[Immune-Related Factors as Prognostic Markers for Resectable Colorectal Cancer].

BACKGROUND: Tumor infiltration of CD3 and CD8-positive T cells has been reported as a good prognostic marker for patients with colorectal cancer(CRC). To clarify the significance of CD4 and FOXP3-positive T cells in CRC for prognosis of intratumoral infiltration. METHODS: CD3, CD8, CD4 and FOXP3-positive T cells were immunostained(IHC)from tissue specimens of 342 CRC patients who underwent curative resection to quantify the number of infiltrating cells in the tumor. Microsatellite instability(MSI)was also evaluated in 322 samples and the clinicopathological factors and survival were analyzed. RESULTS: Highly infiltrated groups of CD3, CD4 and FOXP3-positive T cells were associated with improved relapse-free survival(RFS). Highly infiltrated groups of CD8, CD4 and FOXP3-positive T cells were associated with improved disease- specific survival(DSS). Invasion depth, vascular infiltration, and CD4-positive T cell density were independent prognostic factors for DSS. CD4 and FOXP3-positive T cell infiltration was not associated with the high-frequency microsatellite instability group, in contrast to CD3 and CD8-positive T cell infiltration. CONCLUSIONS: Intratumoral CD4-positive T cell density and FOXP3-positive T cell densities were stronger prognostic indicators than other clinicopathological features. These results may facilitate the establishment of novel prognostic factors and therapeutic strategies for CRC.

Correction: Intratumoural-infiltrating CD4 + and FOXP3 + T cells as strong positive predictive markers for the prognosis of resectable colorectal cancer.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Intratumoural-infiltrating CD4 + and FOXP3 + T cells as strong positive predictive markers for the prognosis of resectable colorectal cancer.

BACKGROUND: CD3 + and CD8 + T-cell infiltration were reported as positive predictive markers of survival in colorectal cancer (CRC) patients. Here, we demonstrate the prognostic significance of CD4 + and FOXP3 + T-cell densities in CRC. METHODS: We quantified the intratumoural densities of CD3 + , CD8 + , CD4 + and FOXP3 + T cells by immunohistochemistry and digital pathology in 342 CRC patients who underwent curative resection. Microsatellite instability was also assessed in 322 specimens. Patient demographics, clinicopathological features and survival rates were analysed. RESULTS: High CD3 + , CD4 + and FOXP3 + T-cell densities were associated with improved relapse-free survival (RFS); high CD8 + , CD4 + and FOXP3 + T-cell densities were associated with improved disease-specific survival (DSS). Patients with low CD4 + and low FOXP3 + T-cell densities exhibited extremely poor prognoses. T stage, vascular/lymphatic invasion and CD4 + T-cell density were independent prognostic indicators for DSS. The distributions of CD4 + and FOXP3 + T-cell densities were not significantly different between the high microsatellite instability group and other groups, in contrast to those of CD3 + and CD8 + T-cell densities. CONCLUSIONS: Intratumoural CD4 + T-cell density and combined CD4 + and FOXP3 + T-cell densities were stronger prognostic indicators than other clinicopathological features. These results may facilitate the establishment of novel prognostic factors and therapeutic strategies for CRC.

[Two Cases of Rupture of Elevated Jejunal Varices after Operation for Hilar Cholangiocarcinoma].

Case 1: A 64-year-old man with a chiefcomplaint ofbloody stools was seen in our hospital. He underwent an extended right lobe resection for hilar cholangiocarcinoma 3 years ago and was in the middle of chemotherapy for multiple metastases. Case 2: A 69-year-old man with a chiefcomplaint ofbloody emesis and stools was seen. He underwent left hepatic trisegmentectomy for hilar cholangiocarcinoma and ligation of the right portal vein for postoperative portal venous thrombus 6 months ago. After careful examination, the patients in both cases were diagnosed with bleeding of the jejunal varices formed at the site ofhepaticojejunostomy. The patient in Case 1 underwent percutaneous transhepatic obliteration ofvarices and the patient in Case 2 underwent transileocolic vein obliteration ofvarices. After hepatobiliary pancreatic surgery with biliary tract reconstruction, we should be aware of ectopic varices during differential diagnosis of gastrointestinal bleeding.

[Use of a Posterior Thigh Flap with the Gluteus Maximus for Perineal Reconstruction - A Case of Fournier's Gangrene with Rectal Cancer].

We present a case of Fournier's gangrene secondary to rectal cancer that was managed with perineal reconstruction using a posterior thigh flap after debridement and tumor resection. A 67-year-old man was admitted with disturbed consciousness as well as hip and right thigh pain. His perineal and gluteal skin was necrotic. CT revealed subcutaneous emphysema that had spread from the rectum to the gluteal region and right thigh. We diagnosed him with Fournier's gangrene, and then removed the necrotic tissue and constructed a sigmoidostomy. A diagnosis of rectal cancer was later confirmed. Fifty-nine days after the initial operation, a laparoscopic abdominoperineal resection was performed. The perineal defect was repaired using a posterior thigh flap with the gluteus maximus. There were no postoperative complications, and the patient was discharged ahead of schedule. We concluded that the use of a posterior thigh flap is a good choice for perineal reconstruction, because it is simple to perform, can cover a large area, and has a low risk of infection.

[A Case of Ascending Colon Cancer with Extensive Abdominal Wall Abscess].

A 51-year-old woman was seen in our hospital because an ascending colon tumor with extensive abdominal wall abscess was detected on computed tomography(CT). On the same day, we performed open drainage and laparoscopic assisted ileocolostomy. Postoperative day 35, we performed right hemicolectomy with abdominal wall resection and closure of the colostomy as a radical surgery. After surgery, we started(negative pressure wound therapy: NPWT)to the surgical wound site; hence, the abdominal wall defect could be healed without a musculocutaneous flap. Laparoscopic assisted open drainage, a two-stage operation, and NPWT are useful in a case of colon cancer with abdominal wall abscess.

[A Case of Anorectal Amelanotic Malignant Melanoma].

We report a case of primary anorectal amelanotic malignant melanoma (MM), treated with a laparoscopic abdominoperineal resection (APR). A 75-year-old woman was referred to our hospital because of anal bleeding and pain. A finger-tip sized, dark reddish tumor, which protruded from her anus, was observed. After a tumor biopsy, the diagnosis was MM. No cutaneous pigmented regions were observed, and distant metastases and regional lymphadenopathy were not detected by computed tomography and magnetic resonance imaging. Therefore, we performed laparoscopic APR in order to relieve her symptoms. The resected specimen showed a partially pigmented tumor with a diameter of 6.0×4.1 cm in the anorectal junction. Histopathological examination of the specimen showed an amelanotic MM (negative for melanin pigmentation, and positive for HMB-45, Melan-A, and S-100). The post-operative course was uneventful, and we could not find any obvious evidence of recurrence of the disease 11 months after surgery. The prognosis of anorectal MM is extremely poor, thus a less invasive surgical procedure is recommended for treatment of anorectal MM. Laparoscopic APR is useful for treating anorectal MM due to its minimally invasive nature.

[A case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery].

We report a case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery. An 86-year-old woman visited our hospital complaining of lower abdominal pain. Multiple tumors in the sigmoidal and ascending colon were detected by using colonoscopy and computed tomography; therefore, we performed surgery. Postoperative pathological examination identified the sigmoidal colon tumor as an adenocarcinoma and the ascending colon tumor as a B cell lymphoma. The tumors in the ileum and the ileal diverticulum, which were simultaneously excised, were also diagnosed as B-cell lymphomas. After surgery, rapid appearance of multiple light purple nodules on the skin of the right thigh was observed. Histological examination of biopsied skin nodules led to a diagnosis of B-cell lymphoma, similar to the previously removed tumors. Although radiotherapy and chemotherapy were administered to the dermatological lesion that reached an advanced stage, the disease condition was progressive. The patient was transferred to another hospital to receive medical treatment 3 months postoperatively. We consider these dermatological lesions to be dermal infiltration of B-cell lymphomas originating from tumors in the intestinal tract.

[A case of locally advanced rectal cancer successfully resected after preoperative chemotherapy].

We present the case of a patient who was admitted because of acute pan-peritonitis but was found to have locally advanced rectal cancer that was successfully excised after preoperative chemotherapy. A 68-year-old man was transferred to our hospital via an ambulance because of severe lower abdominal pain. His abdominal computed tomography scan showed a huge tumor in the pelvis. An emergency sigmoid colostomy was performed because of panperitonitis. However, his postoperative examinations indicated locally advanced rectal cancer accompanied with extensive urinary bladder invasion but without distant metastasis, and chemotherapy was started. Eventually, the tumor reduced to 47% of its maximum size after 4 courses of FOLFOX6 and 2 courses of FOLFOX6+panitumumab, and radical excision( low anterior rectal resection, partial urinary bladder resection, D3 lymph node dissection, and total mesorectal excision) was performed on the 154th day since the first operation. No cancer cells were detected on microscopic analysis of the margins of the excised specimen. Thus, preoperative chemotherapy is useful for treating locally advanced rectal cancer.

[A case of remnant gastric cancer with afferent loop syndrome treated by left upper exenteration].

A 64-year-old man with sudden upper abdominal pain and emesis was admitted to our hospital. Forty years ago, he had undergone distal gastrectomy and reconstruction by Billroth II anastomosis for gastric cancer. Abdominal computed tomography revealed a dilated afferent loop and anastomotic tumor. Gastrofiberscopy showed crookedness and edematization of the afferent loop anastomosis. A biopsy revealed a poorly differentiated adenocarcinoma. He was operated on under the diagnosis of remnant gastric cancer. Left upper exenteration was performed because the transverse colon, lateral segment of the liver, pancreas, and left renal hilus were involved. Liver metastasis and abdominal dissemination were not observed. Histopathological findings revealed severe invasion of poorly differentiated adenocarcinoma to other organs, and intraoperative peritoneal lavage cytology was positive. He was discharged from our hospital; however, adjuvant chemotherapy was impossible because of his poor condition. Four months after the operation, he died from peritoneal carcinomatosis. Remnant gastric cancer with afferent loop syndrome has a poor prognosis. Therefore, it is necessary to select surgical resection or palliative care after immediate chemotherapy, considering each patient's condition and cancer stage.

[A case of far-advanced colon cancer with extraluminal progression that required urgent surgical treatment].

A 60-year-old man was admitted to our hospital because of right flank pain. An irregular cystic mass region with calcification was detected in his right abdomen on computed tomography( CT). On the fifth day after admission, the patient's abdominal pain suddenly worsened. Based on a diagnosis of panperitonitis, we performed an urgent laparotomy on the same day. A bulky tumor involving the right colon, duodenum, and retroperitoneum was found in his abdominal cavity. We performed right hemicolectomy and partial resection of the duodenum but could not completely excise the tumor. The manipulation caused a serious duodenal injury; and therefore, pyloric antrum transection, gastrojejunostomy, and cholecystostomy were performed to reduce the inflow of gastric content and bile. Histological examination of the surgical specimens revealed a moderately differentiated adenocarcinoma that originated from the ascending colon. Many cancer cells were detected in the excised margin; thus, the surgical maneuver of choice was absolute noncurative resection. If peritonitis had not been observed, preoperative chemotherapy would have been more appropriate.

[A case of hepatocellular carcinoma with Vp4 tumor thrombus treated by radiation therapy before hepatectomy].

A 61-year-old man who complained of right hypochondralgia was diagnosed as hepatocellular carcinoma (HCC) associated with hepatitis B virus (HBV) infection. The tumor was located in the right lobe and S3, and the tumor thrombus extended into the main portal and left portal veins. Preoperatively, real-time tumor-tracking radiation therapy was performed on the tumor thrombus (20 Gy/4 Fr),after vessel coils were placed at the anterior hepatic artery as a marker for the radiation. Ten days after radiation therapy, extended right hepatectomy with thrombectomy and S3 partial hepatectomy were performed. There were no postsurgical complications, and intrahepatic artery infusion chemotherapy was performed. The patient was alive with no recurrences 20 months after surgery. Radiation therapy before hepatectomy is an effective treatment for portal venous tumor thrombus in HCC.

[Two cases of asymptomatic ruptured hepatocellular carcinoma].

We describe 2 cases of asymptomatic ruptured hepatocellular carcinoma diagnosed for the first time after the start of the operation. The first case is a 62-year-old woman. A tumor with a diameter of 3.6 cm was observed in the liver lateral segment on the abdominal computed tomography(CT) scan. She had not reported any subjective symptoms. Although we started operation using the laparoscope, we recognized a tumor burst and continuous bleeding. Bleeding was reduced by detaching the left hepatic artery from the left gastric artery, and left lateral hepatectomy was completed using the laparoscope. The second case is an 82-year-old man. A tumor with a diameter of 13 cm was observed in the left liver on the abdominal CT scan. He had also not reported any subjective symptoms. At the start of the operation, we observed about 200 mL of blood and a hematoma in the circumference of the liver. We intercepted the left Glisson's pedicle promptly and performed a left hepatectomy. Although it was unclear when these tumors were ruptured in both cases, they were bleeding from the burst part continuously at the time of the operation. The tumors were safely excised by controlling blood inflow as much as possible in the early stages of the operation.

[Two cases of retroperitoneal liposarcoma].

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

Predictors of prolonged laparoscopic cholecystectomy in the treatment of low-grade acute cholecystitis: a single-center, retrospective, observational study.

Aim: Laparoscopic cholecystectomy is frequently used to treat low-grade acute cholecystitis. Improvements in technical skills have reduced the rate of conversion from laparoscopic to open surgery. In this study, we sought to identify factors that might predict the surgical time of laparoscopic cholecystectomy as possible markers for surgical difficulty. Methods: We carried out a single-center retrospective analysis of a Japanese medical insurance database. Data were retrieved for 87 patients with acute cholecystitis. The analyzed factors included age, sex, body mass index, medical history, blood laboratory data, computed tomography findings, and time from disease onset to surgery. Multiple regression analysis was used to identify factors associated with surgical time. Results: Edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis were significantly associated with surgical time (P = 0.014, 0.027, 0.043, and 0.047, respectively). The conversion rate from laparoscopic surgery to open surgery was 2%. Conclusions: Our results suggest that edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis are associated with surgical time of laparoscopic cholecystectomy in the treatment of acute cholecystitis in our hospital.