condition.

METHODS

We conducted an open-label, single-arm exploratory phase I study to assess the safety and efficacy of a novel ADSC therapy. Using the Celution system, we isolated adipose-derived regenerative cells (ADRCs) containing abundant ADSCs from liposuction-obtained gluteal adipose tissue. A mixture of ADRCs and fibrin glue was subsequently transplanted into the fistula, and ADRCs were percutaneously and endoscopically injected around the fistula. We evaluated the safety and feasibility of ADRC transplantation and fistula closure in six patients (UMIN000007316).

RESULTS

ADRC transplantation was completed in all patients. The fistula closure rates were 83.3 % at 4 and 12 weeks and 100 % at 24 weeks. All patients had grade 1 pain and subcutaneous hemorrhage at the liposuction sites, but no serious adverse events related to this procedure were observed.

CONCLUSIONS

Transplantation of autologous ADRCs is safe, feasible and advantageous, as it can secure a sufficient cell count without culture or multiple passages, and will likely be effective for a postoperative enterocutaneous fistula.