High hand grip strength is a significant risk factor and a useful predictor of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most critical complications of pancreaticoduodenectomy (PD). Studies on predictive factors for POPF that can be identified preoperatively are limited. Recent reports have highlighted the association between the preoperative nutritional status, including sarcopenia, and postoperative complications. We examined preoperative risk factors for POPF after PD, focusing on nutritional indicators.

METHODS

A total of 153 consecutive patients who underwent PD at our institution were enrolled in this study. Preoperative nutritional parameters, including hand grip strength (HGS) and skeletal muscle mass as components of sarcopenia, were incorporated into the analysis. POPFs were categorized according to the International Study Group of Pancreatic Fistula (ISGPF) definition as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C).

RESULTS

Thirty-seven of the 153 patients (24.1%) fulfilled the ISGPF definition of CR-POPF postoperatively. In the univariate analysis, the incidence of CR-POPF was associated with male sex, non-pancreatic tumor diseases, a high body mass index, a high HGS and a high skeletal muscle mass index. In the multivariate analysis, non-pancreatic tumor diseases and an HGS ≥23.0 kg were selected as independent risk factors for CR-POPF (P <0.05).

CONCLUSIONS

A high HGS, a screening tool for sarcopenia, was a risk factor for CR-POPF. It can accurately serve as a useful predictor of POPF risk in patients undergoing PD. These results highlight the potential of sarcopenia to reduce the incidence of POPF and highlight the need to clarify the mechanism of POPF occurrence.

Total Neoadjuvant Chemotherapy in Rectal Cancer: Current Facts and Future Strategies

Despite preoperative chemoradiotherapy (CRT) and total mesorectal excision improving the local control for locally advanced rectal cancer (LARC), oncologic outcomes and survival were not significantly improved because the main prognostic factor is distant metastasis. Thus, total neoadjuvant chemotherapy (TNT) as a novel approach has been proposed to improve chemotolerance. Since the first randomized phase II trial of TNT versus standard CRT demonstrated in 2012, many prospective and retrospective studies have been published. The initial consensus from TNT studies was that pathological complete response, pathological response of the main tumor, and local control are more favorable at TNT than at CRT. Furthermore, recent studies such as the PAPIDO trial and PRODIGE 23 trial made a major breakthrough of the treatment of TNT, showing that TNT improves the disease-free survival compared to standard treatment with long-course CRT. In addition, several innovative findings of TNT were clarified by prospective phase II trial. In this review, we summarize the most recent advances in TNT based on the findings of pivotal clinical trials for patients with LARC.

Erratum forTotal Neoadjuvant Chemotherapy in Rectal Cancer: Current Facts and Future Strategies

[This corrects the article DOI: 10.23922/jarc.2022-060.].

[A Case of Long-Term Survival with S-1/Cisplatin for Liver Hilum Lymph Node Metastasis of Anal Canal Squamous Cell Carcinoma after Chemoradiotherapy]

A 70-year-old woman was admitted to a local hospital because of anal pain during defecation. Anoscopy revealed an anal mass lesion, and the patient was referred to our hospital. Colonoscopy revealed an anal canal tumor with ulceration, and biopsy showed squamous cell carcinoma. The patient was treated with chemoradiotherapy(chemotherapy with capecitabine plus mitomycin C and 54 Gy radiation in the anal region)and achieved complete response. However, metastatic recurrence was detected in a lymph node in the hepatic hilar region. We administered an S-1/CDDP combination chemotherapy (5 courses). For 3 years and 5 months since the initial treatment, the patient survived with no signs of recurrence. We report a rare case of long-term survival with S-1/CDDP for distant metastasis of anal canal squamous cell carcinoma after chemoradiotherapy.

[Two Cases of Elderly Patients with Giant Intrahepatic Cholangiocarcinoma Treated with Multidisciplinary Therapy including Ablation Therapy]

Case 1 consisted of an 86-year-old male diagnosed with intrahepatic cholangiocarcinoma(ICC), approximately 11 cm in diameter, at segment S7/8 of the liver. A total of 4 percutaneous radiofrequency ablations(PRFA)and 3 hepatic arterial infusion chemotherapies(HAIC)of 5-FU were performed. He died after developing lung metastases 27 months after the initial treatment. Case 2 was an 85-year-old female diagnosed with ICC, 8 cm in diameter, at the posterior segment of the liver, with lymph node metastasis. She underwent HAIC of 5-FU and S-1 as well as gemcitabine-based systemic chemotherapy. The main tumor developed 10 months after the initial treatment, and PRFAs were subsequently performed twice for the main lesion. Although the tumor markers gradually decreased, she died of jaundice 33 months after the initial treatment. As one of the multidisciplinary therapies for the giant ICC, ablation therapy may be safe and effective in elderly patients.

[Clinical Study of Peritoneovenous Shunt for Patients with Refractory Ascites Accompanied with Hepatocellular Carcinoma]

BACKGROUND

Hepatic ascites may cause a variety of symptoms and may progress deterioration of quality of life. Peritoneovenous shunt(PV shunt)is technically feasible and useful for the treating of refractory ascites, but sometimes it can be associated with fatal complications. This retrospective study aimed to investigate the effect of PV shunt for patients with refractory ascites, including hepatocellular carcinoma(HCC)patients.

SUBJECTS

Between January 2010 and December 2021, we retrospectively analyzed 54 consecutive patients(including 35 HCC patients)with refractory ascites who underwent PV shunt at our institute.

RESULTS

Body weight loss after surgery was observed in 39 of the 54 cases, and eGFR improved in 34 cases. There were 17(31.5%)in-hospital deaths. Cases with present of portal vein tumor thrombus, Child-Pugh classification C, ALBI score≥-1.12, or serum total bilirubin≥1.7 mg/dL were significantly higher in hospital-death group than in the discharged from the hospital group.

CONCLUSIONS

PV shunt for HCC patients with refractory ascites may be effective for improvement of renal function and symptoms. However, indications for PV shunt should be carefully considered for high-risk patients with adequate preoperative evaluation.

[A Rapid Clinical Course of Pulmonary Embolism Associated with Gallbladder Mucinous Carcinoma]

A 51-year-old woman with edema of the lower extremities and exertional dyspnea was admitted to our hospital. Enhanced CT revealed thrombi of the pulmonary artery and a gallbladder tumor. After anticoagulation therapy was started on her, anemia and jaundice progressed; thus, endoscopic retrograde cholangiopancreatography(ERCP)was performed on suspicion of bleeding from a gallbladder tumor. We performed cholecystectomy in emergency to control the anemia due to hemorrhage. Oxygenation suddenly worsened intraoperatively, maintaining her blood pressure became difficult, and the patient decompensated. The histopathological diagnosis was gallbladder mucinous carcinoma with severe lymphatic invasion. Although an autopsy was not performed, pulmonary artery embolism derived from a tumor embolus was the suspected cause of the sudden change of the clinical course.

[Clinical Efficacy of Recombinant Human Thrombomodulin for Surgical Patients with Disseminated Intravascular Coagulation Associated with Oncologic Emergency]

AIM

We evaluated the clinical efficacy of recombinant human thrombomodulin(rTM)for surgical patients with disseminated intravascular coagulation syndrome(DIC)associated with an oncologic emergency(OE).

SUBJECTS AND METHODS

Thirteen patients who underwent surgery for OE complicated with DIC and were treated with rTM in our institution were evaluated. We retrospectively analyzed the clinical changes of parameters in white blood cell count(WBC), platelet count, CRP, PT-INR and DIC scores after the rTM treatment.

RESULTS

The average length of the days using rTM was 4.7 for 12 patients, excluding one who died within 30 days after surgery. Nine of 12 patients(75%)had DIC scores of less than 3 after the rTM treatment. WBC tended to decrease after the rTM treatment, without statistical difference. However, CRP, platelet count, PT-INR and DIC scores were significantly improved after the rTM treatment(p<0.05).

CONCLUSIONS

rTM may be useful in the treatment of DIC for surgical OE patients.

Neoadjuvant Modified Short-Course Radiotherapy Followed by Delayed Surgery for Locally Advanced Rectal Cancer

Simple Summary

Both short- and long-course neoadjuvant radiotherapy (NA-RT) followed by surgery have been adopted as standard treatments for locally advanced rectal cancer (LARC). We hypothesized that a modified short-course radiotherapy (mSC-RT) using an accelerated hyperfractionated regimen, with a dose of 2.5 Gy twice daily up to a total dose of 25 Gy in 10 fractions, can provide a favorable therapeutic ratio in comparison with the conventional regimens. Ninety-seven consecutive LARC patients undergoing mSC-RT followed by delayed surgery were analyzed in this retrospective study. Additionally, potential prognostic factors for overall survival (OS) were also assessed. The results showed that mSC-RT followed by delayed surgery achieved equivalent anti-tumor efficacy and acute toxicity that were comparable with long- and short-course NA-RT, respectively. A neutrophil-to-lymphocyte ratio (NLR) ≥ 1.83 was independently associated with poor OS in LARC patients receiving mSC-RT. Thus, mSC-RT can be a promising alternative to both standard long- and short-course NA-RT regimens.

Abstract

This study aimed to assess the clinical outcomes and predictive factors of neoadjuvant modified short-course radiotherapy (mSC-RT) for locally advanced rectal cancer (LARC). Data from 97 patients undergoing mSC-RT followed by radical surgery for LARC were retrospectively analyzed. A 2.5 Gy dose twice daily up to a total dose of 25 Gy in 10 fractions was administered through mSC-RT, and this was delivered with oral chemotherapy in 95 (97.9%) patients. Radical surgery was performed 6 (range, 3–13) weeks after mSC-RT. The median follow-up among surviving patients was 43 (8–86) months. All patients completed neoadjuvant radiotherapy with no acute toxicity grade ≥ 3. Three- and five-year local control rates were 96.3% and 96.3%, respectively. Three- and five-year overall survival (OS) rates were 92.7% and 79.8%, respectively. Univariate analyses revealed that poor OS was associated with no concurrent administration of capecitabine, C-reactive-protein-to-albumin ratio ≥ 0.053, carcinoembryonic antigen ≥ 3.4 ng/mL, and neutrophil-to-lymphocyte ratio (NLR) ≥ 1.83 (P = 0.045, 0.001, 0.041, and 0.001, respectively). Multivariate analyses indicated that NLR ≥ 1.83 was independently associated with poor OS (p = 0.018). mSC-RT followed by delayed surgery for LARC was deemed feasible and resulted in good clinical outcomes, whereas poor OS was associated with high NLR.

[A Resected Case of Metachronous Solitary Metastasis of Jejunum after Surgery of Triple Colon Cancers]

A 68-year-old man underwent partial colectomy and double-barrel colostomy for an obstructive colon cancer of the splenic flexure at another hospital 10 years before. He was referred to us with an examination of anemia pointed out in human dock. Lower gastrointestinal endoscopy revealed the tumor occupied the remnant descending colon. We performed remnant left hemicolectomy and diagnosed as triple colon cancers. Six months after the initial operation, he was admitted to us with the chief complaints of abdominal fulness and vomit. Abdominal CT and radiologic enteroclysis after decompression used the ileus tube revealed complete stenosis at the small intestine. We performed surgery with a suspicion of obstruction of the small intestine. The tumor, 5 cm in diameter, occupied the jejunum was detected, and partial resection of the jejunum was performed. Histologically, the tumor was diagnosed as solitary metastasis of jejunum.

[Hepatectomy for Intrahepatic Combined Hepatocellular Carcinoma Recurrence in a Hemophilia a Patient with Human Immunodeficiency Virus and Hepatitis C Virus-A Case Report]

A 40's Japanese man had a history of blood transfusion and administration of treatment coagulation factors for hemophilia A since he was 6 years old. He has been on IFN treatment for hepatitis C since he was 14 years old. Lastly, he has been undergoing HAART therapy for human immunodeficiency virus infection since he was 18 years old. Three years ago, he underwent partial hepatectomy for a tumor located in segment 8 of his liver and was diagnosed with combined hepatocellular carcinoma(CHC). Two years and 7 months after the operation, 2 intrahepatic recurrences were detected in the left lobe. He was referred to our hospital to undergo curative resection, and we performed a left lobectomy of the liver for the CHC recurrences. Perioperatively, supplemental factor Ⅷ was administered via APTT. Its activity was used as an index. Postoperatively, the patient was well, was discharged 13 days after surgery, and remained recurrence-free for 4 months.

[Radiofrequency Ablation for Colorectal Liver Metastases]

AIM

The significance of radiofrequency ablation(RFA)for colorectal liver metastases(CRLM)remains to be elucidated. Therefore, this retrospective study aimed to evaluate the therapeutic efficacy of RFA for local recurrence of CRLM.

SUBJECTS

Between June 2005 and June 2017, we retrospectively examined 63 patients(137 nodules)with CRLM who underwent RFA.

RESULTS

The local recurrence rate was 36.5%, and the median local recurrence free survival(LRFS)was 26.3 months. We compared treatment background between the 2 groups with(50 nodules)and without(87 nodules)local recurrence. In the multivariate analysis, tumor size of the ablated lesion and method for ablation(direct tumor puncture)were independent risk factors for local recurrence. Receiver operating characteristic curve for tumor size of the ablated lesion showed an optimal cutoff value for tumor size of 1.8 cm(AUC=0.734, 95%CI: 0.612-0.855, p<0.0001).

CONCLUSIONS

RFA for effective control of local recurrence of CRLM might be suitable for selected patients with tumor size of ablated lesion ofC1.8 cm and no touch ablation method.

[A Resected Case of Hilar Cholangiocarcinoma Confirmed as Pathological Complete Response Following Neoadjuvant S-1 Monotherapy]

A 74-year-old man was admitted to a local hospital with liver dysfunction. Imaging modalities revealed bile duct stenosis at the bifurcation of the anterior and posterior trunk. Exfoliative cytology of the bile and brushing cytology of the bile duct both revealed Class Ⅴ, and biopsy from the stenotic bile duct showed well differentiated adenocarcinoma. We diagnosed the patient with hilar cholangiocarcinoma and performed extended right bisectionectomy and biliary reconstruction after percuta- neous transhepatic right portal vein embolization(PTPE). Preoperatively, he was administered S-1(80mg/body weight/day) orally for 19 days. Histopathological assessment of the resected specimen revealed hemosiderin-laden macrophages without viable cancer cells, confirmingpatholog ical complete response(pCR).

A review of preoperative chemoradiotherapy for lower rectal cancer

In Western countries, rectal cancer has been treated by chemoradiotherapy (CRT) for several decades now, and good local control has been reported. However, Japanese guidelines did not strongly recommend CRT, because CRT is only useful for achieving local control and imbues no survival benefit. For this reason, CRT was rarely used to treat rectal cancer in Japan. However, in the 2000s, several studies involving CRT began to be reported from Western countries, such as “correlation between pathological complete response and survival,” “induction chemotherapy followed by CRT,” and “watch-and-wait policies.” These studies were directly correlated with survival of and benefits to the patients. Given these findings, Japanese institutions have recently begun to introduce CRT for rectal cancer. Therefore, in the present study, we reviewed several topics regarding CRT for rectal cancer.

Second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer

The aim of the present study was to investigate the short- and long-term outcomes of patients undergoing second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer (LSCC). All patients included in the present study had undergone radical surgery with Hartmann's procedure for obstructive LSCC. Adjuvant chemotherapy was recommended for all patients, and patients with no signs of recurrence following six months of surveillance were planned to undergo second-look surgery. The aim of second-look surgery was early detection of local recurrence and determination of the efficacy of laparoscopic Hartmann procedure reversal. A total of 15 patients with locally advanced colorectal cancer were included in the study. Three patients exhibited peritoneal dissemination at the time of laparoscopic Hartmann procedure reversal and underwent partial peritonectomy. Following adjuvant chemotherapy treatment, laparoscopic Hartmann procedure reversal was performed in all patients. However, two patients underwent colo-anal anastomosis, and two patients underwent right-sided colon or ileum reconstruction. Regarding the oncological outcomes, two of three patients in whom peritoneal dissemination was identified during laparoscopic Hartmann procedure reversal were eventually in remission following the initial surgery and the second-look surgery with partial peritonectomy. Favorable long-term outcomes were observed in 12/15 patients due to no recurrence, which may be due to the surgical techniques used and the timing of the second-look surgery following Hartmann's procedure for the treatment of obstructive LSCC.

Functional Outcomes of Patients Treated with Intensive Medications for Bowel and Pain Control for Low-Lying Rectal Cancer Who Received Preoperative Chemoradiotherapy

PURPOSE

The aim of this study was to assess the functional outcomes of patients treated with intensive medications for bowel and pain control for low-lying rectal cancer who received preoperative chemoradiotherapy (CRT).

METHODS

The inclusion criterion was sphincter-preserving surgery following CRT for T3 middle and low rectal cancer. Postoperative defecation control was conducted using calcium polycarbophil and loperamide, and anal pain control was conducted using oxycodone hydrochloride hydrate. The functional outcomes were determined by an annual questionnaire after stoma closure.

RESULTS

Of 64 patients evaluated, 33 were reconstructed using the double stapling technique (DST) and 31 were reconstructed using the intersphincteric resection (ISR) technique. The median Visual Analogue Scale at ISR was improved from 7 to 1.5 at 1 year after surgery. The median Wexner scores were 6.0, 6.0, 5.0 and 5.0 for DST and 14.5, 12.0, 10.0 and 8.0 for ISR for the first 4 years, respectively. The only independent predictor of a poor bowel function (Wexner score >10) according to a multivariate analyses was pelvic infection (OR 3.994, 95% CI 1.235-13.52, p = 0.021), while ISR was not a predictor.

CONCLUSIONS

Anal pain following ISR can be controlled with oxycodone hydrochloride hydrate therapy. ISR is feasible following CRT for low-lying rectal cancer.

A case of rectal carcinoid, 7 mm in diameter, with skip metastasis to the lateral lymph node

The present case study presented a 59-year-old man with a 7 mm submucosal tumor in the lower rectum and swelling in a 7 mm lateral lymph node (the obturator lymph node). No swelling of the lymph nodes within the mesorectum was observed. The patient underwent laparoscopic intersphincteric resection with left side lateral lymphadenectomy. At the pathological examination, the patient was diagnosed with a rectal neuroendocrine tumor (Grade 1; carcinoid), which had invaded the perirectal tissues and exhibited lateral lymph node metastasis; however, mesorectal lymph node metastasis was not observed, therefore, the definitive diagnosis was rectal carcinoid with skip metastasis to the lateral lymph node. No sign of recurrence was observed at the 3 year follow-up. The treatment algorithm of rectal carcinoid was decided by the risk of lymph node metastasis. The present study confirmed skip metastasis to the lateral lymph node from the rectal carcinoid, which is typically very slow growing and has a low grade malignant potential.

Long-Term Functional Outcomes of Total Mesorectal Excision Following Chemoradiotherapy for Lower Rectal Cancer: Stapled Anastomosis versus Intersphincteric Resection

AIMS

To compare the long-term functional outcomes of total mesorectal excision following chemoradiotherapy for lower rectal cancer between stapled anastomosis and intersphincteric resection (ISR).

METHODS

A total of 105 of 170 sphincter-preserving patients found to be disease-free and anal functional patients were assessed at 6.5 years (range 2.4-13.0 years) of follow-up after surgery. Of these subjects, 87 (double stapling technique [DST]: 41; ISR: 46) of the 105 patients (82.9%) responded to the questionnaire on the low anterior resection syndrome score (LARS score).

RESULTS

The total LARS scores in the DST and ISR groups were not significantly different (Major/Minor/No LARS = 23/14/4 and 31/10/5, p = 0.431). When considering each item of the LARS, ISR was associated with poorer incontinence scores than DST. Conversely, the scores for the frequency of bowel movement, clustering and urgency were not different between the 2 groups. In addition, in the multivariate analysis, the tumor distance from the anal verge and postoperative period was independently associated with Major LARS.

CONCLUSION

In this study, we demonstrate the long-term functional outcomes of irradiated lower rectal cancer reconstructed with DST and ISR. Bowel function improves over time; therefore, long-term patient follow-up is important.

Comparison of the pathological response of the mesorectal positive nodes between short-course chemoradiotherapy with delayed surgery and long-course chemoradiotherapy in patients with rectal cancer

BACKGROUND

The aim of this study was to compare the pathological response of mesorectal positive nodes between short-course chemoradiotherapy with delayed surgery (SCRT-delay) and long-course chemoradiotherapy (LC-CRT) in patients with rectal cancer.

METHOD

The resected primary tumor specimens following the two different approaches were assessed utilizing the tumor regression grade (TRG 0-4), and each positive lymph node was assessed according to the lymph node regression grade (LRG 1-3), with TRG 4 and LRG 3 indicating total regression. The lymph node sizes were measured to elucidate any correlation with LRG scores.

RESULTS

Seventy-four patients with ypN-positive rectal cancer had 220 positive lymph nodes following the SCRT-delay, and 48 patients had 141 positive lymph nodes following the LC-CRT. The distribution of LRG 1/2/3 in the two groups was 123/72/25 and 60/31/50 (p < 0.001), respectively, and the distribution of TRG 0/1/2/3/4 in the two groups was 36/19/19/0 and 12/15/20/1 (p = 0.005), respectively. The requirements of total regression of positive lymph nodes were a primary tumor degenerated to TRG 3 with a size less than 6 mm in SCRT-delay (sensitivity, 60.9 %) or a primary tumor degenerated to TRG 2-4 with a size less than 5 mm at TRG 2 (sensitivity, 57.6 %) or 6 mm at TRG 3 and 4 (sensitivity, 84.2 %) in LC-CRT as indicated by the receiver operating characteristic curve analysis.

CONCLUSION

The tumor regression effect of LC-CRT on the primary tumor and positive nodes was more favorable than SCRT-delay, and LC-CRT is able to predict the LRG 3 response with a high sensitivity.

Diffusion-weighted magnetic resonance imaging for prediction of tumor response to neoadjuvant chemoradiotherapy using irinotecan plus S-1 for rectal cancer

The purpose of this study was to investigate the clinical value of diffusion-weighted (DW) magnetic resonance imaging (MRI) as a predictor of tumor response in patients receiving neoadjuvant chemoradiotherapy (NA-CRT) for rectal cancer (RC) through measurement of the apparent diffusion coefficient (ADC) value in each tumor. Neoadjuvant radiotherapy with a total dose of 45 Gy in 25 fractions was performed in all 16 patients with RC, combined with irinotecan and S-1. MRI was performed before and after NA-CRT. Multiple factors were assessed to predict the pathological response to NA-CRT. The pathological response rate was determined in 9 patients (56.3%). Statistical analyses indicated that the ADC value prior to NA-CRT was significantly lower in patients with a better response to NA-CRT (P=0.023). A cut-off value of 0.750×10^-3 mm²/sec obtained by a receiver operating characteristic curve analysis indicated a sensitivity of 77.8% and specificity of 85.7% for pathological responders to NA-CRT. In addition, the patients with lower ADC values exhibited a greater pathological response to NA-CRT (P=0.041). In conclusion, the ADC value of MRI of RC patients treated with NA-CRT followed by surgery may provide valuable information to predict the response to NA-CRT.

Feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer

BACKGROUND

5-Fluorouracil-based chemotherapy is considered to be a radiosensitizer; however, conventional short-course radiotherapy combined with chemotherapy is generally thought to not be feasible because of the prevalence of side effects.

OBJECTIVE

The aim of this study was to evaluate the feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer.

DESIGN AND SETTINGS

This study was retrospective in nature and used a prospectively collected database.

PATIENTS

Patients with T3 rectal cancer located below the peritoneum reflection were selected.

INTERVENTIONS

A total dose of 25 Gy of radiotherapy was administered in 10 fractions of 2.5 Gy each for 5 days. Radiotherapy was performed with S-1 as a radiosensitizer from day 1 to day 10. Surgery was targeted to be performed 4 weeks after radiotherapy.

MAIN OUTCOME MEASUREMENTS

The morbidity, sphincter-preserving rate, anal function, and long-term outcomes were assessed.

RESULTS

All patients (n = 170) completed the radiotherapy regimen and 166 (97.6%) completed the combination regimen with chemotherapy. A total of 149 patients (87.6%) had sphincter-preserving surgery (double stapling technique (DST), 58 patients; intersphincteric resection (ISR), 91 patients), and postoperative complications were relatively mild (anastomotic leakage, 15.4%; intra-abdominal infection, 8.2%). Among those undergoing sphincter preserving surgery, the 5-year local relapse-free survival rate was 94.3% in the DST group, and 89.8% in the ISR group. With respect to the anal function, the Wexner score the first year after stoma closure for the double-stapling technique group was 6 and that for intersphincteric resection was 15; however, the score for the intersphincteric resection group was improved to 8 at 4 years after stoma closure.

LIMITATIONS

This study had limitations because it was an uncontrolled, 1-arm, retrospective review with a small sample size.

CONCLUSIONS

Modified short-course radiotherapy combined with chemoradiosensitizer is a feasible approach for treating T3 rectal cancer. With the use of the short-course approach, efforts to reduce the incidence of side effects by appropriately prolonging the waiting period enable the administration of combination treatment with short-course radiotherapy and chemotherapy.

Short-course radiotherapy with delayed surgery versus conventional chemoradiotherapy: A comparison of the short- and long-term outcomes in patients with T3 rectal cancer

INTRODUCTION

The aim of this study was to compare the short- and long-term outcomes between short-course radiotherapy with delayed surgery (SRT-delay) and a standard conventional chemoradiotherapy (CRT) regimen.

METHODS

Two collaborating institutions adopted different regimens; the SRT-delay regimen was selected by Meiwa Hospital and the CRT regimen was selected by Hyogo College of Medicine. The inclusion criteria were T3 middle and low rectal cancer patients treated with radical surgery after preoperative therapy. The median follow-up period was 44 months (range, 12-85).

RESULTS

From 2007 to 2013, 104 patients were treated using the SRT-delay regimen and 61 patients were treated using the CRT regimen. The pretreatment characteristics of the 2 groups were not significantly different. The sphincter-preserving rate (93.3%, 85.2%), T downstaging (37.5%, 37.7%), ypN(-) (74.0%, 67.2%), postoperative complications and the bowel, and urinary and sexual functioning of the SRT-delay regimen were noninferior to those of the CRT regimen. The 3-year local recurrence-free survival, recurrence-free survival, and overall survival in the SRT-delay and CRT groups were 90.6% and 90.6% (P = .764), 83.8% and 78.3% (P = .687) and 96.0% and 92.8% (P = .833), respectively.

CONCLUSION

The SRT-delay regimen was noninferior in terms of the downstaging effect, and oncologic and functional outcomes compared with the CRT regimen for T3 middle and low rectal cancer.

The timing of surgery after preoperative short-course S-1 chemoradiotherapy with delayed surgery for T3 lower rectal cancer

PURPOSE

The purpose of this study was to analyze the influence of variations in clinical practice regarding the timing of surgery with short-course chemoradiotherapy with delayed surgery (SCRT-delay) for lower rectal cancer.

METHODS

A total of 171 patients with T3 N0-2 lower rectal cancer treated with SCRT-delay (25 Gy/10 fractions/5 days (S-1); days 1-10) were retrospectively evaluated. The median waiting period of 30 days was used as a discriminator (group A: waiting period, ≤30 days; group B: waiting period, ≥31 days). Preoperative treatment responses and oncological outcomes were analyzed.

RESULTS

The mean waiting periods for groups A and B were 24.4 ± 5.3 and 41.4 ± 12.3 days, respectively. There were no statistically significant differences between the two groups in any of the clinical variables. The clinicopathological outcomes were as follows: T downstaging (43.5 vs 37.2 %; p = 0.400), negative yp N (67.1 vs 75.6 %; p = 0.218), pCR (7.1 vs 1.2 %; p = 0.119). The 5-year local recurrence-free survival (89.3 vs 87.6 %; p = 0.956), the recurrence-free survival (82.2 vs 78.8 %; p = 0.662), and the overall survival (88.5 vs 84.4 %; p = 0.741), all of which were similar between the two groups.

CONCLUSIONS

The longer waiting period did not increase the tumor downstaging and not improve the oncological outcomes for T3 lower rectal cancer treated with SCRT-delay. In addition, considering that the impaired leukocyte response occurred during the sub-acute period, any time after the sub-acute period (day 12) up to 30 days after radiotherapy would be a suitable waiting period.

Acceptance of sphincter-preserving surgery for T3 lower rectal cancer after short-course radiotherapy with delayed surgery

620

Background: One of the reasons for avoiding sphincter-preserving surgery for lower rectal cancer is difficulty in obtaining a sufficient distal margin. Short-course radiotherapy (SRT) with immediate surgery is not expected to reduce tumor volume, and currently available evidence suggests that it does not increase the sphincter-preservation rate. However, SRT with delayed surgery has been linked to downsizing of the primary tumor during the waiting period. We evaluated the feasibility of sphincter-preserving surgery for T3 lower rectal cancer after SRT with delayed surgery and examined whether a distal margin of ≤ 5 mm has an impact on oncologic outcomes. Methods: We retrospectively studied 161 consecutive patients with lower rectal cancer located below the peritoneum reflection who underwent radical surgery with total mesorectum resection (TME) 3 to 4 weeks after the completion of SRT. The median follow-up was 53.5 months. Results: Sphincter-preserving surgery was performed in 149 (92.5%) of the 161 patients. The procedures were as follows: double-stapling technique, 58 patients; intersphincteric resection, 91; abdominoperineal resection, 10; and Hartmann operation, 2. Among the patients who underwent sphincter-preserving surgery, the distal margin was ≤ 5 mm in 41 patients and > 5 mm in 108. The local recurrence rate was respectively 5.8% vs. 10.4% (p = 0.606), the recurrence-free survival 83.4% vs. 82.8% (p = 0.682), and the overall survival at 5 years 82.3% vs. 87.6% (p = 0.418). Our results suggested that there is no difference in long-term outcomes between a distal margin of ≤ 5 mm and > 5 mm. Conclusions: Sphincter-preserving surgery was performed in 92.5% of patients with T3 lower rectal cancer who received SRT with delayed surgery. Our results confirmed the long-term oncologic feasibility of sphincter-preserving surgery with a distal margin of ≤ 5 mm; there was no negative impact on long-term outcomes such as local recurrence, recurrence-free survival, and overall survival.

Preparation of W/O nanoemulsion using tandem acoustic emulsification and its novel utilization as a medium for phase-transfer catalytic reaction

We have successfully demonstrated that W/O nanoemulsion prepared by the tandem acoustic emulsification is extremely useful medium for enhancing the rate of phase-transfer catalytic reactions.

Neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer

The purpose of this study was to examine the safety and feasibility of a novel protocol of neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer. A total of 56 patients with lower rectal cancer of cT3N1M0 (Stage III b) was treated with SC-HART followed by radical surgery, and were analyzed in the present study. SC-HART was performed with a dose of 2.5 Gy twice daily, with an interval of at least 6 hours between fractions, up to a total dose of 25 Gy (25 Gy in 10 fractions for 5 days) combined with S-1 for 10 days. Radical surgery was performed within three weeks following the end of the SC-HART. The median age was 64.6 (range, 39-85) years. The median follow-up term was 16.3 (range, 2-53) months. Of the 56 patients, 53 (94.4%) had no apparent adverse events before surgery; 55 (98.2%) completed the full course of neoadjuvant therapy, while one patient stopped chemotherapy because of Grade 3 gastrointestinal toxicity (CTCAE v.3). The sphincter preservation rate was 94.6%. Downstaging was observed in 45 patients (80.4%). Adjuvant chemotherapy was administered to 43 patients (76.8%). The local control rate, disease-free survival rate and disease-specific survival rate were 100%, 91.1% and 100%, respectively. To conclude, SC-HART combined with S-1 for locally advanced rectal cancer was well tolerated and produced good short-term outcomes. SC-HART therefore appeared to have a good feasibility for use in further clinical trials.

Extranodal natural killer/T-cell lymphoma: a diagnostic dilemma

BACKGROUND

The diagnosis of extranodal natural killer (NK)/T-cell lymphoma (NK/T-cell lymphoma) is often difficult and any delay in its diagnosis leads to a worsened prognosis. We analysed the factors that make the diagnosis of this type of tumour difficult.

METHODOLOGY/PRINCIPAL

We retrospectively reviewed the medical records of 20 patients with NK/T-cell lymphoma treated in our department, and assessed the clinical features and laboratory findings of the cases. Moreover, we classified factors related to delays in diagnosing NK/T cell lymphoma as follows: (1) insufficient specimen size, (2) massive necrosis, (3) large number of inflammatory cells, and (4) poor atypia. We selected cases requiring two or more biopsies for correct diagnosis and checked which factors were the main cause of misdiagnosis.

RESULTS

The average period required for a correct diagnosis was 12.8 months. The most frequent factor leading to diagnostic delay was inflammatory cell infiltration. Massive necrosis and poor atypia were also important factors in diagnostic delay.

CONCLUSIONS

In cases with necrotic lesions of the nose or pharynx, the possibility of NK/T cell lymphoma should be explored and samples, of as large a size as possible, should be obtained together with EBER-ISH for pathological examination. Repeat biopsies should also be performed for diagnosis.

Evaluation of the pathologic features of positive lymph nodes in the mesorectum after short-term preoperative chemoradiotherapy

571

Background: The purpose of this study was to investigate the relationship between the pathological degeneration of primary tumor and positive lymph nodes (LNs) after preoperative chemoradiotherapy for rectal cancer. Methods: We analyzed the resected specimens from 53 patients (pts) with ypN+ rectal cancer received curative resection after chemoradiotherapy (25 Gy/10 fr/5 days+S-1 80 mg/m2×10 days).The primary tumor regression was assessed using the tumor regression grade (TRG 0 to 4) according to Dworak classification. 144 positive LNs in the mesorectum were measured and were assessed using the LN regression grade (LRG) as follows; LRG 1 =minor to moderate regression, LRG 2 =major regression, and LRG 3 =total regression. To confirm apoptosis, the LNs with LRG 2 or 3 were stained by TUNEL method. Furthermore, we examined the relationship among the size of LNs, the TRG, and the LRG. Results: The TRG 1, 2, and 3 was found in 24 pts, 15 pts, and 14 pts, respectively. In addition, there were no pts with TRG 0 or 4. The LRG 1, 2, and 3 was found in 74 LNs, 48 LNs, and 22 LNs, respectively. 14 in 15 LNs equal to or greater than 10 mm (≥10mm) showed the LRG 1.Whereas, in 129 LNs less than 10 mm (<10mm), the proportion of the LRG 2 or 3 in pts with each TRG was 33.8 % (26/77), 69.0 % (20/29), and 100 % (23/23) in the TRG 1, 2, and 3 respectively. Conclusions: 1) Larger LNs (≥10 mm) seemed to be radioresistant. 2) A good correlation of the response to chemoradiation between the primary tumor and LNs were observed in smaller LNs (< 10 mm). 3) Primary tumor with the TRG 3 can predict the efficacy of preoperative chemoradiotherapy for the positive LNs in the pts with rectal cancer.

A novel preoperative protocol for locally advanced rectal cancer: Hyperfractionated short-course radiotherapy combined with chemotherapy

577

Background: Neoadjuvant chemoradiotherapy (NACRT) has become a widely accepted strategy for rectal cancer (RC). The purpose of this study is to examine the safety and efficacy of a novel protocol of neoadjuvant hyperfractionated short-course radiotherapy (NAHSRT) combined with chemotherapy for locally advanced RC. Methods: 82 patients (pts) with RC were treated with NACRT followed by radical surgery between March 2008 and May 2012. 50 pts with RC of cT3N1M0 were analyzed in the present study. NAHSRT was performed with a dose of 2.5 Gy twice daily, with an interval of at least 6 hours between fractions, up to a total dose of 25 Gy (25 Gy in 10 fractions for 5 days) with chemotherapy. Radical surgery was performed within 3 week following the end of the NAHSRT. Results: 50 pts included 37 men and 13 women. The median age was 65.0 (range: 39-85) years. The median follow-up term was 12.0 (2-36) months. S-1, oxaliplatin with capecitabine, and fluorouracil, leucovorin plus irinotecan (FOLFIRI) was administered with NAHSRT in 48 pts, 1 pt, and 1 pt, respectively. 48 pts (96%) had no apparent adverse events before surgery. 49 pts (98%) completed NACRT except for 1 pt stopped chemotherapy (S-1) because of grade 3 gastrointestinal toxicity (CTCAE v.3). In addition, no pts showed grade 4 toxicities. Postoperative complications were found in 30 pts (60.0%). 33 pts (66.0%) received adjuvant chemotherapy. S-1, capecitabine, oxaliplatin with capecitabine, uracil/tegafur (UFT) and oral leucovorin, and oxaliplatin combined with S-1 (SOX) was delivered after surgery in 20 pts, 4 pts, 4 pts, 4 pts, and 1 pt, respectively. No pts. developed local failure, although distant failures were found in 3 pts. The median disease free survival and overall survival was 11.6 (2-36) months and 12.0 (2-36) months, respectively. In addition, disease-specific survival rate was 100.0%. Conclusions: We presented a novel protocol of NAHSRT for locally advanced RC and the short-term outcome. NAHSRT was well tolerated and produced excellent short-term outcomes in pts with locally advanced RC.

Significant effects of preoperative intraluminal brachytherapy on the survival rate after resection of rectal carcinoma

We investigated whether or not preoperative intraluminal brachytherapy (IBT) contributes to a prolongation of the survival after resection of rectal carcinoma. Eighty-five patients with middle and lower rectal carcinoma with penetration into or through the rectal wall were treated with preoperative IBT (30 Gy) and radical resection. The patients were divided into the major effect group (n=59, proportion of remaining viable cells less than 25% of the background stroma) and the minor effect group (n=26, proportion of viable cells over 25%). The major effect group had more down-staged tumors, and a lower rate of positive nodes. Local recurrence rate, distant recurrence rate, and survival rate of the major effect group were 9% (31% in the minor effect group), 15% (55% in minor group) and 74% (36% in minor group), respectively (all parameters: p<0.05). Multivariate analysis indicated that nodal involvement, tumor depth, and proportion of viable cells were the prognostic factors. Preoperative IBT affected not only the tumor morphology but also the prognosis. Our criterion of the proportion of residual viable cells was significantly correlated to the patients' survival. The analyses revealed the positive effects of IBT on the prognosis of rectal cancer.

Genetic and environmental factors affecting peak bone mass in premenopausal Japanese women

The purpose of this study was to examine the relationships between peak bone mass and genetic and environmental factors. We measured whole-body bone mineral density (BMD), lumbar spine BMD, and radius BMD with dual-energy X-ray absorptiometry (DXA) and analyzed eight genetic factors: vitamin D receptor (VDR)-3', VDR-5', estrogen receptor (ER), calcitonin receptor (CTR), parathyroid hormone (PTH), osteocalcin (OC), apolipoprotein E (ApoE), and fatty acid binding protein 2 (FABP2) allelic polymorphisms using polymerase chain reaction-restriction fragment length polymorphisms (PCR-RFLPs). We also surveyed menstrual history, food intake, and history of physical activity using questionnaires.After adjusting for age, body mass index (BMI), current smoking status, current Ca intake, alcohol intake, menoxenia, and physical activity, the mean BMD in subjects with the HH/Hh genotype was significantly higher than that of subjects with the hh genotype for whole-body BMD (mean±SD, 1.20±0.10 vs. 1.18±0.09 g/cm(2); HH/Hh vs. hh, p=0.04) and at lumbar spine BMD (mean±SD, 1.18±0.14 vs. 1.14±0.12 g/cm(2); HH/Hh vs. hh, p=0.02) in OC allelic polymorphism. Furthermore, the results of multiple regression analyses taking the 8 genetic factors plus the 7 environmental factors listed above into account showed that the strongest factor contributing to BMD was BMI at any site (whole-body and lumbar BMD p<0.0001, radius BMD p=0.0029). In addition, OC polymorphism (p=0.0099), physical activity (p=0.0245), menoxenia (p=0.0384), and PTH polymorphism (p=0.0425) were independent determinants for whole-body BMD, and OC polymorphism (p=0.0137) and physical activity (p=0.0421) were independent determinants for lumbar BMD and radius BMD, respectively.

BDNF expression and systemic dissemination via anoikis resistance in gastric cancer

e14541

Background: Anoikis (apoptosis resulting from loss of cell-matrix interaction) has been suggested to act as a physiological barrier to metastasis, and resistance to anoikis is necessary for cancer cell survival during systemic dissemination and metastasis. Brain-derived neurotrophic factor (BDNF) is one of the member of neurotropin family known to activate the high affinity tyrosine kinase (Trk)B receptor as a specific suppressor of anoikis. TrkB activation by BDNF has been shown to facilitate the progression of several cancers, however no reports have shown the clinical and biological effects of BDNF/TrkB axis in gastric cancer. Methods: BDNF expression in gastric cancer tissue and clinicopathological data from 153 consective patients were analyzed by real-time PCR and immunohistochemistry. The extent of target gene expression was calculated from the standard curve, with quantitative normalization of the cDNA in each sample performed using GAPDH gene as an internal control. Recombinant human BDNF and Trk antagonist K252a were used for in vitro assays to evaluate the biological role of the BDNF/TrkB axis in gastric cancer cell lines. Results: The mean BDNF level in gastric cancer tissue was 284.5 (0-2834). One hundred eighteen (77.1%) of 153 patients showed detectable BDNF levels, whereas the remainder had no detectable. BDNF positive expression was significantly associated with histological diffuse type (p=0.019), lymph node metastasis (p<0.001), peritoneal dissemination (p=0.028) and poor prognosis (p=0.022). In addition, BDNF expression is an independent risk factor for lymph node metastasis and peritoneal dissemination. Immunohistochemical analysis indicated intense BDNF expression in the cytoplasm of cancer cells, and intense TrkB expression in the nuclei of cancer cells, respectively. In vitro, administration of recombinant human BDNF promoted proliferation, anoikis resistance, and partial migration. In addition, these effects were generally inhibited by Trk antagonist K252a. Conclusions: BDNF appears to play an important role in gastric cancer progression, and blocking BDNF/TrkB axis might be clinically useful in developing therapies for patients with gastric cancer.

A New p-Type Conductive Oxide with Wide Band GAP, SrCu2O2

SrCu2O2 thin films were prepared onto SiO2 glass substrates by pulsed laser deposition. The film deposited in O2 atmosphere of 7×10-4 Pa at 573 K showed high optical transmission in visible and near infrared regions. The optical band gap of the film was estimated to be -3.3 eV. The dc electrical conductivity of the film was 3.8 × 10-3 Scm-1. Potassium was used for substitutional hole-doping. The dc electrical conductivity of the K-doped film at 300 K increased to 4.8 × 10-2 Scm-1. Positive sign of Seebeck and Hall coefficients demonstrated p-type conduction of the K-doped film. Hole concentration and mobility at 300 K were 6.1 × 1017 cm-3 and 0.46 cm2V-1s-1, respectively.