Impact of regional lymph node metastasis on pulmonary metastasis as the first recurrence site

Little is known about the impact of regional lymph node metastasis (LNM) on the first recurrence sites following curative colorectal cancer (CRC) surgery. The present study aimed to clarify the relationship between regional LNM stratified by N status and the first recurrence pattern in patients with stage I-III CRC. We performed a retrospective analysis of 1181 consecutive patients with stage I-III CRC who underwent curative surgery between 2010 and 2018. The total sample size included 1181 patients who underwent elective stage I-III CRC surgery. Median follow-up time was 60 months, and median time to recurrence was 12 months. Overall, the numbers of liver recurrence and pulmonary recurrence were 94 (7.9%) and 70 (5.9%), respectively. Higher N status was significantly associated with increased risk of pulmonary recurrence (N0 vs. N1a, p = 0.02; N0 vs. N1b, p < 0.01; N0 vs. N2a, p < 0.01; N0 vs. N2b, p < 0.01) and worse pulmonary recurrence-free survival, but not other recurrences. In Non-LNM patients, on the other hand, advanced T status was associated with increased risk of pulmonary recurrence. The regional LNM was strongly associated with pulmonary metastasis as the first recurrence site following stage I-III CRC resection.

Single-incision laparoscopic surgery for intestinal intussusception due to neuroendocrine tumor

BACKGROUND

Small intestinal neuroendocrine tumor (NET) is uncommon, but intestinal intussusception caused by NET is even rare. We report a rare case of single-incision laparoscopic surgery (SILS) for intestinal intussusception due to NET G1.

CASE PRESENTATION

A 72-year-old woman presented with vomiting, diarrhea, and abdominal pain. Contrast-enhanced computed tomography (CT) revealed the target sign in the ascending colon. An enhanced nodule was detected at the lead point, leading us to suspect a tumor. Colonoscopy showed a tumor at the lead point of the intestinal intussusception. Histological findings led to a diagnosis of NET G1. Single-incision laparoscopic ileocecal resection with regional lymphadenectomy was then performed. The patient was discharged 10 days postoperatively with no complications.

CONCLUSION

We achieved SILS with regional lymphadenectomy for preoperatively diagnosed intestinal intussusception due to NET G1. Although this condition is rare, surgeons should take this possibility into consideration in cases showing similar findings.

Abstract 3295: Plasma and tumor expression levels of progranulin osteopontin & matrix metalloproteinase 2 in colorectal cancer patients and assessment of plasma levels for diagnosis

Introduction: PGRN is a growth factor involved in the regulation of cell proliferation, differentiation and pathological processes. OPN is an integrin binding phosphorylated glycoprotein involved in cell-mediated immunity, inflammation, cell survival, and tumor progression. MMP 2 is an extracellular matrix (ECM) remodeling enzyme that breaks down the ECM and also facilitates cancer growth. OPN promotes ERK pathway and VEGF mediated tumor angiogenesis and progression. PGRN stimulates VEGF expression in breast cancer cells in vitro. This study’s goals were to assess: 1) preoperative (preOp) plasma PGRN, OPN and MMP 2 levels in CRC and benign pathology (BP) patients (pts.), 2) tumor mRNA expression, and 3) the diagnostic potential of these proteins.

Method: CRC and BP bowel resection pts enrolled in an IRB approved tissue bank for whom preOp plasma was available were studied. Basic demographic, clinical, operative, and pathology data were evaluated. Plasma PGRN, OPN and MMP2 levels (ng/ml) were measured in duplicate via ELISA (results: median + 95%CI). Also, protein expression levels in tumors and paired normal tissue were determined for a subset of pts by QRT-PCR. CRC and BP plasma levels were compared by the Mann-Whitney test (significant &lt;0.05). The plasma receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to evaluate single and combined proteins levels.

Result: Plasma from 102 BP (adenoma 32%, diverticulitis 53%, other 15%) and 172 CRC (70% colon, 30% rectal) pts. were analyzed. The CRC Stage (STG) distribution was: STG-1, 25%; STG-2, 32%, STG-3, 31%, STG- 4, 12%. Median PreOp proteins levels in CRC patients for all 3 proteins were significantly higher than BP levels (PGRN; 54.71, CI: 51.82,57.12 vs. 43.32, CI: 40.10,46.89; OPN; 82.38, CI: 77.1,89.38 vs. 63.86, CI: 54.95,69.03; MMP2; 205.3 CI:198.2,217.15 vs. 165.3 CI: 156.83,179.06; P&lt;0.0001 for all). Plasma OPN levels were significantly higher in STG 4 pts vs STG 1 group ( p&lt;0.01). The percentage of tumors overexpressing these proteins were: PGRN, 8%; OPN, 77%; and MMP2, 59%. The single AUC values from the ROC curve for PGRN, OPN and MMP2 were 0.724, 0.703 and 0.721 with 71%, 77% and 73% specificity and with 63%, 55% and 64% sensitivity. The 3 protein combination achieved a specificity of 78% (AUC, 0.792) and sensitivity of 71%.

Conclusion: Median PGRN, OPN and MMP2 plasma levels in CRC pts were significantly higher (26%, 29% & 24% respectively) than BP levels; the OPN and MMP2 increases may be related to tumor expression. Increased plasma PGRN and MMP2 may be the result of tumor angiogenesis and inflammation-induced tissue remodeling. OPN levels were increased in stage 4 pts. The 3 protein combination had improved AUC & specificity vs single protein results. Further study is needed.

Citation Format: Chandana S. K. Herath Mudiyanselage, Xiaohong Yan, Neil Mitra, Hansani N. Angammana, Hiromichi Miyagaki, Yanni Yanni, Vesna Cekic, Joseph Martz, Richard L. Whelan. Plasma and tumor expression levels of progranulin osteopontin & matrix metalloproteinase 2 in colorectal cancer patients and assessment of plasma levels for diagnosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3295.

[A Case of Advanced Gastric Cancer in Which Tumor Relapse Was Observed after Discontinuation of Nivolumab Due to Complete Response, and for Which Re-Administration Was Initiated]

A 61-year-old male was diagnosed with unresectable advanced gastric cancer(cT4b[SI; panc], N+, M0, cStage ⅣA). However he was administered S-1 plus oxaliplatin as a primary treatment and ramucirumab plus paclitaxel as a secondary treatment, the primary tumor and lymph nodes were enlarged. We judged PD and switched to the third-line treatment with nivolumab. After starting nivolumab, both the primary tumor and the lymph nodes shrank, and the PET-CT scan after 24 courses showed no FDG accumulation in the primary tumor or lymph nodes, so we judged the response as CR. The patient requested discontinuation of nivolumab, and nivolumab administration was stopped. Twenty months later after nivolumab administration was discontinued, CT scan showed re-growth of the primary tumor, and nivolumab administration was resumed. After resumption, he received 22 courses of nivolumab for 10 months with maintenance of SD.

Osteopontin Levels Are Persistently Elevated for 4 weeks Following Minimally Invasive Colorectal Cancer Resection

INTRODUCTION

Osteopontin (OPN) is an integrin binding phosphorylated glycoprotein secreted by macrophages and leukocytes that is found in extracellular fluids and sites of inflammation; various forms of CD44 serve as receptors. Osteopontin, expressed by numerous cancers, enhances tumor progression and angiogenesis via the PI3K/AKT and ERK mediated pathways in concert with Vascular Endothelial Growth Factor (VEGF); OPN also plays a role in wound healing. The impact of minimally invasive colorectal resection (MICR) for colorectal cancer (CRC) on plasma OPN levels is unknown. This study's goal was to assess blood levels during the first month after MICR.

METHOD

Patients undergoing MICR for CRC who were enrolled in an IRB approved tissue/prospective data bank for whom preoperative, postop Day (POD) 1, POD 3, and at least 1 late postop plasma sample (POD 7-34) were available were studied. Osteopontin levels were determined in duplicate via enzyme linked immunosorbent assay (ELISA) (results reported as mean ± SD). The Wilcoxon signed rank test was used for analysis (significance P < .05).

RESULTS

A total of 101 CRC patients (63% colon and 37% rectal) met study criteria. The mean preop OPN level was 89.2 ± 36.8 (ng/ml) for the entire group. Significantly elevated (P < .001) mean plasma levels were detected, vs preop, on POD1 (198.0 ± 67.4; n = 101), POD 3 (186.0 ± 72.6, n = 101), POD 7-13 (154.1 ± 70.2, n = 70), POD14-20 (146.7 ± 53.4, n=32), and POD 21-27 (123.0 ± 56.9, n = 25). No difference was noted at the POD 27-34 timepoint (P > .05).

CONCLUSION

Plasma OPN levels are significantly elevated over baseline for a month after MICR for CRC. The early rise in OPN levels may be related to the postop acute inflammatory response. The persistent elevation noted in weeks 2-4, however, may be a manifestation of wound healing in which OPN plays a role. Similar persistent plasma elevations of VEGF, angiopoietin 2 (ANG 2), and 11 other proangiogenic proteins have been noted and, collectively, may promote angiogenesis in residual tumors.

[A Resected Case of the Sigmoid Colon Cancer after the Endovascular Aneurysm Repair in Which Intraoperative Indocyanine Green Fluorescence Method Was Useful for Evaluating the Blood Flow in the Colon]

A man in his 70s underwent an endovascular aneurysm repair(EVAR)for abdominal aortic aneurysm. Blood test revealed an anemia and an increased tumor marker. Enhanced computed tomography revealed the wall thickening in the sigmoid colon and the Type Ⅱ endoleak after EVAR. Colonoscopy showed the wall thickening in the sigmoid colon, and biopsy indicated a diagnosis of adenocarcinoma. We performed open sigmoid colectomy with D3 lymph node dissection and ileostomy. We performed intraoperative indocyanine green (ICG) fluorescence method for evaluating the blood flow in the colon before the high ligation of the inferior mesenteric artery and the creation of the anastomosis, and perfusion of the colon was visualized. He was discharged postoperative day 14, and was performed closure of ileostomy 5 months later. Intraoperative ICG fluorescence method was safety and useful for evaluating the blood flow in the colon.

[A Case of Synchronous Secondary Lymph Node Metastasis in the Mesentery of the Ileum with cCR Achievement after Surgery for Sigmoid Colon Cancer]

A 71-year-old woman was hospitalized with loose stools and lightheadedness. She was subsequently diagnosed with sigmoid colon cancer for which we performed a laparoscopic sigmoid colectomy, small intestine partial resection, partial bladder resection, and open conversion. The intraoperative findings and histopathological analysis showed secondary lymph node metastasis in the mesentery of the ileum, and the surgery resulted in R2 resection. Chemotherapy(CAPOX plus Bev) was initiated thereafter, and the L-OHP and Bev were discontinued over time. A complete response was achieved at 1 year postoperative. Capecitabine alone was continued, and no signs of recurrence were noted at 2 years postoperative.

[Outcome of Hepatectomies for Non-Colorectal Liver Metastases]

We performed 16 cases of non-colorectal liver metastasis resection(19 resections)between January 2011 and December 2021. Among the 16 cases, the primary lesions were as follows: gastric cancer in 7 cases; GIST in 2 cases; and neuroendocrine tumor, renal cancer, pancreatic cancer(acinic cell carcinoma), cholangiocarcinoma, breast cancer, ovarian cancer, and leiomyosarcoma in 1 case each. The median time from primary lesion resection to the diagnosis of liver metastasis was 20.6 months. In cases of neuroendocrine tumors and renal cancer, hepatectomy was performed with a preoperative diagnosis of hepatocellular carcinoma. Four cases underwent laparoscopic hepatectomy, and 10 cases underwent anatomical liver resection. Postoperative chemotherapy was performed in 8 cases. Recurrence of liver metastasis was observed in 7 cases. One case of gastric cancer and 1 case of neuroendocrine tumor underwent repeat hepatectomy. The median relapse-free survival was 13.8 months, and the median overall survival was 55.7 months.

[A Case of Resection of Sigmoid Colon Metastasis from Pancreatic Cancer]

A 73-year-old man underwent distal pancreatectomy for invasive pancreatic ductal carcinoma in 2018. He showed stenosis of sigmoid colon due to recurrence of pancreatic cancer and received transverse colostomy in 2020. One year after initiation of gemcitabine monotherapy, he complained of abdominal pain. CT images and colonoscopy revealed accumulation of mucus in sigmoid colon due to stenotic lesions. Because conservative treatment using antibiotics was not effective, we performed sigmoidectomy. Histological examination revealed that tubular adenocarcinoma located mainly in the muscularis propria invaded into the colonic mucosa. Immunohistochemical analysis showed positive staining for CK7, and negative for CK20. We diagnosed sigmoid colon metastases of pancreatic cancer.

Oncological outcomes following minimally invasive surgery for pathological N2M0 colorectal cancer: A propensity score-matched analysis

INTRODUCTION

Whether minimally invasive surgery (MIS) is safe and effective for patients with N2M0 colorectal cancer (CRC) remains controversial. This study aimed to compare short- and long-term outcomes between MIS and open surgery (Open) groups for patients with pathological (p)N2M0 CRC, and evaluate the oncological outcomes of MIS for pN2M0 CRC.

MATERIALS AND METHODS

We retrospectively analyzed 125 consecutive patients with pN2M0 CRC who underwent curative surgery between 2010 and 2017, using propensity score-matching (PSM) analysis.

RESULTS

Median follow-up was 59.4 months. After PSM, we enrolled 68 patients (n = 34 in each group). The conversion rate was 9.6% for the entire patient cohort and 5.9% for the matched cohort. In colon cancer (CC), short-term outcomes were similar between groups. On the other hand, in rectal cancer (RC), estimated blood loss, rate of anastomosis leakage, and length of postsurgical stay were lower in the MIS group than the Open group. R0 resection was achieved in all patients with MIS. No surgical mortality was encountered in any group. No significant differences were found between groups in terms of 3-year local recurrence rate, overall survival, cancer-specific survival, or recurrence-free survival among the entire patient cohort or the matched cohort, regardless of the primary tumor site (CC or RC). Surgical approach (MIS vs Open) had no significant influence on survival outcomes.

CONCLUSIONS

MIS is a safe and effective option for patients with pN2M0 CRC, with acceptable short- and long-term outcomes comparable to the open approach. MIS can be considered for patients with pN2M0 CRC.

Abstract 1415: Osteopontin and matrix metalloproteinase 2 plasma levels are elevated in colorectal cancer (CRC) vs benign disease; The 2 protein combination improves specificity as regards CRC diagnosis

Introduction: Expression of Osteopontin (OPN) and Matrix Metalloproteinase 2 (MMP 2) are elevated in CRC. OPN is an integrin binding phosphorylated glycoprotein implicated in cell-mediated immunity, inflammation, tumor progression, and cell viability. OPN is secreted by macrophages and leukocytes. OPN activity is associated with the PI3K/AKT and ERK pathways and VEGF mediated tumor angiogenesis. MMP-2 degrades type IV collagen and facilitates tumor cell invasion and metastasis. MMP-2 also promotes tumor angiogenesis. This study’s first purpose was to compare preoperative (PreOp) plasma OPN and MMP2 levels in CRC and benign pathology (BP) patients (pts); the 2nd purpose was to assess the combination of these proteins for diagnosis.

Method: PreOp plasma samples obtained from consenting CRC and BP pts undergoing surgery were used for this study. Prospectively gathered demographic, clinical and pathologic data were analyzed. Plasma levels of OPN and MMP2 (ng/ml) were measured via ELISA and reported as median + 95% CI. The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to evaluate the diagnostic value of each protein alone and in combination. Expression levels of OPN and MMP2 were determined in tumor and normal tissue for a subset of pts by QRT-PCR. The Mann-Whitney test was used for analysis.

Results: Plasma from 156 CRC (73% colon, 27% rectal) and 102 BP (polyp 32%, diverticulitis 56%, other 12%) pts was studied. CRC stage breakdown was: 1, 26%; 2, 33%, 3, 29%, 4, 12%. CRC median preop plasma levels were significantly higher vs. the BP group for both proteins [OPN; 82.4,CI:75.4, 89.5 vs 59.2, CI:53.8,63.3;MMP2; 203.6,CI:195.0,214.5 vs 160.2,CI:151.9,172.2; P&lt;0.0001). Higher OPN levels were noted in stg 3(p=0.04) and Stg 4(p=0.01) vs stg 1 pts. The AUC value for the ROC curve for OPN and MMP2 were 0.73 and 0.73 respectively with 61% and 70% specificity. The AUC for the 2 protein combination was 0.80 with 65% sensitivity and 80% specificity. OPN and MMP2 expression was elevated in 75% and 50% of CRC tumors tested, respectively (n=12).

Conclusion: Median CRC OPN and MMP2 levels were significantly higher (39% and 27%) than BP levels. OPN and MMP2 expression was confirmed in a subset of pts. This 2 protein combination improved the AUC and specificity for CRC diagnosis. Further study with more protein combinations is warranted.

Citation Format: Chandana S. k. Herath Mudiyanselage, Hiromichi Miyagaki, Neil Mitra, Yanni Hedjar, Xiaohong Yan, Vesna Cekic, Joseph Martz, Jennifer Agnew, Richard L. Whelan. Osteopontin and matrix metalloproteinase 2 plasma levels are elevated in colorectal cancer (CRC) vs benign disease; The 2 protein combination improves specificity as regards CRC diagnosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1415.

A case in which the ileocolic vein draining into the gastrocolic trunk of Henle could be diagnosed preoperatively: a rare anatomical case report

Background

Numerous variations in vascular anatomy have been reported in the right colon. The ileocolic vein (ICV) generally drains directly into the superior mesenteric vein (SMV), and is an important landmark for laparoscopic surgery in right colon cancer. We present here a patient with a vascular anomaly of the ICV that was diagnosed on preoperative imaging.

Case presentation

A 65-year-old woman was diagnosed with transverse colon cancer by colonoscopy. Preoperative computed tomography scan showed that the ICV drained into the gastrocolic trunk of Henle (GCT) rather than the SMV. Single-incision laparoscopic transverse colectomy with D3 lymph node dissection was performed, dividing the middle colic vein (MCV) and preserving the right gastroepiploic vein (RGEV), anterior superior pancreaticoduodenal vein (ASPDV), GCT and ICV. The intraoperatively identified venous anatomy was consistent with the preoperative evaluation, and the RGEV, ASPDV and ICV were found to form the GCT.

Conclusion

We report a rare vascular anatomical anomaly that was diagnosed preoperatively, facilitating safe and successful single-incision laparoscopic surgery with D3 lymph node dissection.

Impact of prior abdominal surgery on short-term outcomes following laparoscopic colorectal cancer surgery: a propensity score-matched analysis

BACKGROUND

Whether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery.

METHODS

We performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed.

RESULTS

After propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05-5.26) and body mass index ≥ 25 kg/m² (OR 3.56; 95% CI 1.07-11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08-5.20).

CONCLUSIONS

Laparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

[A Case Report of Gastric Cancer with Long-Term Prognosis by Multidisciplinary Treatment]

The patient was a 55-year-old man. For gastric cancer with peritoneal dissemination and pyloric stenosis, gastrojejunostomy was performed and S-1 plus paclitaxel combination therapy was started. After confirming tumor shrinkage and negative peritoneal dissemination, pyloric gastrectomy was performed. Paclitaxel therapy was performed for 1 year after surgery, and the patient was followed up without systemic chemotherapy. Since the CA19-9 level increased 1 year and 8 months after gastrectomy, ramucirumab plus paclitaxel therapy and followed S-1 plus oxaliplatin therapy were performed. Two years and 6 months after gastrectomy, solitary metastasis of the paraportal lymph nodes was observed, and radiation therapy was introduced. One year later after radiation, lymph node metastasis of near the left common iliac artery was detected, and nivolumab therapy was performed. Although nivolumab was discontinued due to hepatic dysfunction, he is alive without recurrence, 7 years after gastrectomy. It could be important to judge treatment decision based on the evaluation of radiographic assessment, tumor markers and clinical symptoms.

[Medication Support and Adverse Events Monitoring System Using Medical Social Networking Service(SNS)]

PURPOSE

We introduced the medication support and adverse events monitoring system using medical social networking service (SNS).

METHODS

Thirty-two gastric cancer patients who were treated with oral anticancer drugs were included in this study. Patients or their families input the status of medication and adverse events using the ICT terminal every day, and the pharmacist confirmed the input contents on the PC. If there was a serious adverse events, the nurse confirmed the status of patient by telephone.

RESULTS

Of the 32 registered cases, 3 cases (9.3%) discontinued input within less than 2 months during treatment. We experienced a case whose adverse events could be dealt with during long vacations and a case whose treatment could be continued by sharing information with home-visit nursing stations. In the questionnaire survey, there were many opinions that it would lead to anxiety reduction.

CONCLUSION

Medication support system using medical SNS can be a safe and useful tool.

[A Case of Cecal Cancer Directly Invading the Duodenum with a Mobile Cecum]

A 70-year-old man showing positive results for a fecal occult blood test was admitted to a local hospital. He was suspected of double cancer in the cecum and duodenum. While performing ileocolic and segmental duodenal resections, he was diagnosed with cecal cancer invading the duodenum, following which he underwent surgical intervention. The tumor directly invaded the duodenum because of the mobile cecum. This case of duodenal invasion by cecal cancer is atypical.

Plasma Levels of Keratinocyte Growth Factor Are Significantly Elevated for 5 Weeks After Minimally Invasive Colorectal Resection Which May Promote Cancer Recurrence and Metastasis

Background: Human Keratinocyte Growth Factor (KGF) is an FGF family protein produced by mesenchymal cells. KGF promotes epithelial cell proliferation, plays a role in wound healing and may also support tumor growth. It is expressed by some colorectal cancers (CRC). Surgery's impact on KGF levels is unknown. This study's purpose was to assess plasma KGF levels before and after minimally invasive colorectal resection (MICR) for CRC. Aim: To determine plasma KGF levels before and after minimally invasive colorectal resection surgery for cancer pathology. Method: CRC MICR patients (pts) in an IRB approved data/plasma bank were studied. Pre-operative (pre-op) and post-operative (post-op) plasma samples were taken/stored. Late samples were bundled into 7 day blocks and considered as single time points. KGF levels (pg/ml) were measured via ELISA (mean ± SD). The Wilcoxon paired t-test was used for statistical analysis. Results: Eighty MICR CRC patients (colon 61%; rectal 39%; mean age 65.8 ± 13.3) were studied. The mean incision length was 8.37 ± 3.9 and mean LOS 6.5 ± 2.6 days. The cancer stage breakdown was; I (23), II (26), III (27), and IV (4). The median pre-op KGF level was 17.1 (95 %CI: 14.6-19.4; n = 80); significantly elevated (p < 0.05) median levels (pg/ml) were noted on post-op day (POD) 1 (23.4 pg/ml; 95% CI: 21.4-25.9; n = 80), POD 3 (22.5 pg/ml; 95% CI: 20.7-25.9; n = 76), POD 7-13 (21.8 pg/ml; 95% CI: 17.7-25.4; n = 50), POD 14-20 (20.1 pg/ml; 95% CI: 17.1-23.9; n = 33), POD 21-27 (19.6 pg/ml; 95% CI: 15.2-24.9; n = 15) and on POD 28-34 (16.7 pg/ml; 95% CI: 14.0-25.8; n = 12). Conclusion: Plasma KGF levels were significantly elevated for 5 weeks after MICR for CRC. The etiology of these changes is unclear, surgical trauma related acute inflammatory response and wound healing process may play a role. These changes, may stimulate angiogenesis in residual tumor deposits after surgery.

Utility of monthly minodronate for osteoporosis after gastrectomy: Prospective multicenter randomized controlled trials

AIM

Osteoporosis in patients after gastrectomy is increasing with the aging of gastric cancer patients. Bisphosphonates are effective treatments for osteoporosis; however, their safety or efficacy in postgastrectomy patients has not been established. The purpose of this multicenter prospective intervention study was to investigate the impact of monthly minodronate on osteoporosis after gastrectomy.

METHODS

Of the 261 enrolled gastric cancer patients, 164 patients were diagnosed with osteoporosis based on criteria of the Japan Society of Osteoporosis. They were randomly assigned 1:1 to groups treated with active vitamin D (VD group) or monthly minodronate (MIN group). The primary endpoint was changes in lumbar bone mineral density (L-BMD) 12 mo after the start of administration. The secondary endpoints were changes in bone metabolism markers, adverse events (AEs), or treatment completion rates.

RESULTS

There was no significant difference in patient background between the VD (n = 82) and MIN (n = 82) groups. In the MIN group, the increase in L-BMD was significantly higher than that in the VD group (4.52% vs 1.72%, P = .001), with a significant reduction in bone metabolism markers; blood NTX (-25.6% vs -1.6%, P < .01) and serum bone-specific alkaline phosphatase (-34.3% vs -20.1%, P < .01). AEs were observed in 26.8% and 9.3% of the patients and treatment completion rates were 77.5% and 89.3% in the MIN and VD groups, respectively. Serious AEs were not observed in either group.

CONCLUSION

This study demonstrated the safety and efficacy of monthly minodronate, suggesting that this treatment may be useful for osteoporosis after gastrectomy (UMIN000015517).

Plasma MMP-2 and MMP-7 levels are elevated first month after surgery and may promote growth of residual metastases

BACKGROUND

MMP-2 also known as gelatinase A and MMP-7 (matrilysin) are members of the zinc-dependent family of MMPs (Matrix metalloproteinase). MMP-2 and MMP-7 are remodeling enzymes that digest extracellular matrix; MMP-2 is extensively expressed during development and is upregulated at sites of tissue damage, inflammation, and in stromal cells of metastatic tumors. MMP-7 is expressed in the epithelial cells and in a variety of cancers including colon tumors. Plasma MMP-2 and MMP-7 levels were assessed before and after minimally invasive colorectal resection for cancer pathology.

AIM

To determine plasma MMP-2 and MMP-7 levels before and after minimally invasive colorectal resection for cancer pathology.

METHODS

Patients enrolled in a plasma bank for whom plasma was available were eligible. Plasma obtained from preoperative (Preop) and postoperative blood samples was used. Only colorectal cancer (CRC) patients who underwent elective minimally invasive cancer resection with preop, post-operative day (POD) 1, 3 and at least 1 late postop sample (POD 7-34) were included. Late samples were bundled into 7 d blocks (POD 7-13, 14-20, etc.) and treated as single time points. Plasma MMP-2 and MMP-7 levels were determined via enzyme-linked immunosorbent assay in duplicate.

RESULTS

Total 88 minimally invasive CRC resection CRC patients were studied (right colectomy, 37%; sigmoid, 24%; and LAR/AR 18%). Cancer stages were: 1, 31%; 2, 30%; 3, 34%; and 4, 5%. Mean Preop MMP-2 plasma level (ng/mL) was 179.3 ± 40.9 (n = 88). Elevated mean levels were noted on POD1 (214.3 ± 51.2, n = 87, P < 0.001), POD3 (258.0 ± 63.9, n = 80, P < 0.001), POD7-13 (229.9 ± 62.3, n = 65, P < 0.001), POD 14-20 (234.9 ± 47.5, n = 25, P < 0.001), POD 21-27 (237.0 ± 63.5, n = 17, P < 0.001,) and POD 28-34 (255.4 ± 59.7, n = 15, P < 0.001). Mean Preop MMP-7 level was 3.9 ± 1.9 (n = 88). No significant differences were noted on POD 1 or 3, however, significantly elevated levels were noted on POD 7-13 (5.7 ± 2.5, n = 65, P < 0.001), POD 14-20 (5.9 ± 2.5, n = 25, P < 0.001), POD 21-27 (6.1 ± 3.6, n = 17, P = 0.002) and on POD 28-34 (6.8 ± 3.3, n = 15 P < 0.001,) vs preop levels.

CONCLUSION

MMP-2 levels are elevated for 5 wk and MMP-7 levels elevated for weeks 2-6. The etiology of these changes in unclear, trauma and wound healing likely play a role. These changes may promote residual tumor growth and metastasis.

An observational study on nutrition status in gastric cancer patients receiving ramucirumab plus taxane: BALAST study

Limited data are available regarding the efficacy of nutrition support in advanced gastric cancer (AGC) patients receiving a standard second-line combination chemotherapy. The BALAST study is conducted as a prospective, multicenter observational study to evaluate the efficacy of nutrition support for patients with AGC treated with ramucirumab plus taxane as second-line treatment. As part of the routine care, patients who are malnourished or at risk of malnutrition will receive nutrition support from dietitians. We will enroll a total of 26 patients to estimate weight control rate at 12 weeks as primary end point. This study will generate valuable data reinforcing the role of nutrition support therapy for AGC patients receiving second-line chemotherapy.

[A Case of Surgical Resection for Solitary Lymph Node Metastasis of Hepatocellular Carcinoma]

A 77-year-old man has undergone 5 times of transcatheter arterial chemoembolization(TACE)and 5 times of radiofrequency ablation(RFA)for hepatocellular carcinoma(HCC)since 2015. In February 2019, serum tumor marker levels extremely increased and CT scan showed a 40 mm mass in hepatoduodenal ligament. Imaging study revealed that intrahepatic lesions of HCC were well controlled and the mass was diagnosed as solitary lymph node metastasis of HCC. We performed surgical resection of the lymph node. The patient discharged 8 days after the surgery. Histopathologicaly, the tumor was diagnosed as lymph node metastasis of HCC. The patient remains free from recurrence 14 months after surgery.

Single-incision laparoscopic repair for a Morgagni hernia: A case report

A Morgagni hernia is a rare type of congenital diaphragmatic hernia. Here, a case of a Morgagni hernia repaired by SILS is presented. A 78-year-old woman was admitted to our hospital with nausea and vomiting. On CT, the transverse colon and antrum of the stomach were prolapsed into the right thoracic cavity. The herniated stomach was repositioned by emergency endoscopy, and SILS repair was performed electively. Laparoscopy showed the hernial orifice, which was 75 × 50 mm in diameter, on the right side and behind the sternum. Although the transverse colon had herniated through the defect into the right diaphragm, it was easily reduced into the abdominal cavity. Composite mesh was sutured to cover the hernial orifice. No perioperative complications or hernia recurrence have been observed in the 8 months since the surgery.

Systematic review of single-port vs. multi-port surgery for rectal cancer

The aim of the current systematic review was to compare the short-term clinical and oncological outcomes of single-port surgery (SPS) to multi-port surgery (MPS) for rectal cancer in MEDLINE, PubMed and Cochrane Library from January 2010 to December 2018. A total of 5 clinical controlled studies composed one randomized pilot study and four non-randomized studies with a total of 461 patients were analyzed after a systematic review. A total of 125 patients (27.1%) underwent SPS and 336 patients (72.9%) underwent MPS for rectal cancer. The rate of conversion to open surgery was lower in the SPS group compared with the MPS group (0.8 vs. 5.4%, respectively). A total of 16.8% of patients in the SPS group required an additional port to complete the operation. The morbidity rate was lower in the SPS group compared with the MPS group (28.0 vs. 39.0%, respectively). The other short-term clinical outcomes were similar in both groups. The R0 resection rate was 99.0% in the SPS group and 98.7% in the MPS group. The oncological clearance was satisfactory and similar in both groups. The current study concluded that SPS can be performed safely and provide satisfactory oncological outcomes in patients with rectal cancer. However, further studies are required to determine the role of SPS in the long-term clinical and oncological outcomes.

[Two Cases of Esophagogastric Junction Cancer after Subtotal Stomach-Preserving Pancreaticoduodenectomy]

We report 2 cases with esophagogastric junction(EGJ)cancer who underwent remnant gastrectomy preserving Braun anastomosis after subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)with modified Child's reconstruction. In case 1, a 73-year-old man was diagnosed with EGJ cancer 4 years after SSPPD for stenosis of lower bile duct. He underwent remnant gastrectomy with Roux-en-Y(R-Y)reconstruction preserving Braun anastomosis using linear stapler(overlap method). In case 2, a 77-year-old man, who underwent SSPPD for intraductal papillary mucinous neoplasm 1 year ago, was performed endoscopic submucosal dissection for EGJ cancer and planned additional gastrectomy, because of non-curative resection. He was performed remnant gastrectomy with R-Y reconstruction preserving Braun anastomosis using circular stapler. In both patients, the postoperative courses were favorable without complication. Remnant gastrectomy after PD is difficult because of anatomical changes due to adhesions and gastrointestinal reconstruction. R-Y reconstruction preserving Braun anastomosis may be a useful surgical procedure for remnant gastric cancer after SSPPD.

[A Case of Advanced Adenosquamous Carcinoma of Pancreas with Conversion Surgery after Chemoradiotherapy Followed by Systemic Chemotherapy]

A man in his 60s with upper abdominal discomfort was referred to our hospital. CT scan revealed the 40 mm tumor in the body and tail of pancreas invading stomach wall. Solid soft tissue contact was also observed around celiac artery(CA)and common hepatic artery(CHA). EUS-FNA from pancreatic mass showed suspicion of adenosquamous carcinoma. We diagnosed it as pancreatic adenosquamous carcinoma, cT4N0M0, cStage Ⅲ. The patient received radiotherapy(46.8 Gy/26 Fr in total)combined with S-1. Although the primary lesion showed shrinkage, solid soft tissue around CA and CHA deteriorated. We judged the tumor unresectable, and the patient received systemic chemotherapy using gemcitabine(GEM). After 6 courses of GEM, solid soft tissue around CA and CHA almost disappeared. Based on these results, we performed distal pancreatectomy and partial gastrectomy 8 months after the initiation of the treatment. Pathological results showed adenosquamous carcinoma of the pancreas with Grade 2 response to the preoperative treatment. Although the tumor invaded into the gastric wall, R0 resection was achieved. The patient is alive with no recurrence a year and 4 months after the initiation of treatment and 8 months after resection.

Abstract 1145: Assessing the diagnostic value of the combination of Matrix Metalloproteinase 2 (MMP2) and Progranulin (PGRN) preoperative plasma levels for colorectal cancer (CRC)

Introduction: MMP 2, also known as Gelatinase A, is an extracellular matrix remodeling enzymes. MMP-2 activity is regulated by various oncogenes, cytokines and growth factors. MMP 2 functions in the breakdown of extracellular matrix (ECM) and participates in tumor neoangiogensis. It is also associated with an angiogenic and metastatic tumor cell phenotype, in vivo. Up-regulation of MMP-2 aggravates the loss of basement membrane type IV collagen, breaks down ECM and promotes tumor progression and invasion. Progranulin (PGRN) is a ubiquitously expressed secreted glycoprotein that activates both the PI3k and ERK pathways, and promotes cyclin D1 and cyclin B expression which supports proliferation and survival of mesenchymal and epithelial origin cells. PGRN stimulates VEGF expression in breast cancer cells, in vitro, and stimulates inflammation, fibroblast accumulation and angiogenesis. Over-expression of MMP2 and PGRN has been reported in many cancers including CRC. The aim of this study was to compare preoperative (preop) plasma MMP2 and PGRN levels in CRC and benign colonic disease (BCD) patients (pts), alone and in combination, as a means of detecting CRC.

Method: Preop plasma samples were obtained from consenting CRC and BCD pts undergoing elective resection for whom adequate preop plasma was available from an IRB approved tissue bank. Demographic, clinical, and pathologic data were collected. PreOp plasma levels of MMP2 and PGRN (ng/ml) were determined via ELISA in duplicate and reported as median + 95%CI. The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to assess single or multiple plasma protein levels as a diagnostic tool for CRC. The Mann-Whitney test was used for statistical analysis (significance p&lt;0.05).

Results: A total of 172 CRC pts (70% colon, 30% rectal) and 102 BCD pts (adenoma 33%, diverticulitis 54%, other 15%) were eligible for the study. The CRC pathologic stage distributions were: Stage-I, 25%; Stage-2, 32%, Stage-3, 31%, Stage- 4, 12%. Median preop plasma protein levels in CRC pts were significantly higher than BCD pts. [MMP2; 205.3,CI 198.2,217.5 vs.165.3,CI 156.8,179.1: PGRN; 54.7,CI 51.8,57.1 vs.43.3,CI 40.1,46.8,P&lt;0.001) The AUC value for ROC curve for MMP2 and PGRN were 0.721 and 0.724 respectively with 73% and 71% specificity. AUC for the combination of these 2 proteins was 0.757 with 97% specificity.

Conclusion: Median MMP2 and PGRN levels were higher in CRC pts and the CRC median values were 24% and 26% higher than BCD median levels respectively. ROC curve analysis showed that the two protein combination improved specificity and AUC values. MMP2 and PGRN are potential candidates for a larger diagnostic panel to include other proteins found to be elevated in CRC pts. Further study is warranted.

Citation Format: Chandana S K Herath Mudiyanselage, Neil Mitra, Dasuni Niyagama Gamage, Hiromichi Miyagaki, Abhinit Shah, Xiaohong Yan, Vesna Cekic, Richard L. Whelan. Assessing the diagnostic value of the combination of Matrix Metalloproteinase 2 (MMP2) and Progranulin (PGRN) preoperative plasma levels for colorectal cancer (CRC) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1145.

Abstract 3138: Colorectal cancer is associated with elevated plasma levels of soluble platelet-derived growth factor-dd (PDGF-DD) compared to plasma levels of benign colon disease patients

Introduction: Platelet-derived growth factor-DD (PDGF-DD), a member of the PDGF family, is secreted as a latent homodimer which is activated by uPA (urokinase). After binding to its receptor, PDGF Rβ, PDGF-DD plays a role in mesenchymal transition, cancer cell growth, migration, and invasion all of which are supported by the PDGF DD induced proangiogenic proteins MMP2, MMP9 and VEGF. Downregulation of PDGF DD suppresses both the expression of VEGF and MMP9 via Notch-1, NF-kappaB and VEGF directed neo-angiogenesis. Upregulated expression of PDGF DD has been noted in colon and many other cancers. This study's purpose was to compare preoperative (PreOp) plasma PDGF DD levels in colorectal cancer (CRC) and benign colon disease (BCD) patients (pts).

Method: Pts undergoing colorectal resection for CRC or benign problems that had been prospectively enrolled in an IRB approved tissue and data bank for whom adequate Preop plasma samples were available were studied. Clinical, demographic, operative, and pathologic data were collected. The PDGF-DD levels in the preoperative plasma samples were determined via ELISA in duplicate and reported as median ±95% CI (pg/ml). The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to evaluate the CRC diagnostic value of plasma protein levels. The Mann-Whitney test was used for statistical analysis, (significance (sig) p&lt;0.05).

Results: A total of 116 CRC (72% colon, 28% rectal) and 86 benign disease pts (adenoma 31%, diverticulitis 55 %, other 14%) were studied. The male: female ratios were similar but the CRC pts were older (p=0.001). The CRC stage distribution was: stage 1, 33 (28%); stage 2, 33 (28%); stage 3, 41 (36%); stage 4, 9 (8%). The median PreOp plasma PDGF DD level was significantly higher in the CRC group (386.8, CI: 341.2, 498.8) than in the benign disease group (320.4, CI: 281.414.5, p&lt;0.001). No correlation was found between PDGF-DD levels and tumor stage. In sub group analysis, tumor expression of PDGF-DD was confirmed by IHC in 8/10 pts (tumor vs. paired normal tissue). The AUC for the ROC curve (AUC) for plasma PDGF DD in association with a diagnosis of CRC was 0.62751 (sensitivity 29%, specificity 95%).

Conclusion: Preoperative plasma PDGF-DD levels were evaluated in CRC pts and compared to those in benign colorectal disease pts. The median plasma PDGF-DD level in CRC pts was 21% higher than the median level in BCD pts. AUC value suggests that PDGF-DD may be a potential candidate for a prognostic marker panel for CRC. The higher levels in CRC pts could be attributed to tumor-related inflammation, progression, and angiogenesis. Further studies with a larger population of cancer free control and CRC pts are necessary to better determine whether PDGF-DD levels correlate with Cancer stage and prognosis.

Citation Format: Chandana S K Herath Mudiyanselage, Neil Mitra, Dasuni Niyagama Gamage, Hiromichi Miyagaki, Abhinit Shah, Xiaohong Yan, Vesna Cekic, Richard L. Whelan. Colorectal cancer is associated with elevated plasma levels of soluble platelet-derived growth factor-dd (PDGF-DD) compared to plasma levels of benign colon disease patients [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3138.

Single-incision laparoscopic totally extraperitoneal repair for bilateral inguinal hernias after femoral-femoral artery bypass in a patient on antiplatelet therapy: A case report

A 77-year-old man visited our hospital due to bilateral painful inguinal swellings. He had a history of femoral-femoral artery bypass surgery for peripheral artery disease and took ethyl icosapentate. Additionally, he had a previous history of open left colectomy for descending colon cancer and had a median incision reaching the lower abdomen. With a diagnosis of bilateral direct inguinal hernias after femoral-femoral artery bypass surgery, he underwent single-incision laparoscopic surgery for totally extraperitoneal repair, continuing on ethyl icosapentate. During surgery, the preperitoneal space was safely and easily dissected, avoiding a subcutaneous vascular graft. No perioperative complications or hernia recurrence have been observed at 3 months follow-up.

[pCR Achievement in Two Cases Treated with XELOXIRI as Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer]

BACKGROUND

Neoadjuvant chemotherapy is designed to prevent disease recurrence, particularly distant recurrence, and to improve overall patient survival. We present 2 cases where pathological complete response(pCR)was obtained after administering XELOXIRI as neoadjuvant chemotherapy for locally advanced rectal cancer. Case 1: The patient was a 63-year-old man diagnosed with rectal cancer(Ra, cT4aN1M0, cStage Ⅲa)and treated with 6 courses of XELOXIRI as neoadjuvant chemotherapy. After systemic chemotherapy, he underwent laparoscopy-assisted low anterior resection and showed a pCR. Case 2: The patient was a 56-year-old man diagnosed with rectal cancer(Rb, cT3N3M0, cStage Ⅲb)and treated with 6 couses of XELOXIRI as neoadjuvant chemotherapy. After systemic chemotherapy, he underwent low anterior resection and showed a pCR.

CONCLUSION

We present 2 cases treated with XELOXIRI as neoadjuvant chemotherapy for locally advanced rectal cancer where pCRwas achieved.

Prognostic impact of postoperative intra-abdominal infections after elective colorectal cancer resection on survival and local recurrence: a propensity score-matched analysis

PURPOSE

Several authors have reported an association between anastomotic leak and/or intra-abdominal abscess and oncological survival and recurrence. However, no reports have investigated whether combining anastomotic leak/intra-abdominal abscess and positive drainage culture influences long-term oncological outcomes. Therefore, we defined these complications as postoperative intra-abdominal infections. The present study aimed to evaluate the prognostic impact of postoperative intra-abdominal infections on long-term oncological outcomes after curative stage I-III colorectal cancer surgery.

METHODS

We performed a retrospective analysis of 755 consecutive patients with stage I-III colorectal cancer undergoing curative surgery between 2010 and 2015 by performing a propensity score-matched analysis to reduce selection bias.

RESULTS

Of the 755 patients, 62 were matched for postoperative intra-abdominal infections analyses. The median follow-up was 48 months. Compared with the non-infections group, the postoperative intra-abdominal infections group had a significantly shorter local recurrence-free survival (P = 0.01 prior to matching, and P = 0.05 after matching). No significant difference was found between the groups in terms of overall, cancer-specific free, recurrence-free, or distant recurrence-free survival. However, multivariate analyses identified postoperative intra-abdominal infections as an independent prognostic factor for local recurrence-free survival (P = 0.04 prior to matching, and P = 0.03 after matching).

CONCLUSIONS

In this matched-pair analysis comparing stage I-III colorectal cancer patients with and without postoperative intra-abdominal infections, postoperative intra-abdominal infections were associated with poor local recurrence-free survival, but not overall, cancer-specific free, recurrence-free, or distant recurrence-free survival.

[A Case of Colon Cancer with Peritoneal Dissemination and Liver Metastasis That Responded to Comprehensive Treatment by Perioperative Chemotherapy and Cytoreductive Surgery]

A 64-year-old man was referred to our hospital to determine the cause of fecal occult blood. Colonoscopy revealed a type Ⅱtumor located in the ascending colon. Histopathologic analysis of the tumor biopsy specimen revealed moderately differen- tiated, tubular adenocarcinoma with KRAS exon 2(G12V)mutation. FDG-PET/CT revealed high trace accumulation in the S4 of the liver and in multiple sites spread across the abdominal cavity(cT4aN1M1c2[H1, P3], cStage Ⅳc). Chemotherapy using S-1 plus oxaliplatin(SOX)with bevacizumab(Bmab)was administered. After 8 courses of SOX with Bmab, the volume of the ascending colon cancer and liver metastasis reduced, and peritoneal disseminations disappeared. We, therefore, considered that curability B resection was suitable, and performed right hemicolectomy, total omentectomy, and resection of the rectovesical peritoneum. Histopathological examination of surgical specimens revealed extensive fibrosis from the submucosa to subserosal tissue with some tubular adenocarcinoma cells(histological effect: Grade 2). For maintenance therapy, trifluri- dine/tipiracil plus Bmab was administered after cytoreduction. The patient is in remission for 26 months without recurrence. Perioperative chemotherapy and cytoreductive surgery are useful for the treatment of colon cancer with diffuse peritoneal dissemination.

[Clinical Outcome of Radiation Therapy for Solitary Lymph Node Metastasis of Gastric Cancer]

We report the clinical course of 6 gastric cancer patients who received radiation therapy at our hospital for solitary lymph node metastasis. The site of the metastatic lymph node was the clavicle, para-aorta, para-portal vein, common hepatic artery, and diaphragm in 1, 1, 2, 1, and 1 case, respectively. Median irradiation dose was 50[range, 45-50.4]Gy, and combination chemotherapy was administered in 4 cases. The clinical outcome was complete response and partial response in 3 cases each, with no adverse events associated with radiation therapy. The median progression-free survival was 11.3 months. In summary, local treatment by radiation therapy is one of the treatment options for patients with solitary lymph node metastasis of gastric cancer.

[A Case of Unresectable Gallbladder Cancer with Relatively Good Prognosis Treated with Upfront Surgery Followed by Systemic Chemotherapy]

A female patient in her 60s was diagnosed with advanced gallbladder cancer invading the hilar plate. Exploratory laparoscopic examination showed limited peritoneal dissemination. Despite endoscopic nasobiliary drainage, it was difficult to treat infectious cholangitis. To initiate chemotherapy, it was imperative to control the infection; hence, we chose to perform extended right hepatectomy, extrahepatic bile duct resection, lymph node dissection, and cholangiojejunostomy. We have been able to continue systemic chemotherapy for more than 2 years after surgery, and the patient did not experience infectious cholangitis. She has survived for almost 2 years and 8 months post-diagnosis.

[A Case of Rectal Cancer with Multiple Liver Metastases Curatively Resected after Systemic Chemotherapy]

A 61-year-old man complainingof bloody stool was diagnosed with advanced rectal cancer with multiple liver metastases (cT3[A]N1M1a[H2], cStage Ⅳ). We introduced bevacizumab combined systemic chemotherapy prior to radical surgery and confirmed tumor shrinkage in both the primary tumor and liver metastases following systemic chemotherapy. We performed laparoscopic lower-anterior resection, and then the patient underwent liver metastases resection. The histologic evaluation was Grade 2. This was a pathologically curative resection, and the patient has been disease-free since the last operation.

Abstract 3313: Plasma levels of MMP7 are significantly increased in patients with colorectal cancer compared to benign disease colon pathology

Introduction: MMP-7 (matrilysin), a matrix metalloproteinase (MMP) family member, is expressed in epithelial cells and some cancers. MMP7 is capable of activating pro-collagenases and digesting extracellular matrix (ECM) proteins. MMP7 supports connective tissue remodeling and regulates intestinal host defense and innate immunity. Increased MMP7 expression is associated with inflammation, tumorgenesis, and metastasis. MMP7 regulates neutrophil recruitment at sites of neoangiogenesis. MMP7 is capable of activating pro-MMP-1,-2,and-9, and osteopontin. Preoperative (preop) colorectal cancer patient’s plasma levels of MMP2, MMP3 and osteopontin have been shown to be higher than benign disease patient’s preop levels. MMP7 overexpression is reported in many malignancies (colorectal cancer (CRC) included). This study’s purpose was to compare PreOp plasma MMP7 levels in CRC and benign colon disease (BCP) patients (pts).

Method: Pts undergoing colorectal resection for CRC or BCP who were prospectively enrolled in an IRB approved tissue/data bank for whom plasma samples were available were studied. Clinical, demographic and pathological data were reviewed. Plasma MMP7 levels were determined via ELISA in duplicate and reported as median +95%CI (ng/ml). Expression levels were determined in tumors and paired normal colon tissues in a subgroup of study pts by QRT-PCR. The candidacy of MMP7 as a diagnostic marker for CRC was validated by the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) results. The Mann-Whitney test was used for statistical analysis.

Results: A total of 120 CRC (72% colon, 28% rectal) and 120 BCP pts (adenoma 33%, diverticulitis 52%, other 15%) were studied. The male: female ratios in both groups were similar but CRC pts were older. The CRC stage distribution was stage 1,30%; stage 2,27%, stage 3,33%, stage 4,10%. The median plasma MMP7 level was significantly higher in the CRC group than in the BCP group(3.69,CI: 3.39,4.07vs 2.79, CI: 2.51,3.2;P=&lt; 0.001). The AUC for the ROC curve (AUC) for plasma MMP7 in association with a CRC diagnosis was 0.698 (sensitivity 48%, specificity 80%). All CRC tumors tested showed elevated MMP7 expression vs. paired normal tissue.

Conclusion: The median PreOp plasma MMP7 level was 33% higher in CRC vs. BCP group. The AUC results suggest MMP7 may have value as a CRC prognostic marker, perhaps, in combination with other protein markers. High MMP7 levels may be related to tumor vascularization and inflammation associated with the cancer. Further studies that assess larger populations are needed to further assess preop MMP7 levels.

Citation Format: HMC Shantha Kumara, Dasuni N. Gamage, Neil Mitra, Carl S. Winkler, Sandhu K. Jaspreet, Xiaohong Yan, Vesna Cekic, Hiromichi Miyagaki, Nipa D. Gandhi, Richard L. Whelan. Plasma levels of MMP7 are significantly increased in patients with colorectal cancer compared to benign disease colon pathology [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3313.

[A Case of Stevens-Johnson Syndrome Induced by Chemotherapy for Metastatic Colon Cancer]

A 78-year-old woman had a semicircular ulcerative lesion of AV 7 cm, as detected using colonoscopy, and pathologic examination based on a biopsy showed well-differentiated adenocarcinoma. On contrast-enhanced CT of the liver, a number of nodular lesions that seemed to be liver metastases were observed. It was decided to administer chemotherapy containing mFOLFOX6 plus panitumumab. Bilateral hemorrhage of the ocular conjunctiva and eyelid edema were observed from the 4th day of chemotherapy. Edema of the lips, epidermolysis, and erythema appeared in addition to vision impairment. We diagnosed her with SJS based on these symptoms. We also administered steroid pulse therapy. Eyelid edema improved, and vision impairment improved 24 hours after the initiation of treatment. For severe cases with visual impairment, systemic administration of corticosteroids is recommended. In this case, administering steroid pulse therapy from an early stage resulted in improvement without sequelae.

Surgical treatment of rectal cancer with a Retzius shunt: a case report

Background

A case of a short circuit (Retzius shunt) from the inferior mesenteric vein (IMV) to the inferior vena cava (IVC) without accompanying portal hypertension due to liver cirrhosis is rare.

Case presentation

An 83-year-old woman who was followed after surgery for thyroid and breast cancer was incidentally found to have rectal cancer on computed tomography (CT). Preoperative three-dimensional CT showed a venous malformation forming a short circuit (Retzius shunt) from the IMV to the IVC. Laparoscopic anterior rectal resection was performed. Operative findings included the Retzius vein crossing the abdominal aorta and the inferior mesenteric artery (IMA) to the IVC and a number of engorged vessels in the mesentery. The Retzius vein and IMA were clipped without major bleeding, and tumor-specific mesorectal excision was then performed. The patient’s postoperative clinical course was good, and she was discharged without complications.

Conclusions

Preoperative imaging enabled identification of an unexpected rare disease, thus reinforcing the importance of preoperative imaging.

[A Case of an Elderly with Locoregional Recurrence of ER-Negative HER2-Positive Breast Cancer Successfully Treated with Local Therapy]

An 80-year-old woman who received on anticoagulant therapy for atrial fibrillation was diagnosed with ER-negative HER2-positive breast cancer(cT4bcN1M0, Stage ⅢB). She underwent mastectomy with skin graft and lymphadenectomy, but was evaluated to be too old for standard chemotherapy and HER2-directed therapy. Four months after the operation, she was diagnosed with regional lymph node metastasis and underwent radiotherapy. Moreover, 9 months later, other recurrent sites were revealed in the parasternal lymph node and thoracic wall without distant metastasis. Radiotherapy could be performed around these secondary recurrent sites while avoiding overlap. After 2 years, solitary contralateral axillary lymph node metastasis was diagnosed by PET-CT. She underwent Lt axillary lymphadenectomy. The intrinsic breast cancer subtype did not change. Patient performance status was kept to achieve a good quality of daily life. Eight months later, she diagnosed with primary pancreatic cancer and received 13 cycles of chemotherapy until her death from pancreatic cancer 14 months later. During chemotherapy, no recurrence of breast cancer was observed.

[A Case of Inflammatory Breast Cancer with Very Severe Obesity]

A 39-year-old woman with very sever obesity was admitted to our hospital for a right breast redness and hardness. Her height, weight and BMI were 166 cm, 145 kg and 52.6 kg/m2. Her breast had peau d'orange. CT scan showed swelling of whole right breast and Level I , II lymph node. We performed core needle biopsy and diagnosed as the inflammatory breast cancer with ER and HER2 positive. We introduced chemotherapy(pertuzumab, trastuzumab and paclitaxel)and nutrition counseling in order to reduce her body weight. After 4 courses of chemotherapy, the clinical complete response was obtained and her body weight decreased to 125 kg. We performed mastectomy and axillary node resection and confirmed pathological complete response. Adjuvant chemotherapy(5-FU, epirubicin and cyclophosphamide), adjuvant trastuzumab therapy, postmastectomy radiation therapy and adjuvant hormonal therapy were administered. There have been no signs of recurrence as of 2 years after the operation.

[A Case of Advanced Transverse Colon Cancer with Relapse behind the Rectum after Laparoscopic-Assisted Resection]

A 60's male patient underwent laparoscopic left hemicolectomy with D3 lymph node dissection for transverse colon cancer. Adjuvant chemotherapy with tegafur-uracil and leucovorin was administered.Thirty -four months later, MRI scan revealed a mass with sacrum invasion.Radiation therapy(39 Gy/13 Fr)was performed followed by chemotherapy(modified oxaliplatin, leucovorin, and 5-fluorouracil plus bevacizumab).Two weeks after the completion of radiation therapy, staging laparoscopy and tissue biopsy was performed in the hard tumor, which was located at the caudal end of the incisional scar of the retroperitoneum, in front of the sacrum.The pathological diagnosis revealed metastasis from transverse colon cancer.Radiographic examination showed partial response to radiochemotherapy, and buttock pain decreased.CT review before pain developed showed a small tumor located mainly in the mesorectum slightly adjacent to the sacrum, suggesting the implantation of cancer cells to the stripped plane behind the mesorectum during the surgery.

Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Superficial surgical site infection (sSSI) is one of the most common complications after colorectal resection. The goal of this study was to determine the comorbidities and operative characteristics that place patients at risk for sSSI in patients who underwent rectal cancer resection.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried (via diagnosis and Current Procedural Terminology codes) for patients with rectal cancer who underwent elective resection between 2005 and 2012. Patients for whom data concerning 27 demographic factors, comorbidities, and operative characteristics were available were eligible. A univariate and multivariate analysis was performed to identify possible risk factors for sSSI.

RESULTS

A total of 8880 patients met the entry criteria and were included. sSSIs were diagnosed in 861 (9.7%) patients. Univariate analysis found 14 patients statistically significant risk factors for sSSI. Multivariate analysis revealed the following risk factors: male gender, body mass index (BMI) >30, current smoking, history of chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists III/IV, abdominoperineal resection (APR), stoma formation, open surgery (versus laparoscopic), and operative time >217 min. The greatest difference in sSSI rates was noted in patients with COPD (18.9 versus 9.5%). Of note, 54.2% of sSSIs was noted after hospital discharge. With regard to the timing of presentation, univariate analysis revealed a statistically significant delay in sSSI presentation in patients with the following factors and/or characteristics: BMI <30, previous radiation therapy (RT), APR, minimally invasive surgery, and stoma formation. Multivariate analysis suggested that only laparoscopic surgery (versus open) and preoperative RT were risk factors for delay.

CONCLUSIONS

Rectal cancer resections are associated with a high incidence of sSSIs, over half of which are noted after discharge. Nine patient and operative characteristics, including smoking, BMI, COPD, APR, and open surgery were found to be significant risk factors for SSI on multivariate analysis. Furthermore, sSSI presentation in patients who had laparoscopic surgery and those who had preoperative RT is significantly delayed for unclear reasons.

Plasma chitinase 3-like 1 is persistently elevated during first month after minimally invasive colorectal cancer resection

AIM: To assess blood chitinase 3-like 1 (CHi3L1) levels for 2 mo after minimally invasive colorectal resection (MICR) for colorectal cancer (CRC).

METHODS: CRC patients in an Institutional Review Board approved data/plasma bank who underwent elective MICR for whom preoperative (PreOp), early postoperative (PostOp), and 1 or more late PostOp samples [postoperative day (POD) 7-27] available were included. Plasma CHi3L1 levels (ng/mL) were determined in duplicate by enzyme linked immunosorbent assay.

RESULTS: PreOp and PostOp plasma sample were available for 80 MICR cancer patients for the study. The median PreOp CHi3L1 level was 56.8 CI: 41.9-78.6 ng/mL (n = 80). Significantly elevated (P < 0.001) median plasma levels (ng/mL) over PreOp levels were detected on POD1 (667.7 CI: 495.7, 771.7; n = 79), POD 3 (132.6 CI: 95.5, 173.7; n = 76), POD7-13 (96.4 CI: 67.7, 136.9; n = 62), POD14-20 (101.4 CI: 80.7, 287.4; n = 22), and POD 21-27 (98.1 CI: 66.8, 137.4; n = 20, P = 0.001). No significant difference in plasma levels were noted on POD27-41.

CONCLUSION: Plasma CHi3L1 levels were significantly elevated for one month after MICR. Persistently elevated plasma CHi3L1 may support the growth of residual tumor and metastasis.

Abstract 4925: Plasma levels of cartilage oligomeric matrix protein (COMP), are significantly increased in patients with colorectal cancer

Introduction: Cartilage Oligomeric Matrix Protein (COMP) is a member of the thrombospondin family of extracellular calcium-binding proteins that plays role in the assembly of extracellular matrix. COMP maintains the structural integrity of cartilage through its interaction with a number of extracellular matrix proteins. COMP has a unique binding site for Vitamin D, indicating that it may also participate in storage and delivery of cell-signaling molecules. An expression array analysis of colorectal cancer samples vs normal tissue has noted overexpression of COMP mRNA. This study was undertaken to assess preoperative blood levels of COMP in the setting of colorectal cancer(CRC). Our hypothesis is that plasma levels of COMP may be elevated due to tumor overexpression and that this protein may have potential as a diagnostic marker for colorectal cancer.

Method: Patients (pts) undergoing elective colorectal resection for CRC or benign colonic pathology (BCP) that had been prospectively enrolled in an IRB approved tissue and data bank for whom adequate PreOp plasma samples were available were studied. Demographic, clinical, and pathologic data were collected. Plasma COMP levels were determined via ELISA in duplicate and are reported as median +95%CI (ng/ml). Tissue expression levels were determined in paired tumor and normal tissue samples of a subpopulation of study pts by QRT-PCR .The candidacy of COMP as a diagnostic marker for CRC was validated by the receiver operating characteristic (ROC) curve and by the area under the ROC curve (AUC) results. The Wilcoxon/Kruskal-Wallis test was used for statistical analysis, (significance p&lt;0.05).

Results: A total of 151 CRC (73%colon, 27%rectal) and 73 BCP pats (Adenoma 21%, diverticulitis 57%, other 22%) were studied. The male/female ratios were similar. The CRC stage distribution was: Stage 1, 22%; Stage 2, 32%; Stage 3, 31%; and Stage 4, 15%. The median plasma COMP levels were significantly higher in the CRC pts (209.2,CI: 187.8,234) vs. the BCP pats(129.6,CI: 110.7,149.2; P = &lt; 0.0001). The plasma COMP levels were significantly higher in Stage III pts. (p = 0.001) and in Stage II+III pats. (p = 0.03) compared to Stage I pts. The AUC value for the ROC curve was 0.781 (sensitivity 53%, specificity 93%). Increased expression of COMP was noted in 59% of the CRC tissue samples tested (10/17) vs. paired normal tissue samples.

Conclusion: The CRC median plasma COMP level was 61% higher than the median BCP result and the Stage 3 median level 50% higher than the median Stage I level. In general, plasma COMP levels increased with advancing cancer stage. The AUC results suggest COMP may have value as a CRC prognostic marker, perhaps, in combination with other protein markers to increase the sensitivity. Tissue expression analysis suggests that the most likely source of the added COMP in the plasma is the tumor itself. Further study with larger populations of control and CRC pts is warranted.

Citation Format: Hmc Shantha Kumara, Hiromichi Miyagaki, Xiaohong Yan, Linda Njoh, Vesna Cekic, Nipa D. Gandhi, Melissa M. Alvarez-Downing, Richard L. Whelan. Plasma levels of cartilage oligomeric matrix protein (COMP), are significantly increased in patients with colorectal cancer. [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 4925.

Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization

Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).

Preoperative Chitinase 3-like-1, Galectin-3, and Activin Aplasma levels: A novel diagnostic panel for colorectal cancer

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Background: Colorectal cancers (CRC) expressChitinase 3-Like-1(Chi3L1), Galectin-3 (Gal-3) and Activin A (Act-A). Chi3L1, indirectly, via IL8 and MCP-1, promotes tumor angiogenesis and progression. Gal-3 promotes tumor cell invasion and angiogenesis while Act-A supports cancer cell migration. This study’s goal was to assess the diagnostic value of plasma levels of Chi3L1, Gal-3 and Act-A, alone or together, for CRC. Methods: PreOp plasma samples were obtained from consenting CRC and benign pathology (BP) patients (pts) undergoing elective resection (IRB approved tissue bank). Plasma levels of Chi3L1, Gal-3 (ng/ml), and Act-A (pg/ml) were determined via ELISA and reported as median + 95% CI. The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to evaluate the CRC diagnostic value of single and multiple plasma protein levels. The Mann-Whitney test was used for statistical analysis (significance p<0.05). Results: A total of 118 CRC (81% colon, 19% rectal) and 42 BP pts (adenoma 31%, diverticulitis 53%, other 16%) were studied. The CRC median plasma protein levels were significantly higher vs. the BP group results [Chi3L1: 120.1, CI: 95.0, 146.6 vs. 36.8, CI; 29.3, 44.4; Gal-3: 12.0, CI: 10.5, 13.3 vs. 7.7, CI: 7.2, 9.9; Act-A: 368.0 CI: 341.0, 421.6 vs. 272.1, CI: 196.0, 327.3 [p<0.001 for all]). The AUC value for the ROC curve for Chi3L1, Gal-3 and Act-A were 0.850, 0.724 and 0.734 respectively with 76%, 52% and 38% specificity. The AUC for the combination of these 3 proteins was 0.890 with 88% specificity. Conclusions: Themedian Chi3L1, Gal-3 and Act-1 values in CRC pts were significantly higher (226%, 55% and 35%) then BP levels. The 3 protein combination had improved AUC and specificity vs single protein results and may have value as a diagnostic panel. A larger study is needed.

[Two cases of radiotherapy-induced sarcoma after breast cancer surgery]

We report 2 cases of radiotherapy-induced sarcoma of the residual breast after breast cancer surgery. In 1 case, the patient was a 64-year-old woman. She underwent breast-conserving surgery and axillary lymph node dissection followed by irradiation to the residual breast in July 2001. A 1.1 × 1.0-cm tumor was noted in the residual breast 7 years 5 months after radiotherapy. An excisional biopsy was performed, and a histological diagnosis of angiosarcoma was made. She died of lung and peritoneal metastases 3 years 2 months after the diagnosis. In the other case, the patient was also 64 years old. She underwent breast-conserving surgery and sentinel lymph node biopsy followed by irradiation to the residual breast in October 2006. A 5.7 × 3.9-cm induration was noted in the residual breast 3 years 5 months after radiotherapy. A core needle biopsy was performed, and a histological diagnosis of sarcoma was made. Mastectomy was performed, and the histological diagnosis was malignant fibrous histiocytoma. She died of chest wall and intrapleural tumor recurrence 3 months after the mastectomy. Although radiotherapy-induced sarcoma is rare, early detection of the tumor in the irradiation area is important, as radiotherapy is often performed for breast cancer patients.

[Locoregional recurrence of HER2-positive breast cancer - treatment after complete remission and long-term clinical benefits]

We report 7 cases of locoregional recurrence in human epidermal growth factor receptor 2 (HER2)-positive breast cancer that we treated. An early complete response (CR) and long-term response was achieved in 5 cases. There were 4 HER2- subtype and 3 Luminal HER2-type cases. Metastasis and recurrence were detected in the residual breast tissue and the supraclavicular, axillary, and parasternal lymph nodes. Chemotherapy consisting of trastuzumab was administered as first-line treatment. A CR was observed 3-4 months after the initiation of therapy in 4 cases, and the time to progression was 27.6- 65.8 months. After achieving a CR, 3 patients terminated treatment and 2 patients continued to take trastuzumab. However, due to adverse effects associated with the chemotherapy, 1 patient changed to endocrine therapy. A second, long-term, CR was achieved in 2 relapsed CR patients by re-challenging with the same chemotherapy regimen. Two patients did not achieve CR and died due to distant metastases. For a better quality of life, it is advisable to continue treatment after a clinical CR for solitary or more complex locoregional recurrences. Following the first-line therapy and a so-called chemoholiday, the patient's disease can be re-challenged using the previously sensitive regimen with careful observation.

Efficacy of laparoscopic-assisted approach for reversal of Hartmann's procedure: results from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

INTRODUCTION

Morbidity after reversal of Hartmann's procedure remains high. The laparoscopic approach (LAP) may be associated with lower morbidity versus open Hartmann's closure. This study's aim is to compare results after LAP and OPEN colostomy takedown and Hartmann's reversal.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for CPT procedure codes 44227 (LAP) and 44626 (OPEN). Exclusion criteria included: ventilator dependence, ASA class 4 or 5, SIRS, sepsis, emergency case, and advanced malignancy. Demographic parameters were assessed as well as comorbidities and short-term outcomes. Statistical methods used include Fisher's exact test for categorical variables and Student's t test for continuous variables.

RESULTS

In total, 4,148 patients underwent stoma closure and Hartmann's reversal (LAP 732 [17.6 %], OPEN 3,416 [82.3 %]). The mean BMI was lower in the LAP (mean ± SD 27.6 ± 6.6) versus OPEN group (28.3 ± 6.8, p = 0.012). The groups were similar as regards comorbidities except for dyspnea (LAP 5.6 %, OPEN 7.8 %, p = 0.043). The mean surgery times were similar and the median LOS shorter in the LAP versus OPEN groups (5 vs 6 days, p < 0.0001). A lower overall morbidity rate was noted for the LAP group (18.4 % vs OPEN 27 %, p < 0.0001) but mortality was statistically similar. Lower rates were noted in the LAP group for the following complications: incisional SSI (10.4 vs 14.1 %, p = 0.033), organ space SSI (3.1 vs 5.0 %, p = 0.033), UTI (1.6 vs 3.3 %, p = 0.005), sepsis (3.4 vs 6.0 %, p = 0.038), and reoperation (3.1 vs 5.4 %, p = 0.011).

CONCLUSION

Only 18 % of Hartmann's reversal's were done using LAP methods. The LAP and OPEN groups were similar except for gender, BMI, and dyspnea history. LAP methods were associated with a 1 day LOS benefit and significantly lower overall morbidity and lower rates of incisional and deep SSI, UTI, sepsis, and reoperations. Operative length was similar. The short-term results of the LAP approach are superior to the OPEN results.

Occurrence and timing of organ space surgical site infections (SSI) in rectal cancer patients: A NSQIP database review

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Background: This study’s aim was to determine the incidence and date of presentation of organ space SSI (in this setting most likely due to anastomotic leak or pelvic abscess) in rectal cancer resection patients. A second purpose was to determine which variable(s) impacted the timing of the presentation. Methods: The NSQIP database was queried from 2007 to 2011 for elective rectal cancer resections. Exclusion criteria included; ASA 5 status, preoperative(preop) shock/sepsis, SIRS, and recent surgery. Demographic parameters, comorbidities, lab data, and incidence and timing of organ space SSI were assessed. The statistical methods used were Fisher’s exact test (categorical variables) and Wilcoxon’s rank tests (continuous variables). Results: 8,093 rectal cancer patients were identified (Male/Female; 60.1%/39.9%; median age, 60; APR, 28 %; sphincter saving procedures,72%). The incidence of organ space SSI was 6 % (485 patients; 2.7% presented before and 3.3% after discharge). The rate was significantly greater for men, younger patients (< 60), smokers, sphincter saving resections (vs. APR). Preop radiotherapy (RT) did not increase the rate of and stomas did not protect against the formation of organ space SSI. The mean date of detection was 14.6±7.3 days after surgery (Mean±SD). A further delay was noted in those who had preop RT regardless of the operation performed (n=184, added delay 2.7 days, p<0.05). Significant delays (p<0.05) were also noted in patients that had APR (n=112, mean delay 2.4days), stoma formation (n=285, mean delay 1.6days) and open surgery (n=368, mean delay 1.8 days). Multivariate analysis revealed preop RT (p=0.0002) and APR (p=0.0258) as independent risk factors for delayed presentation. Conclusions: Most organ space SSI after rectal cancer surgery occur after hospital discharge. The mean presentation date is about 2 weeks after surgery. Patients who received preop RT or underwent APR presented about 2.5 days later than the mean date. Rectal cancer patients should be followed closely for 3 weeks as regards organ space SSI.