[A case of advanced rectal cancer with lung and bone metastasis that was successfully treated with mFOLFOX6+bevacizumab].

A 48-year-old man with respiratory discomfort was diagnosed with rectal cancer with carcinomatous lymphangiosis, together with lung and sternum metastasis. As the patient's performance status(PS) was 2, mFOLFOX6+bevacizumab (Bmab)therapy with a 20% reduction in the dose was started. Three courses of this treatment resulted in improved respiratory function, and his PS dropped to 1. A chest computed tomography(CT) scan taken after four courses of this treatment indicated that pleural effusion had almost disappeared, and that the shadow on the lung had also reduced. However, after 20 courses of this treatment the disease had progressed. The regimen was changed to irinotecan (CPT-11)+Bmab administration. All of these chemotherapeutic treatments were administered on an outpatient basis. Sixteen months after the diagnosis of rectal cancer, the patient died. In recent years, combination chemotherapy for unresectable colorectal cancer has become recognized as a standard regimen, though adverse effects frequently occur. Thus, intensive chemotherapy is not always recommended for patients with poor PS. In this report, we presented a case of pulmonary metastases from rectal cancer, carcinomatous lymphangiosis, and sternum metastasis that was successfully treated with mFOLFOX6+Bmab.

[A case of sigmoid colon cancer, successfully treated by a multidisciplinary strategy for local recurrence and distant metastases].

We report a case of sigmoid colon cancer, successfully treated by a multidisciplinary strategy for local recurrence and distant metastases. This 60-year-old male patient underwent sigmoidectomy for sigmoid colon cancer. Three years after the operation, local recurrence with invasion to the left ureter was found, and we performed colectomy and left nephroureterectomy. One year after the resection, a second relapse lesion was discovered, which was considered unresectable, and was treated instead with radiation therapy(total 50 Gy). One year after the radiation therapy, five pulmonary metastases each of 12 mm in diameter were found in both lungs. He had renal dysfunction due to nephrectomy. Several regimens of chemotherapy [irinotecan (CPT-11), capecitabine+oxaliplatin (CapeOx) and CPT-11+panitumumab] were performed. He is still alive 7.5 years after the initial surgery and 4.5 years after the first recurrence.

Resection with en bloc removal of regional lymph node after endoscopic resection for T1 colorectal cancer.

BACKGROUND: Various guidelines suggest indications for performing additional colectomy with en bloc removal of regional lymph nodes after endoscopic resection for T1 colon cancer. The aim of this study was to evaluate the pathologic outcomes of patients with surgical treatment after endoscopic resection for T1 colorectal cancer. METHODS: We used data from 275 patients who had undergone curative resection for T1 colorectal cancer at a single institution between 1991 and 2009. We evaluated the rationale for additional surgical treatment after endoscopic resection performed on 68 of the 275 patients and the association between various clinicopathologic features and lymph node metastasis. RESULTS: The 5-year overall survival rate was 96.3 %. Reasons for additional surgical treatment included an endoscopic specimen with a pathologically positive margin (n = 20), lymphovascular invasion (n = 25), and submucosal invasion depth of ≥ 1,000 µm (n = 23). When endoscopists failed to find macroscopic cancer residue during endoscopic resection, no pathologically residual cancer was found in the resected specimens. Histologic grade was an independent risk factor for lymph node metastasis (p = 0.028). In the absence of lymphovascular invasion, patients with well-differentiated T1 colorectal cancer did not have nodal involvement. CONCLUSIONS: Although the outcomes of patients with additional surgical treatment after endoscopic resection for T1 colorectal cancer were satisfactory, excessive and unnecessary treatments may have been performed. Additional surgical treatment after endoscopic resection for T1 colorectal cancer might be unnecessary for patients with well-differentiated adenocarcinoma and no lymphovascular invasion.

Laparoscopic-assisted colectomy in a patient with colon cancer after percutaneous endoscopic gastrostomy.

BACKGROUND: A number of patients undergo percutaneous endoscopic gastrostomy (PEG) under various conditions. Open colectomy is usually performed for colon cancer in patients with PEG because the safety of the laparoscopic approach for such patients has not been established. However, if the laparoscopic approach is possible in patients with PEG, it will be less invasive and more helpful in rehabilitation into society. CASE PRESENTATION: We describe the case of a 64-year-old male with a T1 adenocarcinoma of the ascending colon 2 years after surgery for nasal cancer and PEG for dysphagia. The patient did not have any distant metastases or malignant tumors on preoperative computed tomography and positron-emission tomography. He underwent laparoscopic-assisted colectomy (LAC) with lymph node dissection. No complications developed during or after the surgery. CONCLUSIONS: LAC could be a potential option for the treatment of colon cancer in patients who have undergone PEG. To our knowledge, this is the first recorded case of an ascending colon cancer treated with LAC under the condition of gastrostoma.

PIK3CA mutation and methylation influences the outcome of colorectal cancer.

Colorectal cancer (CRC) occurs through the accumulation of genetic and epigenetic alterations. The epigenetic abnormalities, in cooperation with genetic alterations, are capable of causing aberrant gene function that results in cancer. In the present study, we examined mutations and methylation status in 164 CRCs to determine whether the combination of genetic and epigenetic alterations may be used to classify CRC patients in relation to their clinicopathological characteristics and outcomes. Mutation analyses for the KRAS and PIK3CA genes were performed using direct sequencing, and the MethyLight method was used to determine the methylation status of BNIP3, p16 and hMLH1. The combination of the KRAS mutation with methylation status did not have any association with clinicopathological characteristics and outcomes. However, patients with the PIK3CA mutation and/or high methylation (2 or 3 methylated genes) had significantly poorer outcomes in disease-specific survival (DSS) compared with those with wild-type PIK3CA and 0 or 1 methylated genes (P=0.0059). Additionally, multivariate analysis revealed that the PIK3CA mutation and/or a high level of methylation predicts a poor DSS independently of clinicopathological characteristics. Our results suggest that a combination of genetic and epigenetic alterations is a potent biomarker for predicting the prognosis of CRC.

Clinical significance of UNC5B expression in colorectal cancer.

The purpose of this study was to find a methylation-related gene that could become a biomarker or therapeutic target in colorectal carcinoma (CRC). We screened candidate genes suspected to be silenced by DNA methylation using cDNA microarray analysis. To investigate the clinical significance of one candidate gene (UNC5B), we analyzed the correlation between mRNA expression and clinicopathological features using clinical tissue samples. Moreover, methylation specific PCR analysis was performed to reveal whether the promoter region was methylated in CRC cell lines. We found 75 candidate genes that were potentially suppressed by DNA methylation in CRC. We focused on UNC5B, a possible tumor suppressor gene and regulator of apoptosis known to be inactivated in CRC. The mRNA expression analysis using tissue samples revealed that UNC5B mRNA was down-expressed in about 20% of CRC patients, and the patients with low-UNC5B-expression tumors showed a significantly higher recurrence rate after curative surgery. According to the univariate and multivariate analysis, low UNC5B expression was an independent risk factor for postoperative recurrence in stage I, II and III CRC patients. Furthermore, patients with low expression of UNC5B in tumors had significantly poorer prognosis than those with high expression of UNC5B. Although UNC5B mRNA expression was restored by the demethylation treatment in CRC cell lines, the promoter region of UNC5B was not methylated. UNC5B is a potential biomarker for the selection of patients with high risk of postoperative recurrence and worse prognosis in CRC.

[A long-term survival case of neuroendocrine tumor of the sigmoid colon with multiple liver metastases].

It has been reported that neuroendocrine tumor (NET) of the large intestine with distant metastasis is rare and carries poor prognosis. We report a case of colonic NET with hepatic metastases, who was successfully treated by combined therapy. A 71-year-old man with sigmoid colon tumor underwent sigmoidectomy and histopathological examination disclosed the tumor was NET grade 1. Multiple liver metastases and lymph node metastasis on the posterior surface of the pancreatic head were detected at the time of surgery. Trans-catheter arterial chemoembolization (TACE; doxorubicin and ethiodized oil and gelatine sponge particle) was performed. Partial response (PR) was observed after 2 times of administration. Radiation therapy was performed for the lymph node metastasis eight months after surgery and PR was observed. The patient was alive after 48 months and TACE was continued. Combined therapy including surgery, irradiation, and chemotherapy, although not yet standardized, is required against NET with hepatic metastases.

[A case of colonic neuroendocrine carcinoma with severe liver dysfunction by multiple liver metastases successfully treated with hepatic arterial infusion].

A 63-year-old male was diagnosed as ascending colon cancer with severe liver dysfunction caused by multiple liver metastases. Initially, hepatic arterial infusion (HAI) chemotherapy was started to reduce the size of metastatic tumors and to prevent a liver failure. After 7 courses of HAI chemotherapy, he recovered from liver dysfunction, and underwent right hemicolectomy. Pathological examination of the resected specimen revealed the tumor was neuroendocrine carcinoma. After surgery, a systemic infusion of mFOLFOX6/bevacizumab regimen was started. A partial response (PR) of metastatic lesions was observed. Irinotecan/cetuximab was administered as the second-line. He survived for 10 months after HAI. HAI for colonic neuroendocrine carcinoma with severe liver dysfunction by multiple liver metastases might be benefitial to prevent a liver failure.

[Multidisciplinary treatment including pneumonectomy for squamous cell carcinoma of the anal canal-a case report].

In August 2008, a 52-year-old woman presented to our hospital with a complaint of bleeding upon defecation. The patient underwent lower gastrointestinal endoscopy with biopsy. PRb indicated a type 2 lesion in one-third of the circumference. The patient was diagnosed with squamous cell carcinoma by biopsy. Imaging did not reveal any metastasis to other organs. In September, she underwent an abdominoperineal resection of the rectum. Postoperative histopathological findings were PRb, type 2, A, N3, H0, P0, M0, and Stage III b. Adjuvant chemotherapy of oral S-1 was started. In January 2009, contrast-enhanced abdominal CT revealed a pelvic recurrence, and the patient underwent chemoradiotherapy. In October, chest CT showed a 5-mm solitary pulmonary metastasis in the right apex of the lung. In March 2010, chest CT showed a slight enlargement of the tumor in the right apex, but no other metastatic lesion was observed. In April, the patient underwent a thoracoscopic partial pneumonectomy. It has been 16 months postoperatively, and no recurrence has been observed. In the present report, we describe a case of squamous cell carcinoma of the anal canal that underwent multidisciplinary treatment including pneumonectomy. We also include a brief literature review.

[Repeated resections for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy].

We describe the case of a 74-year-old man with liver resection for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy. Eleven bilobar liver metastases appeared four months after curative resection for double cancer of sigmoid colon and upper rectum. After 6 courses of multiagent chemotherapy (mFOLFOX 6 with bevacizumab), the number of liver metastasis decreased from 11 to 5. The patient underwent curative resection for liver metastasis. A new lesion of 7 mm in the segment 6 appeared 8 months after an initial liver resection. After 3 months' observation, two more liver metastases appeared. All liver metastases were resected. Solitary lung metastasis appeared 10 months after the second liver resection. The lung metastasis was also resected. The patient was alive with no evidence of disease in 33 months after the initial liver resection. We experienced the case with repeated liver resections after multiagent chemotherapy for originally unresectable bilobar liver metastasis. The therapeutic strategy which combines surgical resection with cytotoxic chemotherapy will be important more than ever.

[A surgical case of descending colon cancer with abdominal wall abscess after drainage of abscess].

We report a surgical case of descending colon cancer with abdominal wall abscess. A 72-year-old man was admitted to a hospital because of left lower abdominal mass with slight pain. An abdominal CT showed a left lower abdominal wall abscess adjacent to the descending colonic wall thickening. We diagnosed an abdominal wall abscess due to descending colon cancer or colon diverticulitis. The abscess was drained under local anesthesia releasing foul-smelling pus and air. After abscess drainage and general improvement in his condition, we conducted subtotal colectomy with lymph node dissection and excision of abdominal wall abscess cavity. Pathological findings indicated moderately differentiated adenocarcinoma of the descending colon (pT4, pN0, sH0, sP0, sM0, fStage II). The carcinoma had invaded the abdominal wall and transverse colon, but the cancer cells were not shown in the abdominal wall abscess cavity. In abdominal wall abscess treatment, colon cancer should be considered as a potential underlying cause. CT proved useful for assessing the status of the tumor and the abscess. We conducted a radical operation for descending colon cancer after the drainage for abdominal wall abscess.

Clinical significance of lymph node ratio and location of nodal involvement in patients with right colon cancer.

BACKGROUND/AIMS: Increasing negative lymph node count has been reported to be associated with better outcomes in patients with colon cancer. The present study aimed to clarify the clinical significance of the lymph node ratio (LNR) and location of lymph node metastasis (LNM) in patients with stage III right colon cancer. METHODS: We enrolled 820 patients who had undergone curative resection due to colon cancer at a single institution between 1991 and 2005. Among them, 197 underwent curative resection for T2-T4 right colon cancer. We evaluated the oncological outcomes according to LNR (quartiles) and distribution of LNM (n1 = LNM adjacent to the colon or along the vascular arcades of the marginal arteries; n2 = LNM along the major vessels; n3 = LNM near the roots of the major vessels). RESULTS: The rates of LNM in T2, T3 and T4 right colon cancer were 11.1, 38.6 and 58.0%, respectively (p < 0.0001). Recurrence rates were 27.3, 37.5 and 57.1% in patients with n1, n2 and n3 LNM, respectively (p < 0.0001). LNR (p < 0.0001) and distribution of LNM (p = 0.046) were independent risk factors for recurrence in patients with stage III right colon cancer. CONCLUSIONS: Some patients with extensive LNM benefited from lymph node dissection with high ligation. Those with T3-T4 right colon cancer are suitable candidates for lymph node dissection with high ligation. Adding the concept of LNR and location of LNM to conventional TNM staging could improve the accuracy of evaluating nodal status.

Effect of classification based on combination of mutation and methylation in colorectal cancer prognosis.

Colorectal cancer (CRC) is caused by an accumulation of genetic alterations and epigenetic alterations. The molecular classification of CRCs based on genetic alterations and epigenetic alterations is evolving. Here, we examined mutations and methylation status in CRCs to determine if the combination of genetic and epigenetic alterations predicts prognosis. We examined 134 sporadic CRCs. We used the direct sequencing method to identify mutations in BRAF and AKT1, which are downstream of KRAS and PIK3CA, respectively, in the EGFR pathway. We used the Methylight method to determine the methylation status of hMLH1, p16, MINT1, MINT2 and MINT31. Both BRAF and AKT1 mutations were found in only one case (0.75%). Aberrant methylation of hMLH1, p16, MINT1, MINT2 and MINT31 was detected in 22.4, 35.1, 32.8, 59.7 and 41.0% of cases, respectively. The clinicopathological factors were not significantly correlated to mutation or methylation. Among the patients who had no mutation in the EGFR pathway, the overall survival was significantly shorter in the patients with methylation compared to the patients with no methylation in hMLH1 and p16 (p=0.0318). Methylation could play a key role in the prognosis of patients without mutations in the EGFR pathway. The combination of genetic and epigenetic alterations may be a good marker for the prognosis of CRC patients.

Validation and clinical use of the Japanese classification of colorectal carcinomatosis: benefit of surgical cytoreduction even without hyperthermic intraperitoneal chemotherapy.

BACKGROUND: This study aimed to validate an easy to use practical classification of peritoneal metastasis arising from colorectal cancer. PATIENTS AND METHODS: Data from 2,134 consecutive patients who underwent resection for colorectal cancer at a single institution were reviewed. Peritoneal metastasis was classified depending on extent into three groups (P1-P3). The macroscopic radical resection rates and survival of patients with colorectal cancer complicated with peritoneal metastasis were analyzed. RESULTS: Of the 2,134 patients, 116 (5.4%) had peritoneal metastasis. Among them, 20 (17.2%) underwent macroscopic radical resection. Tumor location on the right side was associated with more extensive peritoneal metastasis (p = 0.010). Male gender (p = 0.0027), liver metastasis (p = 0.0021), and P3 peritoneal metastasis were independent risk factors for noncurative resection. The Cox proportional hazards model showed that gender (p = 0.031), operation period (p = 0.031), and macroscopic radical resection for colorectal cancer and peritoneal metastasis (p = 0.031) were independent prognostic factors. CONCLUSIONS: Being female with left colon cancer complicated with P1 or P2 peritoneal metastasis is a good indicator for macroscopic radical resection if liver metastasis is absent. The present classification helped to determine surgical indication for patients with colorectal cancer complicated with synchronous peritoneal metastasis in routine clinical practice.

[A case of unresectable and multiple advanced primary cancers of the stomach and rectosigmoid colon with hepatic metastases successfully treated with FOLFIRI for local control of a gastric lesion].

The patient was a 59-year-old man who was hospitalized at our department for intestinal obstruction. Contrast enhanced abdominal CT showed a rectosigmoid tumor invading the left pelvic wall and multiple metastatic hepatic tumors. Colonoscopy showed a type-2 cancer in the rectosigmoid region. The patient underwent sigmoid colostomy 3 days after admission. Postoperative upper gastrointestinal endoscopy showed a type 3 cancer in the fornix. From the above findings, the patient was diagnosed with unresectable gastric and rectosigmoid cancers with multiple hepatic metastases, and systemic chemotherapy was initiated. The first line treatment was two courses of S-1, but it was discontinued due to PD. FOLFIRI was begun as the second line treatment. After 5 courses of FOLFIRI, upper gastrointestinal endoscopy showed a marked reduction in tumor size. Twelve courses of FOLFIRI chemotherapy were performed in total. Subsequently, 11 courses of mFOLFOX6 and 1 course of RPMI were performed, but the patient died from carcinomatous peritonitis. However, the gastric lesion had been controlled well after the second line treatment. The findings of the present study suggested that FOLFIRI could be an effective treatment for unresectable multiple advanced cancers of the stomach and colorectal cancer.

[A case of colon cancer with multiple liver metastases effectively treated with hepatic arterial infusion followed by systemic chemotherapy].

A 63-year-old female was diagnosed as descending colon cancer with severe liver dysfunction caused by multiple liver metastases. Her performance status (PS) was 3 because of liver dysfunction and high fever. Initially, hepatic arterial infusion (HAI) chemotherapy was started to reduce the size of metastatic tumors and to prevent a liver failure. After 10 courses of HAI chemotherapy, she recovered from liver dysfunction, and CapeOX plus bevacizumab regimen was started. A partial response of metastatic liver tumors was observed after 8 cycles of this regimen and metastatic lung tumors were disappeared. The patient was alive after 12 months with PS 0 and CapeOX was continued.

[Clinicopathological studies and patterns of recurrence of mucinous colorectal carcinoma with curative resection].

In 771 cases of Stage II and III colorectal carcinoma with curative resection, clinicopathological characteristics, recurrent rate, patterns of recurrence, and prognosis of 24 cases (3%) of mucinous carcinoma were compared with those of 725 cases (94%) of well-moderately differentiated adenocarcinoma. Compared with well-moderately differentiated adenocarcinoma, mucinous carcinoma was found to be larger in tumor size, more severe lymphatic invasion, and a greater likelihood of Stage IIIb. Mucinous carcinoma had a highly recurrent rate and poorer prognosis than well-moderately differentiated adenocarcinoma. About the patterns of recurrence, mucinous carcinoma was found to be more significantly often as lymph node recurrences, but there was no liver metastasis in mucinous carcinoma. As for mucinous colorectal carcinoma, we should consider other different therapeutic strategies and surveillance.

[Curative resection for bulky rectal gastrointestinal stromal tumor after neoadjuvant imatinib mesylate].

Gastrointestinal stromal tumor is the most common mesenchymal tumor of the gastrointestinal tract. However, the frequency of rectal gastrointestinal stromal tumor is relatively low. We described the case of a 54-year-old man with bulky rectal gastrointestinal stromal tumor of which a diameter was 10 cm. After eight-week neoadjuvant imatinib mesylate, the diameter of tumor was reduced to 6 cm. The patient did not have any distant metastases on preoperative computed tomography and magnetic resonance imaging. He underwent abdominoperineal resection. The radial margin was negative. Immunohistochemical staining showed that KIT and CD34 were positive. The number of mitosis was 13 per 50 high-power fields. Adjuvant imatinib mesylate was administered for one year. No recurrence was found for 43 months after a curative resection. Curative resection is the most promising treatment for gastrointestinal stromal tumor. However, neoadjuvant imatinib mesylate followed by surgical procedure seems to be one of the treatment options for locally advanced gastrointestinal stromal tumor.