The benefits of interval appendectomy and risk factors for nonoperative management failure in the therapeutic strategy for complicated appendicitis

PURPOSE

Emergency surgery (ES) for complicated appendicitis (CA) is associated with high morbidity. Interval appendectomy (IA) decreases this rate; however, nonoperative management (NOM) is not always successful. Some patients require unplanned ES due to NOM failure (IA failure: IA-F). This study aimed to verify the benefits of IA and to evaluate the risk factors for NOM failure.

METHODS

Patients diagnosed with CA who underwent surgery between January 2012 and December 2021 were included in this study. We compared the surgical outcomes of the ES group with those of the IA success (IA-S) and IA-F groups. We also analyzed 14 factors that predicted NOM failure.

RESULTS

Among 302 patients, the rate of severe complications (Clavien-Dindo grade ≥ III) was significantly higher in the ES group (N = 165) than in the IA-S group (N = 102). The rates were equal between the ES (N = 165) and IA-F (N = 35) groups. NOM was successful in 110 patients and failed in 27. Lack of abscesses, comorbidities, high WBC count, and free air were independent risk factors for NOM failure.

CONCLUSIONS

Considering the benefits of IA and the non-inferior surgical outcomes of IA-F compared to ES, IA is a good therapeutic strategy for CA. However, in patients exhibiting four independent risk factors for NOM failure, careful monitoring of unplanned ES is necessary.

Pks-positive Escherichia coli in tumor tissue and surrounding normal mucosal tissue of colorectal cancer patients

A significant association exists between the gut microbiome and colorectal carcinogenesis, as well as cancer progression. It has been reported that Escherichia coli (E. coli) containing polyketide synthetase (pks) island contribute to colorectal carcinogenesis by producing colibactin, a polyketide-peptide genotoxin. However, the functions of pks+ E. coli in initiation, proliferation, and metastasis of colorectal cancer (CRC) remain unclear. We investigated the clinical significance of pks+ E. coli to clarify its functions in CRC. This study included 413 patients with CRC. Pks+ E. coli of tumor tissue and normal mucosal tissue were quantified using droplet digital PCR. Pks+ E. coli was more abundant in Stages 0-I tumor tissue than in normal mucosal tissue or in Stages II-IV tumor tissue. High abundance of pks+ E. coli in tumor tissue was significantly associated with shallower tumor depth (hazard ratio [HR] = 5.0, 95% confidence interval [CI] = 2.3-11.3, p < 0.001) and absence of lymph node metastasis (HR = 3.0, 95% CI = 1.8-5.1, p < 0.001) in multivariable logistic analyses. Pks+ E. coli-low and -negative groups were significantly associated with shorter CRC-specific survival (HR = 6.4, 95% CI = 1.7-25.6, p = 0.005) and shorter relapse-free survival (HR = 3.1, 95% CI = 1.3-7.3, p = 0.01) compared to the pks+ E. coli-high group. Pks+ E. coli was abundant in Stages 0-I CRC and associated with CRC prognosis. These results suggest that pks+ E. coli might contribute to carcinogenesis of CRC but might not be associated with tumor progression.

Oncologic investigation of the interval from stent placement to surgery in patients with obstructive colorectal cancer

PURPOSE

Self-expandable metallic stent (SEMS) placement is widely used as a bridge to surgery (BTS) procedure for obstructive colorectal cancer. However, evidence regarding the optimal interval between SEMS placement and elective surgery is lacking.

METHODS

We retrospectively collected data from patients with BTS between January 2013 and October 2021. Inverse probability treatment-weighted propensity score analyses were used to compare short- and long-term outcomes between the short-interval (SI) and long-interval (LI) groups, using a cutoff of 20 days.

RESULTS

In total, 138 patients were enrolled in this study (SI group, n = 63; LI group, n = 75). In the matched cohort, the patients' backgrounds were well balanced. The incidence of Clavien-Dindo grade ≥ II postoperative complications was not significantly different between the SI and LI groups (19.0% vs. 14.0%, P = 0.47). There were no significant differences between the SI and LI groups in the 3-year recurrence-free survival (68.0% vs. 76.4%, P = 0.73) or 3-year overall survival rates (86.0% vs. 90.6%, P = 0.72).

CONCLUSIONS

A longer interval did not deteriorate the oncological outcomes. Individual perioperative management with an appropriate interval to improve the patient's condition is required to ensure safe surgery.

A pilot study on the safety and efficacy of neoadjuvant chemo‑adoptive immunotherapy for locally advanced rectal cancer

The safety and efficacy of combination therapy of immune cell therapy and chemotherapy [chemo-adoptive immunotherapy (CAIT)] for patients with stage IV or recurrent colorectal cancer have been reported. In the present study, the safety and efficacy of neoadjuvant CAIT were investigated for preoperative therapy of locally advanced rectal cancer. The study included patients with cT3/T4 or cN (+) rectal adenocarcinoma scheduled for curative surgery. Six patients who consented to participate in the current study were selected as subjects. Neoadjuvant CAIT involves administration of activated autologous lymphocytes, αβ T cells, and mFOLFOX6 every 2 weeks for six courses, followed by surgery 4-6 weeks thereafter. Common Terminology Criteria for Adverse Events grade 3 neutropenia was observed in one patient. Neoadjuvant CAIT and curative surgery were performed on all the patients. The confirmed response rate was 67%. Downstaging was confirmed in five patients (83%). Regarding histological effects, two patients were grade 1a and four were grade 2. Regarding immunological reactions, both CD4+ and CD8+ T cell infiltration rates increased after treatment in three patients on tumor-infiltrating lymphocyte (TIL) analysis. In peripheral blood analysis, the total lymphocyte count was maintained in all patients, and the CD8+ T cell count increased by ≥3 times on the pretreatment count in two patients but may not be associated with changes in TILs. During the median postoperative follow-up duration of 24 months, liver and lung metastases occurred in one patient, but all patients survived. In conclusion, neoadjuvant CAIT (αβ T cells + mFOLFOX6) can be safely administered for the treatment of advanced rectal cancer. Verification of the efficacy of comprehensive immune cell therapy, especially the induction of antitumor immunity for the prevention of recurrence, will be maintained. The current study is registered with the Japan Registry of Clinical Trials (jRCT; ID, jRCTc030190248; January 21, 2019).

Clinical features of extrahepatic portal vein obstruction: Myeloproliferative neoplasms eliminate hypersplenic hematologic changes in extrahepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is a rare disease. Most EHPVO patients are usually referred to a gastroenterologist for intestinal bleeding and hypersplenic thrombocytopenia; however, hypercoagulative diseases may be occult in these patients and require anticoagulation. The purpose of this study was to elucidate the clinical characteristics of EHPVO. We conducted a retrospective analysis of the hospital database, evaluating the medical records of 15 patients (7 males, 8 females, mean age of onset 42.0 years, range 5-74 years). Thirteen of 15 EHPVO patients (86.7%) had intestinal varices. These included 10 esophageal (66.7%), 12 gastric (80.0%), and 6 ectopic varices (40.0%). Nine (60.0%) of 15 had a history of intestinal bleeding. Regarding comorbidities, 5 of 15 (33.3%) suffered from vascular diseases, including acute myocardial infarction, cerebral infarction, pulmonary embolism, Budd-Chiari syndrome, and mesenteric vein thrombosis. The former 3 vascular commodities manifested at less than 32 years of age. Four patients (26.7%) with JAK2V617F mutation were diagnosed as myeloproliferative neoplasm (MPN). 72.3% of EHPVO patients without MPN experienced thrombocytopenic state. No EHPVO patients with MPN experienced thrombo-leukocytopenia. The elevation of white blood cell and platelet counts, and decrease of protein S were seen in EHPVO with MPN, compared with EHPVO without MPN. EHPVO is frequently associated with underlying hypercoagulative factors, causing a dilemma between thrombotic complications and portal hypertensive bleeding. Most EHPVO patients experience an evident thrombocytopenic state due to severe hypersplenism; however, hypersplenic hematologic changes are eliminated in EHPVO with MPN. MPN should be suspected in EHPVO patients negative for thrombo-leukocytopenia.

Successful management of malignant colovesical fistula using covered colonic self-expanding metallic stent: a case report

BACKGROUND

A colovesical fistula (CVF) is commonly treated by resection of the intestine containing the fistula or creation of a defunctioning stoma. We herein report a case of successful fistula closure and avoidance of colostomy after placement of a covered colonic self-expanding metallic stent (SEMS) as a palliative treatment for a malignant CVF.

CASE PRESENTATION

A 75-year-old man undergoing infusional 5-fluorouracil and irinotecan chemotherapy plus bevacizumab for recurrent peritoneal dissemination of rectal cancer was admitted to our hospital because of fecaluria with a high-grade fever. Blood tests showed a moderate inflammatory reaction (white blood cell count, 9200/mm3; C-reactive protein, 11.03 mg/dL; procalcitonin, 1.33 ng/mL). Urinary sediment examination showed severe bacteriuria. Abdominal contrast-enhanced computed tomography showed intravesical gas, thickening of the posterior wall of the bladder, and irregular thickening of the sigmoid colon wall contiguous with the posterior bladder wall. Magnetic resonance imaging (MRI) clearly showed a fistula between the bladder and sigmoid colon. Colonoscopy revealed a circumferential malignant stricture 15 cm from the anal verge, and a fistula to the bladder was identified by water-soluble contrast medium. We diagnosed a complicated urinary tract infection (UTI) associated with a CVF due to peritoneal dissemination and started empirical treatment with sulbactam/ampicillin. Given the absence of active inflammatory findings around the fistula on MRI and the patient's physical frailty, we decided to place a covered SEMS to close the fistula. Under fluoroscopic and endoscopic guidance, a covered colonic SEMS of 80-mm length and 20-mm diameter was successfully deployed, and the fistula was sealed immediately after placement. Urine culture on day 3 after stenting was negative for bacteria, and a contrast study on day 5 showed no fistula. The patient was discharged home on day 6 with no complications. The UTI did not recur for 4 months after discharge.

CONCLUSIONS

A covered colonic SEMS was useful for sealing a malignant CVF in a patient unfit for surgery, and MRI was valuable to determine the status of the fistula. A covered colonic SEMS could be an alternative to surgical treatment for CVFs in patients who require palliative care.

The Outcomes of Neoadjuvant Chemoradiotherapy Using Moderately Hypofractionated Intensity Modulated Radiotherapy for Borderline Resectable Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

Complete resection of borderline resectable pancreatic cancer (BRPC) is difficult because of its invasion to the vital vessels. Although neoadjuvant therapy is recommended for BRPC, its optimal regimens remain unclear. Neoadjuvant chemoradiotherapy using moderately hypofractionated intensity-modulated radiotherapy (NAC-MH-IMRT) has potentials to improve the treatment outcomes with shorter treatment periods. Therefore, we evaluated the outcomes for BRPC patients treated with NAC-MH-IMRT.

MATERIALS/METHODS

Between February 2013 and June 2021, patients with BRPC treated with NAC-MH-IMRT at our institution were evaluated. All patients were classified as BRPC-A and BRPC-V according to NCCN guidelines. Information regarding patient status, tumor and treatment characteristics, margin-negative resection (R0) rates, histological effects assessed by Evans classification, and outcomes were obtained from the clinical records. Overall survival (OS) and progression-free survival (PFS) were calculated by the Kaplan-Meier method from the start date of any first treatment for BRPC. Toxicity was evaluated by CTCAE version 5.0.

RESULTS

Sixty-eight patients were included in this study (Table). All patients underwent induction chemotherapy, and 67 were treated with IMRT at 42 Gy in 15 fractions with concurrent gemcitabine (for 65) or S-1 (for 2). All patients achieved completion of radiotherapy. Fifty-seven of the 68 patients (83.8%) underwent surgical exploration, and 48 patients (70.6%) had a resection. The R0 resection was achieved in 44 patients, and the R0 resection rate was 91.7% in resected patients. Therapeutic effects by Evans classification showed as below: Grade 1/2a/2b/3/4 = 6 (12.5%)/17 (35.4%)/17 (35.4%)/7 (14.6%)/1 (2.1%). Adjuvant chemotherapy was performed for 41 patients, and S-1 and gemcitabine were used for 40 and 1 patient(s), respectively. The median follow-up time and median survival time (MST) were 23.6 months and 42.7 months, and 2-year OS and PFS were 67.3% and 30.2%, respectively. Recurrence was observed in 54 patients (79.4%), and the first recurrence pattern was as follows: 7 (13.0%)/42 (77.8%)/5 (9.3%) patients had local recurrence, distant metastases, and both of them, respectively. Regarding ≥ Grade 3 gastrointestinal toxicity related NAC-MH-IMRT, grade 3 ileus was observed in 1 patient.

CONCLUSION

NAC-MH-IMRT for BRPC showed preferable outcomes and acceptable toxicities with high completion rate.

Investigating the Underutilization of Uterine Fibroid Embolization by Surveying OB/GYN Practice Preferences

This study aimed to survey OB/GYN practice preferences that may be contributing to the underutilization of uterine fibroid embolization (UFE) in the treatment of symptomatic uterine fibroids (SUF). A 22-question survey was created using Qualtrics XM software and distributed to an OB/GYN-specific social media group to resident or attending OB/GYNs practicing in the US. 112 responses met inclusion criteria. For patients with symptomatic UF, UFE was offered as a first choice option less than 2% of the time. For patients with symptomatic UF seeking to maintain fertility, UFE was recommended only 1% of time, behind medical therapy (54%) and myomectomy (42%). Respondents reported lower rates of confidence (selecting "strongly agree" or "agree") regarding risks and benefits of UFE (77%) in comparison to myomectomy (99%) or hysterectomy (100%). Since UFE was seldom recommended by respondents, further, more robust polling of OB/GYNs is warranted.

Surgical Site Infections in Gastroenterological Surgery

Surgical site infections (SSIs) remain one of the most common serious surgical complications and are the second most frequent healthcare-associated infection. Patients with SSIs have a significantly increased postoperative length of hospital stay, hospital expenses, and mortality risk compared with patients without SSIs. The prevention of SSI requires the integration of a range of perioperative measures, and approximately 50% of SSIs are preventable through the implementation of evidence-based preventative strategies. Several international guidelines for SSI prevention are currently available worldwide. However, there is an urgent need for SSI prevention guidelines specific to Japan because of the differences in the healthcare systems of Japan versus western countries. In 2018, the Japan Society for Surgical Infection published SSI prevention guidelines for gastroenterological surgery. Although evidence-based SSI prevention guidelines are now available, it is important to consider the appropriateness of these guidelines depending on the actual conditions in each facility. A systemic inflammatory host response is a hallmark of bacterial infection, including SSI. Therefore, blood inflammatory markers are potentially useful in SSI diagnosis, outcome prediction, and termination of therapeutic intervention. In this review, we describe the current guideline-based perioperative management strategies for SSI prevention, focusing on gastroenterological surgery and the supplemental utility of blood inflammatory markers.

The prediction of pathological complete response after total neoadjuvant therapy for locally advanced rectal cancer using versatile liquid biopsy

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Background: Total neoadjuvant therapy (TNT) has conferred a dramatic paradigm shift in the treatment for locally advanced rectal cancer (LARC), which can prolong the survival associated with high pathological complete response (pCR) rate and introduce non-operative management (NOM). However, useful biomarkers predicting the treatment efficacy of TNT and the prognosis has not been developed. Our previous study demonstrated that volume of blood long- and short-fragments DNA ( > 300 bp and < 180 bp) in LINE-1 gene are derived from tumor cell necrosis, and normal cell apoptosis, and the ratio (LSR) could reflect tumor growth or shrinkage, and minimal residual disease. Methods: A total of 17 LARC patients receiving consolidation TNT consisting of short-course radiation (5Gy x 5days) and 4 courses of CapOX, followed by total mesorectal excision were included. Blood concentrations of long-, short-fragment DNA and LSR in neoadjuvant phase were serially measured at pre-treatment, every treatment cycle, and pre-operation by real-time PCR. Results: Median age of patients were 64 years old and 65% were female. Clinical stage (IIa/IIc/IIIb/IIIc) were 2/1/8/6, respectively. Down staging was shown in 88% of patients. Tumor regression grade (0/1a/1b/2/3(pCR)) were 1/2/3/34/7(41%), respectively. Only 44% of patients had elevated CEA levels before TNT, which indicates less usefulness as the biomarker. The dynamics of the LSR in the entire cohort showed the gradual decrease until pre-operative phase (decrease to 77.8%). The LSR change from pre-treatment (or just after SCRT) to early preoperative treatment phase (1 or 2 course after CapOX) was significantly greater in the pCR(+)(n = 7) than the pCR(-)(n = 10) groups (66.8% vs. 101%, p = 0.03). The AUC of ROC analysis was 0.72 (cut off: 66.8%). Conclusions: NGS based liquid biopsy is the gold standard for the cancer prediction and monitoring, but limitations such as unsatisfied sensitivity and high cost are still involved. However, LSR measurement has great benefits on those points. Early phase LSR measurement could be a good predictive marker for the response of TNT and might be clinically useful for optimizing the preoperative therapy.

Useful Preoperative Simulation of Laparoscopic Surgery for Rectal Cancer in Patients with Kyphosis

Kyphosis complicates abdominal surgery. Here, we report a case of rectal cancer in a patient with kyphosis who underwent successful laparoscopic surgery after a preoperative simulation. An 81-year-old woman with rectal cancer was admitted to our department, and laparoscopic surgery was planned. Physical examination revealed severe kyphosis. To ensure successful laparoscopic surgery, we conducted a detailed preoperative simulation, including three-dimensional CT simulations of port arrangement and anatomy, simulation of body position, selection of surgical instruments, and preoperative discussion with the anesthesiologist. We planned to insert the first port in the umbilical region for pneumoperitoneum and the camera port in the ventral region under pneumoperitoneum. We planned to insert the ports on the right side of the patient's body from the caudal regions, after considering the location of the inferior mesenteric artery and the limitations in degrees and space attributable to the costal arch and promontorium. Beach chair position was planned. We used a fan-shaped retractor and sponge retractor to remove the small intestine from the surgical view. In preoperative discussions with the anesthesiologist, we decided to maintain pneumoperitoneum pressure at less than 8 mm Hg during the operation, to safeguard respiratory function. Lower anterior resection with D2 lymph node dissection was performed, without intraoperative complications. At 2 years postoperatively, the patient was healthy with no signs of recurrence. Laparoscopic surgery appears to be a suitable choice for patients with kyphosis. We believe that preoperative simulation will result in successful outcomes.

Characterization of lipidic plaque materials at calcified atheroma: its association with calcification thickness evaluated by optical coherence tomography and near-infrared spectroscopy imaging

Introduction

The degree of calcification and its thickness have been considered to affect stent expansion, leading to an increases risk of repeat revascularization in patients receiving PCI. Pathophysiologically, accumulation of lipidic materials within vessel wall could trigger the formation of plaque calcification. Elucidating characteristics of lipidic plaque components at calcified atheroma may enable to identify phenotypes with thick calcification which less likely responds to PCI.

Purpose

This study investigated the relationship of calcification thickness with lipidic plaque materials at calcified atheroma by using OCT and near-infrared spectroscopy (NIRS) imaging.

Methods

We analyzed 52 calcified lesions (culprit/non culprit lesions=44/8) in 47 CAD patients (stable CAD/ACS=36/11) from the REASSURE-NIRS registry (NCT04864171). OCT and NIRS imaging evaluated 4-mm segment exhibiting maximum superficial calcification arc. Calcification thickness on OCT imaging, its arc on IVUS imaging, and NIRS-derived lipid arc were analyzed at every 1-mm interval cross-sectional images. In addition, yellow-calcification ratio (YCR = lipid arc/calcification arc) was calculated (Figure 1).

Results

53% of study subjects exhibited chronic kidney disease and 70% of them received a statin (averaged on-treatment LDL-C =89mg/dL). Throughout OCT and NIRS/IVUS imaging analysis of 260 cross-sectional images, the averaged calcification arc, its maximum thickness, lipid arc and YCR were 210° (167–285°), 0.78mm (0.62–0.95mm), 95° (31–169°) and 0.33 (0.09–0.59), respectively. As expected, thicker calcification more likely exhibited a greater calcification arc (r=0.30, p&lt;0.001). Furthermore, a greater thickness of calcification was associated with smaller lipidic plaque burden, reflected by yellow arc (r=−0.36, p&lt;0.001) and YCR (r=−0.36, p&lt;0.001) (Figure 2). After adjusting age, gender and ACS, calcification arc (p&lt;0.001) and YCR (p&lt;0.001) continued to predict thicker calcification.

Conclusion

Thickening of calcification was associated with severer calcification arc, which was accompanied by the shrinkage of lipidic plaques. Our findings suggest the evaluation of lipidic plaque component as a potential tool to identify calcified atheroma harbouring thick calcification, which may cause a greater risk of stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.

Deterioration of cardiogenic shock after acute myocardial infarction defined by the society for cardiovascular angiography and intervention cardiogenic shock classification scheme

Background

Cardiogenic shock (CS) in patients with AMI presents worse cardiovascular outcomes, which suggests the need for better risk stratification and management. The Society for Cardiovascular Angiography and Intervention (SCAI) has recently proposed CS classification scheme, which stratifies CS into 5 groups according to hypotension and hypoperfusion. While stage A and B exhibits CS without hypotension and/or hypoperfusion, their clinical condition could rapidly deteriorate into stage C-E. However, clinical characteristics and in-hospital outcomes of CS exhibiting its deterioration remains uncertain.

Purpose

To characterize AMI patients who deteriorated their CS status from stage A and B into stage C-E.

Methods

This single-center observational study included 326 consecutive AMI patients receiving primary PCI who presented CS stage A and B on arrival (2019.09.01–2021.09.30). Deterioration of CS (D-CS) was defined as the progression from stage A and B on arrival to stage C-E after primary PCI. Clinical characteristics and outcomes were compared in those with and without D-CS.

Results

D-CS was identified in 16.0% of entire subjects (=52/326). Of these, 94.2 and 5.8% of them exhibited stage C and E, respectively (Figure). Patients with D-CS more likely presented STEMI (84.6 vs. 67.9%, p=0.01) with a lower systolic BP (sBP) level (130±31 vs. 148±26mmHg, p&lt;0.001) and a reduced LVEF (43±13 vs. 51±9%, p&lt;0.001), whereas there was no significant difference in lactate level (1.5±0.4 vs. 1.2±0.3 mmol/L, p=0.22). Pre-TIMI flow grade 0–1 (69.2 vs. 47.8%, p=0.006), left main trunk stenosis (9.6 vs. 1.5%, p=0.007) and chronic total occlusion (21.2 vs. 8.4%, p=0.01) were more frequently observed in those with D-CS. Despite achieving a shorter onset-to-reperfusion time (199 vs. 276 minutes, p=0.002), D-CS was associated with in-hospital all-cause mortality after adjusting clinical characteristics (HR=33.6, 95% CI: 2.2–502.0, p=0.01). Furthermore, mechanical circulatory support (MCS) (30.8 vs. 0%, p&lt;0.001) was more frequently required in patients with D-CS (IABP: 28.8 vs. 0%, p&lt;0.001, ECMO: 11.5 vs. 0%, p&lt;0.001, Impella: 3.8 vs. 0%, p=0.02). Further analysis identified sBP (HR=0.98, 95% CI: 0.97–1.00, p=0.008), LVEF (HR=0.94, 95% CI: 0.90–0.97, p&lt;0.001) and pre-TIMI flow grade 0–1 (HR=0.41, 95% CI: 0.19–0.86, p=0.01) as independent contributors to D-CS. ROC analysis demonstrated sBP &lt;135 mmHg (AUC=0.65) and LVEF &lt;50% (AUC=0.69) as best cut-off values to predict D-CS. Of note, a risk of D-CS increased in association with the number of these three factors (p&lt;0.001), and 44.0% of those with all of these factors presented D-CS (Figure).

Conclusion

16.0% of AMI without any hypotension/hypoperfusion on arrival exhibited deterioration of CS status on SCAI classification. The combination of sBP, LVEF and pre-TIMI flow grade could help to identify AMI subjects with a risk of D-CS, who may benefit from early adoption of intensified management including MCS prior to PCI.

Funding Acknowledgement

Type of funding sources: None.

[Is Cell-Free DNA a Useful Biomarker for Predicting the Efficacy of Preoperative Chemotherapy for Advanced Colon Cancer?]

OBJECTIVE

To examine the potential of peripheral circulating cell-free DNA(cfDNA)as a predictor of response in patients undergoing neoadjuvant chemotherapy(NAC)for advanced colon cancer.

METHODS

We compared histological response, background factors, and cfDNA molecular volume changes in cT4 and cT3N+ colon cancer patients.

RESULTS

Six of 11 patients responded. The patients with muc and pap histology were non-responders. There was no relationship between CEA or cfDNA levels and response. Responders showed >50% change in DNA integrity index(=cfDNA long fragment/ short fragment ratio), while non-responders showed <50% change(p=0.015).

CONCLUSION

Our results suggest that the variability rate in DNA integrity index of peripheral blood cfDNA may be useful in predicting the therapeutic efficacy of colon NAC.

Epsilon Aminocaproic Acid’s Safety and Efficacy in Pediatric Surgeries Including Craniosynostosis Repair: A Review of the Literature

Craniosynostosis, the premature fusion of skull sutures in children, requires surgical correction. This procedure routinely requires allogeneic blood transfusions, which are associated with multiple risks of their own. Since 2008, antifibrinolytics tranexamic acid (TXA) and epsilon aminocaproic acid (EACA or Amicar) have been widely used. There is literature comparing the two agents in scoliosis and cardiothoracic surgery, but the literature comparing the two agents in pediatric craniofacial surgery (CF) is limited. Tranexamic acid use is more common in pediatric CF surgery and has been thoroughly studied; however, it costs about three times as much as EACA and has been associated with seizures. This study compiles the literature assessing the safety and efficacy of EACA in reducing blood loss and transfusion volumes in children and explores its potential use in pediatric CF surgery.

Papers from 2000 to 2021 regarding the effectiveness and safety of EACA in Pediatric scoliosis, cardiothoracic, and craniosynostosis surgery were reviewed and compiled. Papers were found via searching PubMed and Cochrane databases with the key terms: Epsilon aminocaproic acid, EACA, Amicar, Tranexamic acid, TXA, craniosynostosis, scoliosis, cardiothoracic, and pediatric. Prospective studies, retrospective studies, and meta-analyses were included.

Twenty-nine papers were identified as pertinent from the literature searched. Four were meta-analyses, 14 were retrospective, and 11 were prospective. Of these papers, seven were of cardiac surgery, 12 were of scoliosis, and nine were of craniosynostosis. During our search, EACA has been shown to consistently reduce blood transfusion volumes compared to control. However, it is not as effective when compared to TXA. EACA has a similar safety profile to TXA but has a reduced risk of seizures. There are not many studies of EACA in craniosynostosis repair, but the existing literature shows promising results for EACA's efficacy and safety, warranting more studies. 

[Long-Term Response to UFT/UZEL/Bevacizumab Therapy for Lung Metastasis after Surgery for Early-Stage Colon Cancer in a Late-Stage Elderly Patient]

Late-stage elderly patients have low tolerance to chemotherapy, and they have difficulties when they are treated with standard chemotherapy. We report a case of a late-stage elderly patient who had a long-term response to UFT/UZEL/bevacizumab( Bev)therapy for lung metastasis after surgery for early-stage colon cancer. He was 82-years-old and underwent laparoscopy-assisted sigmoid colectomy for sigmoid colon cancer at another hospital. The pathological diagnosis was pT1b, ly1, v0, N0, M0, pStage Ⅰ. Six months after the surgery, a small nodule was noted in the middle lobe of the right lung. It grew five months later and was definitely diagnosed as lung metastasis. Considering his physical condition and tumor size, we opted to introduce less invasive chemotherapy instead of standard chemotherapy. UFT/UZEL/Bev was started 14 months after surgery. Although he required dose reduction due to anorexia, he safely continued the treatment with partial response (PR), which was maintained for 2 years and 6 months. While UFT/UZEL/Bev has no convincing evidence, it may be an option for vulnerable patients, especially those with non-life-threatening disease.

[A Case of Advanced Gastric Cancer Successfully Treated with FOLFOX]

The Japanese gastric cancer clinical practice guideline recommends FOLFOX as one of the first-line chemotherapy for advanced gastric cancer. Since FOLFOX is administered intravenously, it is helpful for patients who have difficulty in oral intake. Herein, we report a patient in which FOLFOX was significantly effective after failure to treatment with S-1 plus CDDP. A 75-year-old gastric cancer patient with paraaortic lymph node metastasis and multiple liver metastases(Stage ⅣB)was treated. Severe stomatitis and impaired consciousness due to dehydration appeared after administration of S-1 plus CDDP. After his general condition recovered, we changed his regimen to FOLFOX. No serious adverse events were observed, and partial response was achieved after 4 courses of treatment. Partial response was maintained until the onset of oxaliplatin drug allergy in the 10th course. FOLFOX is a promising option for patients with difficulties in oral intake.

TGF-β1 increases cellular invasion of colorectal neuroendocrine carcinoma cell line through partial epithelial-mesenchymal transition

Epithelial–mesenchymal transition (EMT) plays a pivotal role in cancer progression and metastasis in many types of malignancies, including colorectal cancer. Although the importance of EMT is also considered in colorectal neuroendocrine carcinoma (NEC), its regulatory mechanisms have not been elucidated. We recently established a human colorectal NEC cell line, SS-2. In this study, we aimed to clarify whether these cells were sensitive to transforming growth factor beta 1 (TGF-β1) and whether EMT could be induced through TGF-β1/Smad signaling, with the corresponding NEC cell-specific changes in invasiveness. In SS-2 cells, activation of TGF-β1 signaling, as indicated by phosphorylation of Smad2/3, was dose-dependent, demonstrating that SS-2 cells were responsive to TGF-β1. Analysis of EMT markers showed that mRNA levels changed with TGF-β1 treatment and that E-cadherin, an EMT marker, was expressed in cell-cell junctions even after TGF-β1 treatment. Invasion assays showed that TGF-β1-treated SS-2 cells invaded more rapidly than non-treated cells, and these cells demonstrated increased metalloproteinase activity and cell adhesion. Among integrins involved in cell-to-matrix adhesion, α2-integrin was exclusively upregulated in TGF-β1-treated SS-2 cells, but not in other colon cancer cell lines, and adhesion and invasion were inhibited by an anti-α2-integrin blocking antibody. Our findings suggest that α2-integrin may represent a novel therapeutic target for the metastasis of colorectal NEC cells.

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NEC cell line SS-2 is responsive to TGF-β1.

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TGF-β1 stimulation induces partial EMT, maintaining E-cadherin in SS-2 cells.

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TGF-β1-treated SS-2 cells exhibit increase in metalloproteinase activity and cell adhesion.

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α2-integrin is exclusively upregulated in TGF-β1-treated SS-2 cells.

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Use of anti-α2-integrin blocking antibody inhibits enhanced adhesion and invasion.

Colonic stent as a bridge to surgery versus emergency resection for right-sided malignant large bowel obstruction: a meta-analysis

BACKGROUND

Preoperative colonic stenting for malignant large bowel obstruction (MLBO), also called bridge to surgery (BTS), is considered a great substitute treatment for emergency resection (ER) in the left-sided colon. However, its efficacy in the right-sided colon remains controversial. This systematic review and meta-analysis aimed to compare the postoperative short-term outcomes between BTS and ER for right-sided MLBO.

METHODS

A comprehensive electronic literature search throughout December 2020 was performed to identify studies comparing short-term outcomes between BTS and ER for right-side MLBO. The main outcome measures were postoperative complications and mortality rates. A meta-analysis was performed using a fixed-effect or a random-effect method to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Seven studies were included in this meta-analysis, comprising 5136 patients, of whom 1662 (32.4%) underwent BTS and 3474 (67.6%) underwent ER. This meta-analysis demonstrated that BTS resulted in reductions in postoperative complications (OR = 0.78; 95% CI: 0.66-0.92) and mortality (OR = 0.51; 95% CI: 0.28-0.92) than ER.

CONCLUSION

The results of this meta-analysis indicate that BTS for right-sided MLBO confers preferable short-term outcomes as well as for left-sided. This suggests that BTS results in a reduction of postoperative complications and mortality for right-sided MLBO than ER.

Substantially elevated thromboembolic and bleeding risks in patients with AMI following acute/subacute stroke events

Introduction

AMI infrequently but concomitantly occurs after stroke events. Current guideline recommends primary PCI with DAPT in the setting of AMI. However, this approach is not necessarily applicable in AMI subjects following acute/subacute stroke events due to its bleeding risk. Clinical management and outcomes of these AMI subjects following remains uncertain.

Purpose

To characterize management and clinical outcomes in patients with AMI following acute/subacute stroke events (=post-stroke AMI).

Methods

The current study retrospectively analyzed 2041 AMI patients hospitalized at our institute from 2007 to 2018. Post-stroke AMI was defined as its occurrence within 14 days after ischemic/hemorrhagic stroke. The use of reperfusion and anti-thrombotic therapies, and the occurrence of major adverse cardiovascular events (=CV death, non-fatal MI and non-fatal stroke) and major bleeding events (BARC type 3 or 5) were compared in post-stroke and non-post-stroke AMI patients.

Results

Post-stroke AMI was identified in 1.1% of entire subjects (=23/2041). Of these, 65% of them (=15/23) had AMI within 3 days from the onset of stoke event. Over 60% of them was due to cardioembolic stroke, followed by hemorrhagic (9%), atherothrombotic ones (8%) and other causes (22%). Post-stroke AMI patients were more likely to exhibit Af (p=0.02) and a history of hemodialysis (p=0.009), and have a lower BMI (p=0.04) and hemoglobin level (p=0.02). They were less likely to receive emergent coronary angiography, and primary PCI was conducted in only 65% of post-stroke AMI patients (Table). Furthermore, they more frequently received thrombectomy (p=0.04) alone rather than stent implantation (p=0.002) (Table). With regard to anti-thrombotic therapy, the proportion of DAPT use was significantly lower in post-stroke AMI subjects (52 vs. 89%, p=0.0001), and 17% of them did not receive any anti-thrombotic agents. Of note, only 48% (p=0.04) and 43% (p=0.0001) of post-stroke AMI patients were treated with other established medical therapies including β-blocker and statin, respectively. During the observational period (median = 2.9 years), post-stroke AMI was associated with a greater likelihood experiencing major adverse cardiovascular events (log-rank p&lt;0.001, Figure), CV death (log-rank p&lt;0.0001) and stroke events (log-rank p&lt;0.0001). Furthermore, the frequency of their major bleeding events was substantially elevated (log-rank p&lt;0.001, Figure).

Conclusions

In our real-world data, the adoption of guideline-recommended reperfusion and anti-thrombotic therapies were considerably low in AMI subjects following acute/subacute stroke events. Given their elevated risk of cardiovascular and bleeding events, it is required to establish better therapeutic management for mitigating their thrombotic/bleeding risks.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

The relationship of the underlying lipidic plaque at the implanted newer-generation drug-eluting stents with future stent-related events: insights from the REASSURE-NIRS registry

Background

Lipid-rich plaque is an important substrate causing acute coronary events. Near-infrared spectroscopy (NIRS) imaging has been shown to visualize lipidic coronary plaque at non-culprit site associated with future coronary events. Given that histopathological studies reported that the unstable plaque underlying the implanted drug-eluting stent (DES) could cause neoatherosclerosis formation, we hypothesized that NIRS-based evaluation of lipidic plaque burden behind the implanted DES may clinically predict the occurrence of stent failure in patients with CAD receiving PCI.

Purpose

We aimed to investigate the relationship of stent-related events' risk with lipidic plaque materials behind the implanted DES imaged by NIRS/intravascular ultrasound (NIRS/IVUS) imaging.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/IVUS-guided PCI. In this registry data, 406 lesions in 379 CAD subjects (ACS/non-ACS=150/229) receiving new-generation DES were analyzed. Minimum stent area (MSA) after PCI and maximum lipid-core-burden index in any 4mm-segment within the implanted stents (in-stent maxLCBI4mm) were measured. A 3-year lesion-oriented composite outcome [LOCO: culprit lesion-related MI + ischemia-driven target lesion revascularization (ID-TLR)] was compared in subjects stratified according to the tertile of in-stent maxLCBI4mm.

Results

The mean value of in-stent maxLCBI4mm was 221, and 17% of lesions exhibited in-stent maxLCBI4mm &gt;400. Patients with a greater in-stent maxLCBI4mm were more likely to exhibit a higher LDL-C level (p=0.026) with a longer stent length (p&lt;0.001) and a smaller MSA (p=0.033) (Picture 1). Over 95% of entire study subjects received a statin. During the observational period (median=726 days), the frequency of LOCO up to 3 years was 3.4% in entire study subjects (culprit lesion-related MI=1.0%, ID-TLR=2.8%). Kaplan-Meier curve analysis demonstrated that the occurrence of LOCO did not increase in association with in-stent maxLCBI4mm (log-rank p-value=0.25, Picture 2). In addition, in-stent maxLCBI4mm did not associate with each component of LOCO (culprit lesion-related MI: p=0.502, ID-TLR: p=0.872). Receiver Operating Characteristic analysis revealed that the predictive ability of in-stent maxLCBI4mm for the occurrence of LOCO was unsatisfactorily (c-statistics=0.486).

Conclusion

The amount of underlying lipidic materials at culprit lesions receiving new-generation DES implantation did not necessarily predict future stent-related events. Clinical significance of maxLCBI4mm behind the implanted DES may be different from that at naïve non-culprit plaques.

Funding Acknowledgement

Type of funding sources: None. Background and lesion characteristicsKaplan-Meier analysis for LOCO

Comparison of coronary atherosclerotic features in response to achieving LDL-C &lt;55 mg/dl between non-diabetic and diabetic patients: insights from the REASSURE-NIRS registry

Introduction

Current ESC guideline recommends achieving LDL-C &lt;1.4 mmol/l in very high-risk subjects. Despite fabvourable anti-atherosclerotic effects of lowering LDL-C, its efficacy is diminished in type 2 diabetic patients. Whether response of coronary atheroma to on-treatment LDL-C &lt;1.4 mmol/l differs in diabetic and non-diabetic subjects has not been elucidated yet.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving PCI under the guidance of near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS: DualProTM, Nipro, Tokyo, Japan) imaging. Culprit lesions in 557 CAD patients who already received a statin were evaluated by NIRS/IVUS. Maximum 4-mm-lipid-core burden-index (maxLCBI4mm) and plaque calcification grade at culprit sites were measured. Calcification grade at each 1-mm cross-sectional image was defined as follows: calcium arc 0° = 0, 0–90° = 1, 90–180° = 2, 180–270° = 3, 270–360° = 4. MaxLCBI4mm and the averaged calcification grade were compared in diabetic and non-diabetic subjects stratified according to on-treatment LDL-C level, respectively.

Result

The proportion of diabetic (n=293, HbA1c; 6.9±0.9%) and non-diabetic patients (n=264) with on-treatment LDL-C &lt;1.4 mmol/l was 8.54 and 16.67%, respectivey (p=0.01). In non-diabetic patients, achieving LDL-C &lt;1.4mmol/L was associated with a lower maxLCBI4mm, whereas, in diabetic patients, maxLCBI4mm was numerically smaller under achieving LDL-C &lt;1.4 mmol/l, but this comparison did not meet statistical significance (Figure 1). Furthermore, a greater degree of calcification grade in non-diabetic patients was observed in association with on-treatment LDL-C level (Figure 2). However, plaque calcification at diabetic coronary atheroma was not necessarily induced under achieving stricter LDL-C goal. Subgroup analysis demonstrated that diabetic patients with body mass index ≥25 (odds ratio = 0.15; 95% CI: 0.18–1.19, p=0.04), estimated glomerular filtration rate &lt;60 (mL/min/1.73m2) (odds ratio = 0.31; 95% CI: 0.10–0.90, p=0.03) and non-insulin use (odds ratio = 0.36; 95% CI: 0.14–0.87, p=0.02) benefit from achieving LDL-C &lt;1.4 mmol/l.

Conclusion

Achieving LDL-C &lt;1.4 mmol/l was associated with more stabilized atheroma in non-diabetic patients with CAD, whereas these favourable effects were not observed in diabetic subjects. Our findings suggest the potential need to modify additional atherogenic risks for stabilizing diabetic coronary atheroma under achieving LDL-C &lt;1.4 mmol/l.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Characterization of residual lipid-rich plaques despite achieving LDL-C &lt;1.8mmol/l with a statin in patients with coronary artery disease: insights from the REASSURE-NIRS registry

Introduction

Recent studies have demonstrated favourable modification of lipidic plaque materials under achieving LDL-C &lt;1.8mmol/l with a statin, which potentially accounts for its clinical benefit. However, coronary events still occur even under optimal LDL-C management. This may suggest the presence of residual lipid-rich coronary plaque despite on-treatment LDL-C &lt;1.8mmol/l. Given that near-infrared spectroscopy (NIRS) enables quantitative evaluation of lipidic plaque in vivo, we employed this imaging modality to investigate characteristics and drivers of residual lipid-rich plaques in statin-treated patients with coronary artery disease (CAD) who achieved LDL-C &lt;1.8mmol/l.

Purpose

To clarify the frequency, clinical demographics and factors associated with residual lipid-rich plaques under LDL-C &lt;1.8mmol/l.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/intravascular ultrasound-guided PCI. The current analysis included 133 statin-treated stable CAD patients with on-treatment LDL-C &lt;1.8mmol/l from August 2015 to December 2020. The maximum 4-mm lipid core burden index (maxLCBI4mm) at culprit lesions was measured by NIRS imaging prior to PCI. Clinical characteristics were compared in patients with and without maxLCBI4mm ≥400 at culprit lesions.

Results

In the current study, 45% (=58/128) of study subjects exhibited maxLCBI4mm ≥400 at culprit lesions under on-treatment LDL-C &lt;1.8 mmol/l. They were more likely to be female, whereas there were no differences in age and the frequency of risk factors. Most of study subjects received moderate to high-intensity statin (p=0.79), and over one-fourth of them were treated with ezetimibe (p=0.56). Under these lipid-lowering therapies, LDL-C level was significantly higher in patients with maxLCBI4mm ≥400 (Table). Additionally, a lower frequency of LDL-C &lt;1.4mmol/l was observed in those exhibiting maxLCBI4mm ≥400 (31.0 vs. 45.7%), but this comparison failed to meet statistical significance (p=0.09). Despite LDL-C control with a statin, deterioration of coronary flow after PCI with stent implantation more frequently occurred in patients with maxLCBI4mm ≥400 (Table). Multivariate analysis demonstrated that an independent factor associated with maxLCBI4mm ≥400 was LDL-C level (OR=1.05; 95% CI=1.00–1.10, p=0.03), but not other lipid and clinical parameters.

Conclusion

Almost half of CAD subjects who achieved LDL-C level &lt;1.8mmol/l still exhibited the accumulation of lipidic plaque materials within vessel wall. Given that LDL-C level was associated with this residual lipid-rich plaque features, our findings support current ESC-guideline recommended LDL-C goal (&lt;1.4mmol/l) to optimize the secondary prevention in stable CAD patients.

Funding Acknowledgement

Type of funding sources: None.

A rapidly growing small intestinal metastasis from lung cancer

Small intestinal metastasis from lung cancer is a relatively rare occurrence, and often causes intestinal obstruction, gastrointestinal perforation, and/or gastrointestinal bleeding making it is an oncological emergency. Many patients have been reported to undergo emergency surgery owing to the rapid progression of the intestinal metastatic lesion; however, information regarding the changes that occur in such metastases over time remains lacking. Therefore, we analyzed 4 patients who had small intestinal metastases arising from lung cancer, who were treated during a 10-year period (January 2011 to December 2020), and whose tumor diameter changes were recorded. The average tumor volume growth rate was 1.48 (1.31-1.78) -fold, and the median observation period was 22 (4-39) days, showing a rapid increase. Histopathologically, in patients with a high degree of primary tumor atypia, rapid tumor growth caused by intratumoral hemorrhage may occur. This was considered to be one of the factors responsible for the rapid increase in tumor volume.

Detection of KRAS mutations in circulating tumour DNA from plasma and urine of patients with colorectal cancer

BACKGROUND

Circulating tumour DNA (ctDNA) is very useful for purposes of cancer genetics; however, it has some limitations. Recently, ctDNA in body fluids, such as urine, sputum, and pleural effusion, has been investigated. The aim of this study was to evaluate the quantity of ctDNA derived from urine (trans-renal ctDNA) and the accuracy of KRAS mutation detection in relation to disease stage in colorectal cancer.

METHODS

Urine, plasma, and tissue samples were collected from consecutively resected colorectal cancer patients. DNA was extracted from each sample and the quantity was determined. From each DNA sample, KRAS mutations were detected using droplet digital PCR.

RESULTS

200 patients participated and KRAS mutations were detected in 84 patients (42.0%) from tumour tissue. The concentration of trans-renal ctDNA (trtDNA) was significantly lower than that of plasma; however, there was no significant difference between the sensitivity using ctDNA and that using trtDNA (29.8% VS 33.3%, p = 0.62). Concordance between these two tests was only 17.5%. Combination analysis (ctDNA + trtDNA) improved the sensitivity to 53.6%, and sensitivity was significantly higher than that of corresponding single assays (p = 0.003). In early cancer stages, trtDNA had greater sensitivity for detecting KRAS mutations than ctDNA (37.7% vs. 21.3%, p = 0.047). Conversely, it was less useful for advanced cancer stages (21.7% vs. 52.2%, p = 0.07). Notably, KRAS mutations were detected using ctDNA or trtDNA in 12 of 116 (10.3%) patients who had no KRAS mutations in their tissue samples.

CONCLUSIONS

trtDNA and ctDNA have equal potential and combination analysis significantly improved the sensitivity.

Elevated serum carcinoembryonic antigen level after curative surgery is a prognostic biomarker of stage II-III colorectal cancer

BACKGROUND

High preoperative carcinoembryonic antigen (CEA) is a well-known risk factor for stage II-III colorectal cancer (CRC); however, in most cases, cancer does not recur. Conversely, postoperative CEA (post-CEA) is occasionally measured, and high post-CEA patients often develop recurrence; however, the clinical significance of post-CEA testing is unknown. The purpose of this study was to determine whether post-CEA elevation might indicate a poor prognosis for stage II-III CRC patients who underwent curative surgery.

PATIENTS AND METHODS

482 patients with pathological stage II-III CRC were included. Univariate and multivariate analyses were performed to evaluate post-CEA levels.

RESULTS

Multivariate analysis showed that elevated post-CEA (hazard ratio (HR): 3.14, P < 0.001), pathological lymph node metastasis (pN+), and pathological T4 (pT4) are associated with poor recurrence-free survival (RFS), and that elevated post-CEA (HR: 3.12; P = 0.002), pN+, pT4, age >70, and smoking are independently associated with poor overall survival. Subgroup analysis among stage III patients, in combination with the risk classification of the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) study, showed that elevated post-CEA is a significant indicator of poor prognosis for RFS in both low-risk (73.8% vs. 21.2%, P < 0.001) and high-risk (49.9% vs. 25.0%, P = 0.04) groups.

CONCLUSIONS

Post-surgical CEA elevation is independently associated with poor prognosis in stage II-III CRC. Adding post-CEA levels to the IDEA risk classification may provide a more reliable indicator of the need for individualized surveillance and adjuvant chemotherapeutic strategies.

Systemic Chemotherapy is a Promising Treatment Option for Patients with Colonic Stents: A Review

Approximately 10% of patients with colorectal cancer (CRC) develop malignant large bowel obstruction (MLBO) at diagnosis. Furthermore, for 35% of patients with MLBO, curative primary tumor resection is unfeasible because of locally advanced disease and comorbidities. The practice of placing a self-expandable metallic stent (SEMS) has dramatically increased as an effective palliative treatment. Recent advances in systemic chemotherapy for metastatic CRC have significantly contributed to prolonging patients' prognosis and expanding the indications. However, the safety and efficacy of systemic chemotherapy in patients with SEMS have not been established. This review outlines the current status of this relatively new therapeutic strategy and future perspectives. Some reports on this topic have demonstrated that 1) systemic chemotherapy and the addition of molecular targeted agents contribute to prolonged survival in patients with SEMS; 2) delayed SEMS-related complications are a major concern, and this requires strict patient monitoring; however, primary tumor control by chemotherapy might result in decreased complications, especially regarding re-obstruction; and 3) using bevacizumab could be a risk factor for SEMS-related perforation, which may be lethal. Although this relatively new approach for unresectable stage IV obstructive CRC requires a well-planned clinical trial, this therapy could be promising for patients who are unideal candidates for emergency surgery and require immediate systemic chemotherapy.

[A Case of Peritoneal Dissemination of Colorectal Cancer in Which Conversion Surgery Could Be Performed after Reduction with CAPOX/Bevacizumab]

A woman in her 60s underwent lower endoscopy due to a positive fecal occult blood test. A type 2 tumor was found in the cecum, and a biopsy resulted in the diagnosis of adenocarcinoma(tub2). Contrast-enhanced CT showed an enlarged paracolonic lymph node but no distant metastasis, so the patient underwent a laparoscopic-assisted ileocolic resection and D3 lymph node dissection for cecum cancer. The pathology was pT3, pN2b, pM0, pStage Ⅲc, and 12 courses of FOLFOX were administered as adjuvant chemotherapy. Twenty-four months after the completion of adjuvant chemotherapy, an elevated CEA was observed, and a PET-CT was performed, which showed multiple peritoneal disseminated nodules with FDG accumulation. Based on this finding, CAPOX/bevacizumab therapy was introduced, and on completion of 4 courses, the PET-CT showed a decrease in the size of the nodules and the disappearance of FDG accumulation. Based on this, the patient underwent resection. A peritoneal dissemination resection and bilateral ovariectomy were laparoscopically performed, and the patient is currently under observation. In patients with metastatic recurrence of peritoneal dissemination who underwent complete resection, treatment with CAPOX/bevacizumab may allow for disease control and provide a long-term prognosis.

Even a partial pathological response is associated with lower relapse rates in patients with operable rectal cancer undergoing neoadjuvant chemotherapy

BACKGROUND

Neoadjuvant chemotherapy to treat locally advanced rectal cancer is an effective therapeutic strategy for the prevention of local recurrence and distant organ metastasis after surgery.

OBJECTIVES

To assess the prognostic significance of histopathological tumor response in rectal cancer patients undergoing neoadjuvant chemotherapy.

METHODS

This study included patients with operable rectal cancer who received neoadjuvant chemotherapy using the FOLFOX regimen (5-fluorouracil, l-leucovorin, and oxaliplatin) in a hospital between February 2012 and November 2017. The main outcome measure was disease-free survival with respect to histopathological response to neoadjuvant chemotherapy in resected specimens.

RESULTS

The median follow-up was 32 months. Of 48 patients treated with neoadjuvant FOLFOX, 24 (50%) were classified as responders, which included two patients with pathological complete response and 22 patients with partial response. The remaining 24 patients (50%) were classified as nonresponders. Responders had a significantly better 3-year disease-free survival than nonresponders (86% vs. 62%, p = .02).

CONCLUSIONS

Patients whose surgical specimens show a pathological complete response or partial response have good oncologic outcomes.

Abstract 6015: A newly established neuroendocrine carcinoma cell line from a human ascending colon tumor shows high proliferation and CD133 expression in spherical cancer stem cell-like formation

BACKGROUND: The current incidence of neuroendocrine tumor (NET) is 0.6 cases per 100,000 people, although it has increased 50-fold over the last 35 years and is becoming increasingly clinically important. Neuroendocrine carcinoma (NEC) is a type of malignant NET associated with poor prognoses. However, the molecular basis and clinical characteristics of NEC have not yet been fully investigated due to a lack of patient biopsies to derive cell lines and established cell lines. Here, we report a newly established and characterized NEC cell line (SS-2) derived from a human ascending colon tumor. Furthermore, we investigated the ability of SS-2 cells to form spherical cancer stem cells (CSCs) and express CSC markers.

MATERIALS AND METHODS: The SS-2 cell line was derived from a tumor resection of the ascending colon from 59-year old Japanese woman with stage four NEC. The Ki-67 labeling index of the resected tumor was &gt;20% and, thus, the tumor was diagnosed as NEC. The characteristics of SS-2 cells transplanted subcutaneously into nude mice was determined. siRNA suppression of the neuroendocrine marker, INSM-1 was detected in SS-2 cells by western blotting. Additionally, SS-2 cells were seeded onto ultra-low attachment plates to detect sphere-formation and the expression of CSC markers, with confirmation by FACS analysis. Additionally, we compared the effect of commonly-used anti-colorectal chemotherapeutics on SS-2 cells and conventional colorectal cancer cells (Caco-2) using cell viability assay. Statistical analysis was done using Student's t test with P-values &lt; 0.05 considered statistically significant.

RESULTS: Characteristics of the resected tumor were retained in the SS-2 cells and in the xenograft in nude mice. INSM-1 was detected in SS-2 cell lysates and in nuclei of established SS-2 cells. siRNA targeting INSM-1 decreased INSM-1 mRNA levels but did not affect levels of chromogranin A and synaptophysin mRNA. SS-2 cells formed spheres when seeded onto ultra-low attachment plates that expressed higher levels of CD133 compared to SS-2 cells cultured under adherent conditions, which was also confirmed upon FACS analysis. After the addition of oxaliplatin and 5-FU, cell viabilities were higher in SS-2 cells than Caco-2 cells.

CONCLUSION: We established a novel NEC cell line, derived from a human ascending colon tumor, which we transplanted into nude mice. We determined that the CSC marker, CD133 is highly expressed in SS-2 cells, and hence posit that combination therapy of chemotherapeutics together with anti-CSC therapy may have increased efficacy against NEC.

Citation Format: Seiichi Shinji, Norihiko Sasaki, Takeshi Yamada, Michihiro Koizumi, Ryo Ohta, Akihisa Matsuda, Goro Takahashi, Masahiro Hotta, Takuma Iwai, Keisuke Hara, Kohki Takeda, Koji Ueda, Sho Kuriyama, Toshiyuki Ishiwata, Hiroshi Yoshida. A newly established neuroendocrine carcinoma cell line from a human ascending colon tumor shows high proliferation and CD133 expression in spherical cancer stem cell-like formation [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 6015.

Oxaliplatin-induced increase in splenic volume: experiences from multicenter study in Japan

BACKGROUND

Chemotherapy with oxaliplatin is known to induce sinusoidal obstruction syndrome (SOS). In a previous single-center study, we reported that oxaliplatin-induced increase in splenic volume (SV) is strongly indicative of SOS, and that this increase in SV persisted for > 1 year after completing chemotherapy. The aim of this study was to confirm the oxaliplatin-induced SV change in a multicenter study in patients with stage III colon cancer in Japan.

METHODS

We enrolled 59 patients who underwent curative resection for stage III colon cancer in the FACOS study in a phase II multi-center clinical study. Participants received mFOLFOX6 or CAPOX as adjuvant chemotherapy. SV change was assessed three times by computed tomographic volumetry: before surgery, on completion of adjuvant chemotherapy, and 1 year after completing adjuvant chemotherapy.

RESULTS

SV on completing and 1 year after chemotherapy was significantly higher than that before surgery (P < 0.001). Oxaliplatin-induced SOS persisted for > 1 year after the completion of adjuvant chemotherapy in half of the patients. There was no difference in 3-year disease-free survival with respect to the presence or absence of increased SV. An increase in SV was observed in 72% of patients treated with mFOLFOX6 and 94% of patients treated with CAPOX (P = 0.13).

CONCLUSION

This study can be verified the findings observed in our previous single-center study, oxaliplatin-based adjuvant chemotherapy was associated with an increase in SV. Furthermore, this increase can persist for > 1 year. The continuous presence of SOS may have a negative impact on prognosis in patients that develop recurrent disease.

Abstract B43: Genetic analysis of circulating tumor cells of colorectal cancer patients captured by multiantibodies technique

Background: Accurate genetic analysis is essential for molecular therapy. Conventionally, DNA derived from tumor tissue has been the source of the gold standard of DNA information in solid tumors including colorectal cancer (CRC). However, it is well known that molecular therapy induces emerging mutations that are not found in primary tumor; thus, real-time monitoring of gene information is ideal. Circulating tumor cells (CTCs) are circulating malignant cells of solid tumor origin that are found in the bloodstream and can be a powerful candidate to play an important role. Capturing a large amount of CTCs improves the accuracy of genetic analysis of DNA derived from CTC (ctcDNA). We used 3 (EpCAM, Her2, Trop2) or 4 (EpCAM, Her2, Trop2, EGFR) antibodies to capture CTCs, and analyzed ctcDNA using next-generation sequencing (NGS).

Methods: Cohort 1: Untreated CRC patients were enrolled. Ten mL of whole blood was collected from each patient. The blood was processed using 3 antibodies (EpCAM, Her2, Trop2) and CTCs were collected. Tumor tissue was also collected from each patient. Tumor tissue DNA and ctcDNA were extracted and analyzed using NGS. Cohort 2: CRC patients, both treated and untreated, were enrolled. Twenty mL of whole blood was collected from each patient. Ten mL of the blood was processed using 3 antibodies (EpCAM, Her2, Trop2), and the remaining 10 mL was processed using 4 antibodies (EpCAM, Her2, Trop2, EGFR). The numbers of collected CTCs were counted and compared.

Results: Cohort 1: We enrolled 34 patients (stage II: n=4, stage III: n=7, stage IV: n=23). Median number of extracted CTC was 34 cells. From tumor tissue DNA, 53 mutations were detected. The most frequent mutation was within TP53 (n=18), followed by mutations in APC (n=13) and KRAS (n=12). From ctcDNA, 16 mutations, including 5 mutations which were not found in tissue DNA, were detected. The most frequent mutation was within TP53 (n=5), followed by mutations in KRAS and APC (n=4 each). Cohort 2: We enrolled 10 patients (stage II: n=1, stage III: n=1, stage IV: n=8). Using 3 antibodies, the median number of collected CTCs was 27 cells (range, 2–112). Using 4 antibodies, the median number of collected CTCs was 33 cells (range, 7–260). There were no statistically significant differences between the 2 groups (p=0.40).

Conclusions: Mutations not detected in primary tumors can be identified in ctcDNA, indicating the potential of CTCs in complementing gene analysis. The technique to capture CTCs using 3 antibodies appears to increase the detection rate and yield of CTCs. However, the present study did not show advantages of the 4-antibodies method, and future studies should investigate the best combination of antibodies to extract more CTCs with higher specificity.

Citation Format: Kohki Takeda, Takeshi Yamada, Michihiro Koizumi, Seiichi Shinji, Akihisa Matsuda, Ryo Ohta, Yasuyuki Yokoyama, Goro Takahashi, Masahiro Hotta, Takuma Iwai, Keisuke Hara, Koji Ueda, Sho Kuriyama, Hiroshi Yoshida. Genetic analysis of circulating tumor cells of colorectal cancer patients captured by multiantibodies technique [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr B43.

Laparoscopic Cholecystectomy During Pregnancy: A Case Report and Review of Literature in Japan

Herein we report a case of laparoscopic cholecystectomy in a 26-year-old pregnant woman with no remarkable medical history. Laparoscopic cholecystectomy was performed at 21 weeks of gestation. To prevent uterus injury, the first trocar was inserted into the right hypochondrium using the open method after marking the site of the uterus via ultrasonography. After confirming the site of the uterus, the second trocar with a balloon was inserted 3 finger widths above the umbilicus. Additional 5-mm trocars were inserted into the epigastric and hypochondrial regions. A good surgical view was obtained with a pneumoperitoneal pressure of 8 mmHg. Laparoscopic cholecystectomy was successfully performed without any complications during or after the operation. She had a normal delivery at 39 weeks of gestation. Laparoscopic cholecystectomy is a viable treatment option during pregnancy, provided there is close consultation and cooperation between obstetricians and anesthesiologists.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

Analysis of colorectal cancer-related mutations by liquid biopsy: Utility of circulating cell-free DNA and circulating tumor cells

We recruited 56 colorectal cancer patients and compared the mutational spectrum of tumor tissue DNA, circulating cell‐free DNA (ccfDNA) and circulating tumor cell (CTC) DNA (ctcDNA) to evaluate the potential of liquid biopsy to detect heterogeneity of cancer. Tumor tissue DNA, ccfDNA, and ctcDNA were extracted from each patient and analyzed using next‐generation sequencing (NGS) and digital PCR. To maximize yields of CTC, three antibodies were used in the capture process. From 34 untreated patients, 53 mutations were detected in tumor tissue DNA using NGS. Forty‐seven mutations were detected in ccfDNA, including 20 not detected in tissues. Sixteen mutations were detected in ctcDNA, including five not detected in tissues. In 12 patients (35.3%), mutations not found in tumor tissues were detected by liquid biopsy: nine (26.5%) in ccfDNA only and three (8.8%) in ctcDNA only. Combination analysis of the two liquid biopsy samples increased the sensitivity to detect heterogeneity. From 22 stage IV patients with RAS mutations in their primary tumors, RAS mutations were detected in 14 (63.6%) ccfDNA and in eight (36.4%) ctcDNA using digital PCR. Mutations not detected in primary tumors can be identified in ccfDNA and in ctcDNA, indicating the potential of liquid biopsy in complementing gene analysis. Combination analysis improves sensitivity. Sensitivity to detect cancer‐specific mutations is higher in ccfDNA compared with ctcDNA.

Liquid Biopsy for the Management of Patients with Colorectal Cancer

Liquid biopsy is a collective term that refers to the analysis of tumor-derived biomarkers isolated from biological fluids of cancer patients. Recently, many authors reported the usefulness of liquid biopsy for the management of malignancy. Summary and Key Messages: The peripheral blood of cancer patients is a pool of cells and/or cell products derived from the primary or metastatic tumor, including circulating tumor cells (CTCs), circulating free (cf) DNA or RNA, and exosomes containing proteins, nucleic acids, and lipids. CTCs are tumor cells that can be isolated from peripheral blood. Free circulating DNA with a tumor-specific mutation is called circulating tumor DNA (ctDNA). Some patients who undergo curative surgery experience recurrent disease, which can be due to the presence of minimal residual disease (MRD). Thus, MRD indicates a high risk of relapse. Detection of ctDNA or CTC after surgery is a direct proof of MRD. Molecular volume (e.g., the number of CTCs and level of ctDNA) might reflect tumor burden, thus high molecular volume may indicate poor prognosis. The most notable application of liquid biopsy in cancer is to understand spatial and temporal heterogeneities. Heterogeneity is one of the causes of refractoriness and hampers prediction of chemotherapeutic effect. Emerging mutations that are not present in primary tumors but are found in their metastases can be detected in ctDNA. Some colorectal cancer patients with wild-type RAS do not respond to epidermal growth factor receptor blockade. In a subset of these patients, RAS mutation is detected in ctDNA, indicating heterogeneity.

Intestinal Obstruction Caused by a Fruit Seed: A Rare Case Without Gastrointestinal Disease

We report here a rare case of intestinal obstruction caused by a peach seed. A 15-year-old boy was admitted to our hospital because of abdominal pain and vomiting. The patient had no history of previous gastrointestinal surgery and his medical comorbidity was autism. A computed tomography (CT) scan showed an obstruction of the ileum by a foreign body. Surgical treatment was successfully performed, and we found a peach seed in the ileum. He was discharged eight days after the operation without postoperative complications. Intestinal obstruction caused by plant seeds without gastrointestinal disease is rare.

Primary small intestinal volvulus after laparoscopic rectopexy for rectal prolapse

Primary small intestinal volvulus is defined as torsion in the absence of congenital malrotation, band, or postoperative adhesions. Its occurrence as an early postoperative complication is rare. A 40-year-old woman presented with rectal prolapse, and laparoscopic rectopexy was uneventfully performed. She could not have food on the day after surgery. She started oral intake on postoperative day 3 but developed abdominal pain after the meal. Contrast-enhanced CT revealed torsion of the small intestinal mesentery. An emergent laparotomy showed small intestinal volvulus, without congenital malformation or intestinal adhesions. We diagnosed it as primary small intestinal volvulus. The strangulated intestine was resected, and reconstruction was performed. The patient recovered uneventfully after the second surgery. To the best of our knowledge, this is the first report of primary small intestinal volvulus occurring after rectopexy for rectal prolapse. Primary small intestinal volvulus could be a postoperative complication after laparoscopy.

Feasibility of Neoadjuvant FOLFOX Therapy Without Radiotherapy for Baseline Resectable Rectal Cancer

BACKGROUND/AIM

The combination of oxaliplatin, leucovorin and fluorouracil (FOLFOX) has been established as postoperative adjuvant chemotherapy for stage III colon cancer. However, the safety and efficacy of neoadjuvant FOLFOX in patients with rectal cancer are still controversial. This prospective pilot study aimed to evaluate the feasibility of neoadjuvant FOLFOX therapy without radiation for baseline resectable rectal cancer (RC).

PATIENTS AND METHODS

The study included 30 patients with clinical stage II/III RC between February 2012 and December 2015. The patients were treated with six cycles of FOLFOX followed by elective surgery. The primary endpoint was the R0 resection rate. The secondary endpoints were the scheduled treatment completion rate, adverse events, pathological response and the disease-free survival (DFS) rate.

RESULTS

All the patients underwent elective R0 resection after neoadjuvant FOLFOX therapy. The completion rate of the 6-cycle regimen was 93.3% (28/30 patients). Grade 3-4 adverse events occurred in seven patients (23.3%). Pathological complete response was noted in two patients (6.7%). The 3-year DFS rate was 77.5% (95% confidence interval, 61.4%-93.7%).

CONCLUSION

Neoadjuvant FOLFOX therapy without radiation is a feasible therapeutic strategy for baseline resectable RC.