[Experience of the Pharmacotherapy against Appendix and Sigmoid Colon Signet Ring Cell Carcinoma with the Peritoneal Dissemination]

We report 2 cases of signet ring cell carcinoma of the appendix and colon. Case 1: A 61-year-old man was admitted for lower abdominal pain. Colonoscopy revealed an elevated lesion in the orifice of the appendix. Signet ring cell carcinoma was diagnosed on biopsy. The surgical findings showed multiple peritoneal dissemination nodules, while the primary tumor was unresectable owing to extensive invasion into the retroperitoneum. The histopathological findings were signet ring cell carcinoma, T4b (retroperitoneum), NX, P3, Stage Ⅳ. Although the patient received 14 courses of treatment with S-1 as postoperative chemotherapy, he died of his illness at 32 postoperative months. Case 2: A 76-year-old man was admitted for abdominal pain. Perforation of the lower gastrointestinal tract was diagnosed on abdominal CT, and an emergency operation was performed. The surgical findings demonstrated a large number of peritoneal dissemination nodules, cecal invasion of a sigmoid tumor, and perforation of the ascending colon. The primary tumor was thought to be unresectable, and the perforated segment was resected. The histopathological findings were signet ring cell carcinoma, T4b (cecum), NX, P3, Stage Ⅳ. Although 11 courses of treatment using FOLFIRI+Bev were administered as postoperative chemotherapy, the patient died of his illness at 26 postoperative months.

[Clinicopathological Features and Outcomes of Treatment for HER2 Positive Gastric Cancer]

In March 2011, trastuzumab was approved for treating human epidermal growth factor receptor 2 (HER2) positive advanced gastric cancer (AGC) in Japan. Therefore, all patients with AGC should be evaluated for HER2 status. In this study, we analyzed the clinicopathological features and current status of treatment in HER2 positive gastric cancer. One hundred 6 gastric cancer patients were examined for HER2 expression in our hospital between March 2011 and August 2014. Sixteen patients (15.1%) were HER2 positive. There was no correlation between HER2 status and age, sex, and location of tumor; however, HER2 positivity was significantly more frequent in patients with intestinal type tumors and had a tendency towards being more frequent in patients with macroscopic types 0, 1 or 2. Trastuzumab was administered to 10 patients with HER2 positive AGC. The total number of doses of trastuzumab was 1 to 44 (median 7.5), and the therapeutic effect of trastuzumab combination chemotherapy was 1 patient with a complete response and 4 with a partial response. Adverse events due to trastuzumab were not observed. The incidence of HER2 over-expression was 15.1%, and trastuzumab combination chemotherapy was relatively safe and effective.

Effects of rotational acetabular osteotomy on the mechanical stress within the hip joint in patients with developmental dysplasia of the hip

In this study we used subject-specific finite element analysis to investigate the mechanical effects of rotational acetabular osteotomy (RAO) on the hip joint and analysed the correlation between various radiological measurements and mechanical stress in the hip joint.

We evaluated 13 hips in 12 patients (two men and ten women, mean age at surgery 32.0 years; 19 to 46) with developmental dysplasia of the hip (DDH) who were treated by RAO.

Subject-specific finite element models were constructed from CT data. The centre–edge (CE) angle, acetabular head index (AHI), acetabular angle and acetabular roof angle (ARA) were measured on anteroposterior pelvic radiographs taken before and after RAO. The relationship between equivalent stress in the hip joint and radiological measurements was analysed.

The equivalent stress in the acetabulum decreased from 4.1 MPa (2.7 to 6.5) pre-operatively to 2.8 MPa (1.8 to 3.6) post-operatively (p < 0.01). There was a moderate correlation between equivalent stress in the acetabulum and the radiological measurements: CE angle (R = –0.645, p < 0.01); AHI (R = –0.603, p < 0.01); acetabular angle (R = 0.484, p = 0.02); and ARA (R = 0.572, p < 0.01).

The equivalent stress in the acetabulum of patients with DDH decreased after RAO. Correction of the CE angle, AHI and ARA was considered to be important in reducing the mechanical stress in the hip joint.

Cite this article: Bone Joint J 2015;97-B:492–7.

Optimizing the selection of patients with low rectal cancer for intersphincteric resection by evaluating vertical invasion to the levator and external sphincter

AIM

The indications for intersphincteric (ISR) anterior resection are not clearly defined. The aim of this study was to evaluate vertical extension of T2 or T3 low rectal cancer treated by rectal amputation to optimize patient selection for ISR.

METHOD

The abdominoperineal excision specimens of T2 or T3 low rectal cancer from 53 patients treated between 1992 and 2004 were retrospectively reviewed. Vertical invasion was quantified by measuring the shortest distance between the tumour and the striated muscle (T-SM), assuming that this represented the surgical margin that would have be achieved had an ISR been performed.

RESULTS

Involvement of the dentate line (DL) and intramural distal spread were independent risk factors for T-SM ≤ 2 mm. The T-SM was less when the inferior border of the tumour was on the distal side of the DL (r = 0.572, P < 0.001). The probability of involvement of the DL, intramural distal spread or either one of these being associated with T-SM ≤ 2 mm was 43, 46 and 43%, respectively. All patients without both intramural distal spread and involvement of the DL had T-SM > 2.

CONCLUSION

We recommend that ISR should only be performed for patients with T2 or T3 low rectal cancer in whom the lowest edge of the tumour is above the DL and there is no intramural distal spread. Such patients are relatively unlikely to have a T-SM ≤ 2 mm.

[Outcomes of laparoscopic surgery after preoperative metallic stent placement for obstructive colorectal cancer]

AIM

To assess the outcomes of preoperative colonic stent placement for obstructive colorectal cancer.

PATIENTS AND METHODS

A total of 30 patients with colorectal cancer were treated after preoperative colonic metallic stent placement between July 2012 and March 2014. We reviewed their medical records to assess the usefulness of stent placement and the clinical course. The effects of various clinicopathological variables on post-operative complications were analyzed statistically.

RESULTS

Stent insertion was effective in 93% of the 30 patients with obstructive colorectal cancer. Preoperative colonoscopy or enema for proximal colonic survey was possible in 70% of the patients after stent placement; colonic lesions requiring simultaneous resection were noted in 5 patients (24%). The mean interval between stent insertion and operation was 19 days, and 23%of the patients underwent laparoscopic surgery. Statistical analysis revealed that the occurrence of complications was associated with laparoscopic surgery and the amount of operative blood loss.

CONCLUSION

Preoperative stent placement in patients with obstructive colorectal cancer is feasible and laparoscopic surgery can be selected after stent placement.

Solo surgery in laparoscopic colectomy: a case-matched study comparing robotic and human scopist

BACKGROUND/AIMS

Recent technical developments have enabled solo surgery in laparoscopic surgery. Our experience of solo surgery using the voice-guided robotic arm in laparoscopic colectomy for colorectal cancer was analyzed.

METHODOLOGY

The colon-lifting method was used in this study. The laparoscope was handled by AESOP3000. The colon was retracted anteriorly by the thread that passed through the mesocolon. This method enables lymphadenectomy by stretching of feeding vessels and obviates the need for an assistant. The short-term outcomes and survival between robotic arm and human scopist in a series of laparoscopic colectomies were compared with a case-matched control study.

RESULTS

The numbers of both group patients were 11 respectively. There was no conversion to open surgery in both groups. The operation time (Robotic vs. Human=269 min. vs. 265) and laparoscopic time (209 vs. 212) were not significant differences. There were also no significant differences in the bleeding, the morbidity rate and the numbers of dissected lymph nodes between the two groups. The five-year overall (81.8% vs. 72.7%) and disease-free (72.7% vs. 62.3%) survivals showed no significant differences.

CONCLUSIONS

Laparoscopic solo-surgery in colectomy is safe and feasible, without any deterioration of the curative potential of the procedure.

Gastrointestinal stromal tumor with two genetic abnormalities on different alleles: report of a case

We report a case of a gastrointestinal stromal tumor (GIST) with strong and faint KIT protein staining, respectively, at two different sites. A single point mutation (c1727 T>C) was detected in DNA extracted from both sites, and a further deletion mutation (c1678_1680 del GTT) was detected in DNA from the site with strong KIT protein staining. Cloning analysis indicated that the point mutation and the deletion were present on different alleles.

[Long survival of a case of unresected duodenal cancer treated by S-1 before and after duodenojejunostomy]

A 52-year-old woman visited our hospital with epigastralgia. Detailed examination revealed a duodenal cancer of the ascending limbs. Since she refused the resection, the administration of S-1 alone was commenced. After one course of this treatment, oral intake became impossible. Duodenography and endoscopy showed duodenal obstruction, and she underwent surgery. The tumor proved to be unresectable due to direct invasion of the inferior vena cava. Duodenojejunostomy was performed. After surgery, she was treated by S-1 and survived 2 years and 11 months, which resulted in 3 years and 2 months' long survival from her first visit. The intervals of the intake and home stay, after the operation, were 2 years and 8 months and 2 years and 5 months, respectively. The combination of S-1 administration and bypass operation provides a useful alternative for the treatment of unresectable duodenal cancer with stenosis.

Identification of Cystatin SN as a novel tumor marker for colorectal cancer

The goal of this study was to investigate Cystatin SN, a cysteine protease inhibitor, as a novel tumor marker for colorectal cancer (CRC). Gene expression profiles of mRNA from normal tissues and cancer cell lines were performed. Twenty-eight monoclonal antibodies for Cystatin SN were generated and serum Cystatin SN was quantified using ELISA in sera from 159 patients with CRC and 40 healthy controls. Cystatin SN was highly expressed in colon cancer cells. Employing a receiver-operating characteristic curve, we obtained an area under the curve of 0.708 for Cystatin SN, 0.819 for carcinoembryonic antigen (CEA) and 0.703 for carbohydrate antigen 19-9 (CA19-9). The combination assay of Cystatin SN, CEA and CA19-9 showed 62.9% sensitivity and 90.0% specificity. Especially, the sensitivity of the combination assay in stages I and II detection, in which stages curative operation would be possible, was improved over that of the assay testing only for CEA and CA19-9 (from 37.5 to 42.5% in stage I, from 49.0 to 60.8% in stage II). Furthermore, Western blot analysis revealed that Cystatin SN was increased in the urine from patients with CRC. Our results suggest the possibility of utilizing this novel tumor marker that can be tested in urine samples. These observations suggest that Cystatin SN in combination with CEA and CA19-9 is a useful tumor marker for detecting early stage CRC and that it is a unique urinary excretory protein, suggesting that Cystatin SN might be a novel candidate for use in mass screening for CRC.

Reduction of postoperative abdominal adhesion and ileus by a bioresorbable membrane

BACKGROUND/AIMS

This study examines the efficacy of a bioresorbable sodium hyaluronate-carboxy-methylcellulose-based membrane (HA/CMC membrane) in reducing postoperative abdominal adhesion and ileus after intestinal resection. Also, this study attempts to identify the possible factors that influence effectiveness through qualitative analysis of an individual patient case.

METHODOLOGY

Bioresorable membranes were applied just prior to abdominal closure in 121 patients who underwent abdominal surgery. The incidence of adhesion-related postoperative ileus was compared between the treatment and control group. Severity and extent of adhesions were also examined in 27 patients who underwent follow-up laparotomy.

RESULTS

The incidence of postoperative ileus was low in the treatment group. For the partial colectomies with lymph node dissection for colorectal cancers, there was no difference between the treatment and control group in the incidence of postoperative ileus. In patients who underwent a second operation, the incidence and severity of adhesions were significantly lower for the treated area compared with the untreated area.

CONCLUSIONS

HA/CMC membrane was effective in reducing postoperative abdominal adhesions. The incidence of adhesion-related postoperative ileus after colorectal cancer surgery was unchanged. The results of qualitative analysis imply that further improvement of application may allow HA/CMC membrane to be more effective in reducing postoperative ileus.

Surgical strategy for local recurrence after resection of rectal cancer

BACKGROUND/AIMS

To evaluate surgery for local recurrence after rectal cancer resection.

METHODOLOGY

In total, 76 patients with local recurrence after rectal cancer resection were enrolled between 1978 and 1998. Of these, 61 underwent curative resection. Outcomes were assessed according to treatment. Recurrence was classified as visceral or parietal based on preoperative computed tomography or magnetic resonance imaging.

RESULTS

The 5-year survival rates were 17.8%, 25.9%, and 36.9% for patients who underwent total pelvic exenteration, abdomino-perineal resection, and local resection, respectively. Of the 61 patients who underwent curative resection, 18 (29.5%) showed visceral recurrence and 43 (70.5%) showed parietal recurrence. Among patients with visceral recurrence, 9 (50%) underwent total pelvic exenteration, 6 (33.3%) underwent abdomino-perineal resection, and 3 (16.7%) underwent local resection. Among patients with parietal recurrence, 27 (62.8%) underwent total pelvic exenteration, 4 (9.3%) underwent abdomino-perineal resection, and 12 (27.9%) underwent local resection. Mucinous adenocarcinomas were most common among patients with parietal recurrence. Overall 5-year survival rates were 64.9% and 14.0% for patients with visceral and parietal recurrence, respectively.

CONCLUSIONS

Curative resection was effective in rectal cancer patients with visceral recurrence. Novel systemic chemical radiotherapy should be considered for patients with parietal recurrence.

Activities of daily living and quality of life of elderly patients after elective surgery for gastric and colorectal cancers

OBJECTIVE

To establish reliable standards for surgical application to elderly patients 75 years old or older with gastric or colorectal cancer with special reference to the postoperative recovery of activities of daily living (ADL) and quality of life (QOL).

SUMMARY BACKGROUND DATA

ADL and QOL are important outcomes of surgery for the elderly. However, there has been only limited evidence on the natural course of recovery of functional independence.

METHODS

Two hundred twenty-three patients 75 years old or older with gastric or colorectal cancer were prospectively examined. Physical conditions, ADL, and QOL were evaluated preoperatively and at the first, third, and sixth postoperative month.

RESULTS

The mortality and morbidity rates were 0.4% and 28%, respectively. Twenty-four percent of patients showed a decrease in ADL at 1 month postoperatively, but most patients recovered from this transient reduction, with only 3% showing a decline at the sixth postoperative month (6POM). ADL of these patients was likely to decrease after discharge from the hospital. QOL of the patients showed a recovery to an extent equal to or better than their average preoperative scores.

CONCLUSIONS

Of the patients 75 years old or older who underwent elective surgery for gastric or colorectal cancer, only a few showed a protracted decline in ADL and most exhibited better QOL after surgery. This indicates that surgical treatment should be considered, whenever needed, for elderly patients 75 years old or older with gastric or colorectal cancer. Estimation of Physical Ability and Surgical Stress is useful for predicting postoperative declines in ADL and protracted disability; this could aid in establishing a directed rehabilitation program for preventing protracted disability in elderly patients.

Colonic J-pouch decreases bowel frequency by improving the evacuation ratio

BACKGROUND/AIMS

To compare the functional outcome of ultra-low anterior resection for rectal cancer with colonic J-pouch reconstruction with that of straight reconstruction.

METHODOLOGY

Twenty-three patients who underwent ultra-low anterior resection with or without J-pouch reconstruction underwent bowel transit study, videodefecography, and answered a questionnaire survey 4 months and 1 year after surgery. Eleven healthy subjects underwent similar testing as controls.

RESULTS

Patients with a J-pouch had less frequent stools than patients with straight reconstruction 4 months after surgery (p<0.05), but the two groups were similar at 1 year. Bowel transit time was similar at both study points. The evacuation ratio was higher after J-pouch than straight reconstruction 4 months after surgery (p<0.05). However, the ratio improved in the straight group, and no difference existed at 1 year. Colonic contraction was seen only near the anastomosis 4 months after surgery, but the contraction proximal to the anastomosis improved over the next 8 months.

CONCLUSIONS

J-pouch reconstruction facilitates evacuation by improving the evacuation ratio. Although straight anastomosis caused excessive stool frequency 4 months after surgery, colonic function continued to improve and was comparable with J-pouch and straight reconstruction 1 year after surgery because the contraction ratio proximal to the anastomosis improved.

[A case of radiation-induced rectal cancer]

We report a case of radiation-induced rectal cancer, which is thought to originate from dysplasia due to radiation colitis. The patient is a 73 year-old woman, who underwent radical hysterectomy and radiotherapy for uterine cervical cancer 31 years ago. She visited to our hospital complaining of hematochezia. Colonoscopy in January 2004 disclosed redness of the rectal mucosa accompanied with contact bleeding and pathological study of the biopsy specimen revealed severe dysplasia. However, colonoscopy showed an ulcerative lesion of the rectum in December 2004, and pathological findings of the biopsy specimen disclosed moderately differentiated adenocarcinoma. She underwent a rectal resection in January 2005. Pathological study of resected specimen revealed fibrous change induced by radiation. Predominant histological type of the tumor was moderately differentiated carcinoma followed by well differentiated type. However, multiple dysplasias were found around the main tumor or in the mucosa which was treated with radiotherapy.

Bile duct hamartomas (von Mayenburg complexes) mimicking liver metastases from bile duct cancer: MRC findings

We present a case of a 72-year-old man with a common bile duct cancer, who was initially believed to have multiple liver metastases based on computed tomography findings, and in whom magnetic resonance cholangiography (MRC) revealed a diagnosis of bile duct hamartomas. At exploration for pancreaticoduodenectomy, liver palpation revealed disseminated nodules at the surface of the liver. These nodules showed gray-white nodular lesions of about 0.5 cm in diameter scattered on the surface of both liver lobes, which were looked like multiple liver metastases from bile duct cancer. Frozen section of the liver biopsy disclosed multiple bile ducts with slightly dilated lumens embedded in the collagenous stroma characteristics of multiple bile duct hamartomas (BDHs). Only two reports have described the MRC features of bile duct hamartomas. Of all imaging procedures, MRC provides the most relevant features for the imaging diagnosis of bile duct hamartomas.

Matrilysin (MMP-7) degrades VE-cadherin and accelerates accumulation of beta-catenin in the nucleus of human umbilical vein endothelial cells

Matrilysin, MMP-7, is an important target for anti-metastasis therapy of colorectal cancer because it is a strong proteolytic factor secreted from the cancer cell itself and it induces tumor angiogenesis. In a previous report, we showed that matrilysin accelerated human umbilical vein endothelial cell (HUVEC) proliferation in low serum conditioned medium. In the present study, we show that matrilysin stimulation decreased VE-cadherin expression, induced accumulation of beta-catenin in the nucleus of the HUVEC, and up-regulated matrilysin mRNA expression. These results compel a hypothesis that matrilysin cleaves VE-cadherin and releases beta-catenin from the VE-cadherin/catenin complex; the free beta-catenin can activate T-cell factor (Tcf) DNA binding protein, which accelerates cell proliferation and matrilysin expression.

The impact of advanced age on hepatic resection of colorectal liver metastases

BACKGROUND

The aim of this study was to evaluate the impact of patient age on surgical therapy for colorectal liver metastases.

STUDY DESIGN

Between 1992 and 2004, 212 consecutive patients underwent potentially curative hepatic resection. Sixty-two patients were 70 years or older at the time of resection (older group) and 150 patients were less than 70 years at the time of resection (younger group).

RESULTS

A proportion of older patients had a history of severe cardiopulmonary disease (32.3%) and respiratory insufficiency (6.5%). Intraoperative variables, such as resected liver volume, operation time, estimated blood loss, and blood transfusion, were not notably different between older and younger patients. Postoperative complications after resection occurred in 19.7% of older patients and at a similar rate (23.3%) in the younger group. Resection mortality was 0% in older patients and 0.49% in younger patients. The 5-year survival rates of older and younger patients were 34.1% and 53.1%, respectively. Compared with younger patients, the overall survival rate of older patients was markedly lower (p<0.01).

CONCLUSIONS

Advanced chronologic age cannot be regarded as a medical contraindication for hepatic resection of colorectal liver metastases in patients who are more than 70 years of age.

Practical usefulness of ultrasonic surgical aspirator with argon beam coagulation for hepatic parenchymal transection

The objective of this study was to evaluate the effectiveness and feasibility of using the Cavitron ultrasonic surgical aspirator (CUSA) with argon beam coagulation (ABC) during hepatic resection, in comparison with a conventional method using CUSA with bipolar cautery. Between April 2003 and March 2004, a series of 14 consecutive patients underwent hepatic resection of normal liver. Hepatectomies were performed using CUSA and bipolar irrigation electrocautery (BP) in eight patients between April 2003 and December 2003. CUSA and an ABC were used in six patients between January 2004 and March 2004. There were no differences in patient characteristics between the two groups. Blood loss per area of transected liver surface was significantly lower for CUSA with ABC than for CUSA with BP (2.9 +/- 1.44 vs. 6.33 +/- 3.14 ml/cm2). Furthermore, the speed of resection, defined as resection time per area of transected liver surface, was significantly greater for CUSA with ABC than for CUSA with BP (0.53 +/- 0.14 vs. 2.18 +/- 1.73 min/cm2). This new technique of combining CUSA with ABC can decrease blood loss during hepatic parenchymal transection and shorten the resection time.

Two-stage hepatectomy for multiple bilobular liver metastases from colorectal cancer

BACKGROUND/AIMS

To determine an appropriate surgical treatment for patients with multiple liver metastases, we evaluated the efficacy of two-stage hepatectomy in patients with multiple bilobular liver metastases from colorectal carcinoma.

METHODOLOGY

Some patients with multiple liver metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. Two-stage hepatectomy was performed in 11 patients.

RESULTS

Two-stage hepatectomy was feasible in all of the 11 patients. In 3 of them, the first stage was a major resection (more extensive than a lobectomy). This first hepatectomy was uneventful in all patients. The second hepatectomy was also uneventful in nine patients, but in one of the other two, a perihepatic fluid infection occurred, and in the other, postoperative liver failure developed due to a right subphrenic abscess. However, all patients were discharged. The percentage of the expected resection volume at one time, calculated from CT volumetry, was 75.5+/-1.2% and the prognostic score as surgical risk was 56.6+/-4.5. In two-stage hepatectomy cases, the percentage of the resected volume and the prognostic score in the first hepatectomy were 25.4+/-6.4% and 6.7+/-7.3, and in the second, 45.7+/-4.5% and 28.5+/-5.8. During the follow-up procedures, a residual hepatic recurrence was observed in 6 patients, and pulmonary recurrence in 9. The 1- and 3-year survival rates after the first hepatectomy were 90% and 45%, with median survivals of 18 months from the first hepatectomy.

CONCLUSIONS

Two-stage hepatectomy is a surgical modality intended for patients with initial unresectable metastases. However, following such surgery, protective treatment against residual liver recurrence and lung metastasis will be a most important issue.

Successful pancreatoduodenectomy for carcinoma of the ampulla of vater after esophagectomy with remnant gastrectomy

A 59-year-old man was admitted to our hospital because his serum hepatobiliary enzymes were elevated on the medical check-up in September 2003. In his past history, he had undergone distal gastrectomy for a gastric adenoma 17 years before. Furthermore, he had undergone subtotal esophagectomy with remnant gastrectomy, the right colon and ileum were used for the reconstruction, and a cervical esophago-ileostomy and an abdominal colo-duodenostomy were made in the fashion of an interposition. Duodenoscopy was performed and showed the protruded lesion of the ampulla of Vater, biopsied specimens from this tumor revealed adenocarcinomas. Accordingly, we performed pancreaticoduodenectomy with regional lymph nodes dissection. The problem in this case was that the rt middle colic artery (MCA), and the middle colic vein (MCV) tend to be injured because these vessels are situated near the caudal region of the pancreas. We were able to identify the superior mesenteric vein (SMV) safely due to approaching this vein from the flank and mobilizing the duodenum, dissecting behind the mesenteric trunk from right to left. Double cancer of the ampulla of Vater and the esophagus are extremely rare, with only 4 cases reported. And we recommended the use of the dorsal approach to the SMV to avoid injuring the MCV such as in this case.