[A Case of Rectal Neuroendocrine Carcinoma That Developed Two Years after Curative Resection for Sigmoid Colon Cancer].

We report a rare case ofrectal neuroendocrine carcinoma(NEC)following sigmoidectomy of sigmoid colon cancer. NEC of the rectum is a rare disease. It has an extremely poor prognosis and a high potential for malignancy with hematogenous and lymph node metastases. A 90-year-old man who had carcinoma ofthe sigmoid colon 2 years ago was found to have rectal NEC based on endoscopy findings. He underwent the Hartmann operation. Histological and immunohistochemical analyses showed NEC. Four months after the surgery, he developed local recurrence with lymph node metastasis. He was not administered chemotherapy because ofhis old age. Although the patient needed strict outpatient care, he remained symptom-free 4 months after the Hartmann operation.

[Assessment of Less Invasiveness Based on Serum CRP Level on Postoperative Day Three in Laparoscopic Surgery for Colorectal Cancer].

To evaluate the less invasiveness of laparoscopic surgery for colorectal cancer, we compared open and laparoscopic surgery for sigmoid or recto-sigmoid cancer operations undergoing the same procedures. One hundred forty-three patients curatively resected with D3 dissection were enrolled. All cases underwent the following procedure; high ligation of the inferior mesenteric artery(IMA)with median approach and double stapling technique(DST)for anastomosis. The clinicopathological factors were examined in 70 cases of open surgery(OC)and 73 cases of laparoscopic surgery(LAC). The mean age of all cases was 66(38-88)years, including 83 men and 60 women. The mean operation time was 189(82-413)minutes and the mean blood loss was 45(5-1,025)mL. Postoperative complications were reported in 45 cases including 10 cases with surgical site infection(SSI)and 10 cases with remote infection(RI). There was no difference in sex, BMI, PS, and ASA between the 2 groups; however, the patients were significantly older and the tumor maximum diameter significantly larger in the OC group. There was no significant difference in operation time but the blood loss was significantly lower in the LAC group. There were no differences in postoperative complications, first gait, WBC, and body temperature on postoperative day(POD)3, but the first flatus was earlier and the CRP level was significantly lower on POD 3 in the LAC group. There was no difference in the CRP level on POD 3 in the age, tumor diameter, and blood loss which showed a difference in the both group. Laparoscopic surgery was considered less invasive than open surgery because the serum CRP level was lower in the LAC group.

Subcuticular Suturing with Closed Suction Drainage for Wound Closure Following Stoma Reversal.

Incisional surgical site infection (SSI) is a leading complication of stoma reversal procedures. This retrospective study was conducted to assess the incidence of incisional SSI and other wound complications when wound closure was achieved by subcuticular suturing and closed suction drainage following stoma reversal. We analyzed data from a total of 49 patients, all of whom had undergone insertion of a 10 Fr closed suction drainage tube in the fascia, following irrigation with approximately 300 mL of physiological saline. We then performed subcuticular suturing with 4-0 monofilament absorbable sutures. The median age of our patient population (34 men and 15 women) was 68 (range, 35-84) years. Six patients had an end stoma and 43 had a loop stoma. The wound category was 'contaminated' in 18 patients, while an incisional SSI was observed in one patient (2.0%). No wound disruptions, seromas, or drain infections were evident. Our data are reliable, but our study is limited in terms of general applicability; however, the low SSI rate indicates that the procedure is acceptable. Further research into this procedure will require a randomized trial design.

[A Prognostic Factor Based on Inflammation, Nutrition, and Immune Status for fStage II/III Colorectal Cancer].

INTRODUCTION: We investigated whether the prognostic nutritional index(PNI), controlling nutritional status(CONUT), modified Glasgow prognostic score(mGPS), and the neutrophil count/lymphocyte number ratio(NLR)could be prognostic factors for fStage II/III colorectal cancer. SUBJECTS AND METHODS: The subjects were 115 patients with fStage II/III colorectal cancer who underwent curative resection. We studied the relationship with 3-year disease-free survival(DFS)and 5-year survival rate(OS). RESULTS: DFS and OS were 75.6% and 84.4%, respectively, and 81.3% and 69.6% for DFS and 82.4% and 84.4% for OS were in fStage II and III, respectively. Univariate analysis of DFS showed significant differences for sex, age, PNI, and NLR, but there was no difference in PS, location, adjuvant chemotherapy, CONUT, or mGPS. In multivariate analysis, sex(male)and NLR(>2)were independent prognostic factors(p=0.006 and p=0.01, respectively). As for OS, although significant differences were recognized for sex, age, PS, PNI, NLR, and CONUT, there was no difference in location, adjuvant chemotherapy, or mGPS. In multivariate analysis, PS(≥1)and NLR(>2)were independent prognostic factors(p=0.009 and p=0.006, respectively). CONCLUSIONS: NLR(>2)was an independent prognostic factor for DFS and OS among prognos- tic factors based on inflammation, nutrition, and immunity in fStage II/III colorectal cancer patients.

[A Case of Recurrence in the Posterior Wall of the Virginal after Radical Resection for Rectal Cancer Well Responded in a Long Period by Chemo-Radiotherapy].

We report a case of an advanced rectal cancer recurrence that responded completely to chemo-radiotherapy. The patient was an 80-year-old woman. Low anterior resection with D2(prxD3)lymph node dissection was performed. Sixteen months after operation, CEA level elevated but no recurrence foci were found in any image tests. Administration of TS-1 was initiated since recurrence was highly suspected. Twenty seven months after operation, PET-CT detected local recurrence in the posterior wall of the vagina. After construction colostomy, chemo-radiotherapy(60 Gy+oral UFT)was performed and CEA level dropped promptly to the normal value. No relapse was pointed out in CT scans or MRI tests. There were not any signs of recurrence through 112 months after chemo-radiotherapy.

[Prognostic Factors in Elderly Patients with Stage II/III Colorectal Carcinomas with Invasion of pT3 or Deeper].

Three hundred and fourteen patients with pT3 or deeper, Stage II/IIIcolorectal carcinoma who underwent curative operation were divided into two groups: age 75 years and more(elderly)and 74 years and less(non-elderly), to identify prognostic factors and risk factors for postoperative complications. Higher comorbidity rates and poorer nutritional status where found in the elderly group, which led to a shorter operation time and less lymph node dissection. There were no significant differences in 5-year OS and 3-year RFS between the two groups. These results suggest that elderly patients with colorectal carcinoma can achieve outcomes equal to the non-elderly group by curative resection even if it is not standard radical resection.

[Clinical Significance of Serum p53 Antibody Measurement in Colorectal Cancer Patients].

We investigated the significance of serum p53 antibody in colorectal cancer. The subjects included 239 patients with colorectal cancerwithout any history of priortr eatment. Patients with multiple cancerordouble cancerwer e excluded. Serum p53 antibodies and relationships with clinicopathological factors and prognosis were examined. The preoperative positive rate of serum p53 antibody was 28.9%. There was no relationship between p53 antibody and clinicopathological factors or degree of progression. Examination of a possible relationship with prognosis revealed that p53 antibody was not related to whether recurrence occurred, and there was no difference observed for survival rate. Examination of the cases in which serum p53 antibody was measured continuously after curative resection revealed that there was a tendency to find a low incidence of cancer recurrence in cases in which serum p53 antibody became negative postoperatively. Furthermore, cancer recurred at a low incidence in the cases in which p53 antibody was on the decrease postoperatively(p=0.0008). Thus, ourr esults show that serum p53 antibody in colorectal cancer cases is not related to clinicopathological factors or prognosis. However, in cases positive for preoperative serum p53 antibody, changes in postoperative levels of the titer could be a marker for recurrence.

[The Significance and Limitations of Curative Resection for Peritoneal Metastases of Colorectal Cancer].

The objectives of the present study were to investigate the treatment outcomes of curative resection in patients with peritoneal metastases from colorectal cancer and to clarify the significance and limitations thereof. The study included 38 patients with colorectal cancer who underwent curative resection of peritoneal metastases between 1996 and 2014. Peritoneal metastases were classified as follows: metachronous(n=9)and synchronous(n=29); P1(n=13)and P2(n=25); and ovarian(n=5). Thirty patients received postoperative chemotherapy, includingoxaliplatin -based regimens(n=14)and other regimens, such as 5-FU/Leucovorin(n=16). The 3-year survival rate amongall patients was 59.9%. There were no differences in survival rates accordingto gender, serum CEA levels, location, differentiation, depth of invasion of tumor, number of organs with distant metastases, severity of peritoneal metastasis, and types of postoperative chemotherapy. However, poor outcomes were observed in patients with more advanced lymph node disease and in patients with metachronous metastases compared to those with synchronous metastases. Although curative resection can contribute to long-term survival in colorectal cancer patients with peritoneal metastases, the therapeutic effect may be limited in patients with lymph node metastases and those with metachronous metastases.

[Preoperative Prognostic Nutritional Index in Elderly Patients Over 80 Years Old Who Underwent Curative Resection for Colorectal Cancer].

PATIENTS AND METHODS: From 2001, cases of 76 patients who underwent Cur A resection for colorectal cancer and preoperative prognostic nutritional index (PNI) assessment were analyzed in terms of clinicopathological factors, surgical outcomes, and prognosis. RESULTS: Median age of the 36 men and 40 women included in the study was 83 years. Median PNI was 42.1. Twenty-four patients had a PNI below 40. There were 36 patients with pulmonary dysfunction, and 60 patients with D2 or wider LN dissection. Median operating time was 177 minutes. Postoperative complications were reported in 48 patients and SSI in 15 patients. Postoperative hospital stay was 16 days. During a median 30 month follow-up period, there were 16 deaths, including 8 from cancer-related causes and 8 from other disease-related causes. Patients with a PNI below 40 often had fewerD2 LN dissections(p=0.082)and significantly shorter operating times(p=0.015). First gait and first flatus were observed significantly later(p=0.0051, 0.0307). There were no significant differences in postoperative complication rates, SSI, postoperative hospital stay, cause of death, or survival. CONCLUSIONS: In the elderly aged over 80-years-old, because those with a PNI below 40 underwent resection with fewer LN dissections and shorter operating time, there were no significant differences in postoperative complications, cause of death, or prognosis. These results suggest that PNI could be a selection factor for surgical procedure in elderly patients aged over 80 years.

[Short-Term Outcome of TAS-102 for Refractory Metastatic Colorectal Cancer].

We retrospectively analyzed 7 patients with refractory colorectal cancer treated with TAS-102 as salvage therapy. Subjects were 3 men and 4 women. The median age at initiation of TAS-102 was 71 years (range, 41-82 years). The number of target organs was 1 in 5 patients, 2 in 1 patient, and 3 in 1 patient. The median treatment courses were 2 courses (range, 1-6 courses). The reason for discontinuation was hematological toxicity in 1 patient, patients' wish in 3 patients, disease progression in 2 patients, and worsening of general condition in 1 patient. The median survival time since the first administration of TAS-102 was 9 months.

[The Significance of Primary Tumor Resection in Unresectable Stage â £ Colorectal Cancer].

The significance of primary tumor resection for unresectable Stage Ⅳcolorectal cancer is controversial. In the present study, we examined cases of unresectable Stage Ⅳ colorectal cancer treated in our department. The subjects were 78 patients with unresectable Stage Ⅳ colorectal cancer who received either resection of the primary tumor, intensive chemotherapy, or both, between 2006 and 2012. The patients were divided into 2 groups: the group that received primary tumor resection (67 patients) and the non-resection group (11 patients). No differences were noted between a history of primary tumor resection and various clinicopathological factors, but the prognoses in the primary tumor resection group were favorable. The subjects were divided into 3 groups based on the selection of primary tumor resection and chemotherapy. The median survival time was 21.6 months, 11.8 months, and 8.1 months for patients who underwent chemotherapy after primary tumor resection (52 patients), patients who received primary tumor resection only (15 patients), and patients who received only chemotherapy (11 patients), respectively. The prognoses of patients who received primary tumor resection were favorable in comparison with those who received only chemotherapy. The results of the present study suggest the possibility that primary tumor resection can improve the prognoses of patients who have unresectable Stage Ⅳ colorectal cancer.

[A Case of Peritoneal Metastasis in Which Colostomy Was Useful for Restenosis after Stenting].

We report a case of restenosis after performing stenting twice for ileus caused by peritoneal dissemination that occurred after surgery for sigmoid colon cancer, in which colostomy was performed to improve the patient's QOL. The patient was a 58-year-old woman who underwent sigmoidectomy for sigmoid colon cancer. She presented with a peritoneal recurrence 3 times, and the third surgery was a non-curative resection. Chemotherapy was administered but was discontinued because of severe adverse events, and the patient was followed up with the best supportive care. An anastomotic stricture occurred 4 years after the initial surgery, and despite performing stenting twice, stenosis occurred 3 times within a few months. The third stenosis occurred shortly after the second episode, and colostomy was therefore performed. The patient died from cancer 4 months after colostomy without having another episode of stenosis. Although stenting is effective for patients with malignant colon stenosis, colostomy appears to be more effective for repeated post-stenting stenosis, when the patient is in an eligible general condition.

The Clinical Effects of Dai-kenchu-to on Postoperative Intestinal Movement and Inflammatory Reaction in Colorectal Surgery.

BACKGROUND/AIMS: We analyzed the effects of the Kampo medicine "Dai-kenchu-to" (DKT) on clinical aspects in colorectal surgery. METHODOLOGY: Total 122 patients who underwent colorectal cancer surgery were divided into a DKT group (n = 53) and a non-DKT group (n = 69). The differences of postoperative course and anti-inflammatory responses between those two groups were analyzed. RESULTS: The 53 out of 59 patients could completely take DKT. In the postoperative course, significant difference was observed in the first flatus day. In the anti-inflammatory effects, differences were observed in the heart rate (HR) of the 3rd POD. In the change between 1st POD and 3rd POD, HR in the DKT group was well controlled compared to the non-DKT group. In the patients who had over 37.5°C of body temperature in 1st POD (n = 53), inflammatory response of the DKT group was reduced compared to the non-DKT group. CONCLUSIONS: The DKT might have the favorable influences on postoperative bowel movement and systemic inflammatory reaction, and induce the better postoperative course.

Hepatic Arterial Infusion Chemotherapy for Life Threatening Patients due to Liver Metastases from Colorectal Cancer with Cetuximab.

BACKGROUND/AIMS: This retrospective report evaluated the safety and efficacy of hepatic arterial infusion chemotherapy (HAIC) for life threatening patients with unresectable hepatic metastases. METHODOLOGY: Seven life threatening patients with hepatic metastases who were treated with HAIC up to September 2011 were retrospectively analyzed. As HAIC regimen, 5-FU (1000mg/m2) was administered weekly via continuous 5-hour infusion using a continuous-infusion device. After improvement of liver dysfunction, cetuximab was administered simultaneously by the same dose of single administration. Treatment was repeated weekly until progression of hepatic lesion or discontinuity by unacceptable toxicity or patients' proposal. RESULTS: In 5 patients with hepatic metastasis related complaints, 3 patients improved after the initiation of HAIC. Three out of 4 patients with PS 2 or 3 were improved by the initiation of HAIC. The median OS was 9.5 months. No severe adverse toxicities and no treatment death related to HAIC were observed. The most severe non-hematologic adverse events were ALP in 3 patients, transaminase and bilirubin in 1 patient with grade 3. CONCLUSION: HAIC may be considered to perform when the hepatic metastases progress as life threatening status even though those are refractory to standard systemic chemotherapy.

Incidence and risk factors for incisional hernia after open surgery for colorectal cancer.

BACKGROUND/AIMS: To confirm the incidence and risk factors of incisional hernia after colorectal cancer surgery, we analyzed the clinical data including the surveillance computed tomography (CT) examination. METHODOLOGY: One hundred sixty seven patients with open abdominal surgery for colorectal cancer were analyzed retrospectively. RESULTS: Incisional hernia was recognized in 27 cases (16.2%), and occurred at median 7 (1-21) months after surgery. Multivariate analysis showed the risk factors for incisional hernia were female (p=0.0014), distal colon and rectal cancer (p=0.0038), high body mass index (p=0.0055) and lower serum albumin (p=0.0081). CONCLUSIONS: Obesity, lower median incision and malnutrition might seem to relate to the incisional hernia after colorectal cancer surgery.

Liquid tissue adhesive, subcuticular suture and subcutaneous closed suction drain for wound closure as measures for wound infection in a colorectal cancer surgery with stoma creation.

BACKGROUND/AIMS: Stoma creation is one of the risk factors for the incisional surgical site infection (SSI) which can develop the patient's pain in a colorectal surgery. METHODOLOGY: We performed the subcuticular suture with subcutaneous negative pressure drainage and sealing with liquid tissue adhesive for the prevention of wound infection at the stoma creation. RESULTS: A total of 72 patients between January 2006 and December 2012 were retrospectively analyzed. Up to December 2008, the wound closure was performed by the percutaneous transdermal interrupted suture with monofilament nylon sutures (conventional procedure). From January 2009, the 10-Fr silastic flexible drains were placed at the subcutaneous space and subcuticular suture using a monofilament absorption string was performed. A liquid tissue adhesive was used to seal the skin wound (revised procedure). There was no difference between the conventional group and the revised group in age and gender. Risk factors in two groups were not found the significant difference except diabetes mellitus. Incisional SSI was observed in 23 patients out of 72 patients (31.9%). There was no significant difference in incidence in clinicopathological factors. Only the revised procedure of wound closure significantly decreased 13.8% of incisional SSI rate from 44.2% in the conventional procedure. CONCLUSIONS: Our several changes of wound closure including tissue adhesive, subcuticular suture and subcuticular closed suction drainage reduced incisional SSI.

[Two cases of intrapelvic recurrence after radical resection of rectal cancer, treated with carbon ion radiotherapy].

We report two cases of intrapelvic recurrence after radical resection of rectal cancer, which were successfully treated with Carbon Ion Radiotherapy (C-ion RT). The first case is of a 71-year-old man who underwent abdominoperineal resection (APR) with D2 lymphadenectomy for rectal cancer in December 2010, followed by adjuvant chemotherapy with S-1 plus oxaliplatin. The patient was diagnosed with a recurrence on the left pelvic wall in August 2012, and underwent C-ion RT (73.6 Gray equivalent) for this lesion in October 2012. Three months after this treatment, the lesion had regressed significantly, as ascertained by computed tomography (CT). He remains alive with no signs of recurrence. The second case is of a 63-year-old man who underwent APR with D3 lymphadenectomy for rectal cancer, followed by adjuvant chemotherapy with uraciltegafur ( UFT). The patient was diagnosed with a recurrence on the right pelvic wall in January 2013, and underwent C-ion RT (73.6 Gray equivalent) for this lesion in March 2013. Three months after this treatment, the lesion reduced significantly, and the patient is alive with no signs of recurrence. Although the long-term outcomes need to be assessed, C-ion RT could be a safe and effective therapy.

[Successful resection of recurrent lesions in a patient with ovarian torsion diagnosed with rectal cancer].

We report the successful resection of recurrent tumors, including brain metastasis, in a patient with StageIV rectal cancer. A 29-year-old female patient was admitted with lower abdominal pain to the gynecological department in April 2005. The patient underwent emergency surgery following the diagnosis of left ovarian torsion. She was transferred to the Department of Surgery with suspected rectal cancer based on a pathological diagnosis of a Krukenberg's tumor. She underwent surgery for local advanced cancer using high anterior resection, hysterectomy, right oophorectomy, partial ileal resection, and appendectomy. In September 2007, she underwent very low anterior resection for an anastomotic recurrence. The patient then received 6 courses of modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6) as adjuvant chemotherapy. In March 2009, left paresis was observed. She underwent tumor resection and g-knife radiosurgery for brain metastasis in the right temporal lobe. In December 2009, metastasis in the right rectal muscle was resected following diagnosis by computed tomography (CT). In September 2013, she underwent further surgical resection of a tumor recurrence in the right rectal muscle. The pathological diagnosis of each resected tumor was metastatic rectal cancer. The patient has been disease-free since the last operation.

Practical use of capecitabine plus oxaliplatin (CAPEOX) with bevacizumab for patients with metastatic colorectal cancer that cannot expect conversion therapy.

BACKGROUND/AIMS: The cytotoxic regimens and bevacizumab (Bev) or anti-EGFR antibody are used for metastatic colorectal cancer (mCRC) that can expect conversion therapy. In this paper, we would present our practical data including the response, survival and toxicity of the capecitabine plus oxaliplatin (CAPEOX) with Bev for mCRC that cannot expect conversion therapy. METHODOLOGY: Nineteen patients with mCRC who were treated with CAPEOX with Bev were enrolled. All the patients had the disseminated hepatic, lung, peritoneal metastases or distant lymph node metastasis assessed as no possibility of R0 resection. RESULTS: The median age was 66 (45-85) years old. Target lesion was liver and lung in 9 patients, peritoneum in 5 patients and distant lymph node in 3 patients. CAPEOX with Bev therapy was administered for a median of 8.0 cycles (range, 4-21 cycles). In the 16 evaluable cases, there were no patient with complete response (CR), 9 patients with partial response (PR), 6 with stable disease (SD), and 1 with progressive disease. The objective response rate (CR plus PR) was 56.3%, and disease control rate (CR, PR plus SD) was 93.8%. The median TTP was 9.3 months and the median OS was 21.1 months. No patients treated with surgery even though the good responses were obtained. No severe hematologic adverse toxicities were observed except only one case with grade 3 platelet decrease. Nonhematologic grade 3 events were observed totally 8 patients including 3 for peripheral neuropathy, 2 for bilirubin, and 1 for nausea/vomiting, amylase and stomatitis. CONCLUSIONS: We obtained the quite good results of CAPEOX plus Bev as the first-line treatment practically. This regimen might be useful for mCRC that cannot expect conversion therapy.

[Assessment of host status in patients treated with mFOLFOX6 adjuvant chemotherapy after colorectal cancer surgery].

BACKGROUND: We examined the association of the physical, nutritional, and immune status with adverse events in patients treated with mFOLFOX6 adjuvant chemotherapy after colorectal cancer surgery. METHOD: This study included 17 patients, 7 male and 10 female. The median age was 62( range, 32-75) years. The median number of treatment cycles was 12 (range, 4-12). Age, performance status( PS), body mass index( BMI),serum albumin level( Alb),Onodera's prognostic nutritional index( PNI), controlling nutritional status( CONUT),Glasgow prognostic score( GPS),the granulocyte/lymphocyte ratio( G/L),neutrophil count, and the total lymphocyte count( TLC) were evaluated with regard to the nutrition and immunity status of the host before chemotherapy. The incidents of toxicity of greater than Grade 2 severity, excluding gastrointestinal events or gastrointestinal toxicities, were analyzed to determine the correlation with host status. RESULT: Any toxicities and toxicities without digestive symptoms were observed in 11 patients( 64.7%),and the number of incidents was significantly increased in patients with a PNI of <45. Gastrointestinal toxicities were observed in 4 patients (23.5%), but there were no significant correlations with any of the factors investigated. CONCLUSION: Toxicities are observed to a greater extent in patients with a PNI of <45 during adjuvant chemotherapy. These findings suggest that nutritional support may be required to safely administer mFOLFOX6 adjuvant chemotherapy.