Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients.

PURPOSE: To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors. METHODS: We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure. RESULTS: MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm. CONCLUSION: MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.

Mixed neuroendocrine-non-neuroendocrine neoplasm with squamous cell carcinoma covered by tubulovillous adenoma in the rectum.

A variety of histologies is often mixed in neuroendocrine carcinoma (NEC) called mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN). However, tumors consisting of both large-cell NEC and squamous cell carcinoma (SCC) are rare. NEC of the large intestine is aggressive; however, an ideal treatment strategy has not been established. In this study, we have reported a case of rectal MiNEN containing large-cell NEC and SCC that was covered by tubulovillous adenoma. A 73-year-old man was referred to our hospital for the treatment of an upper rectal tumor. The results of preoperative biopsy indicated tubulovillous adenoma, whereas computed tomography revealed multiple liver tumors and swollen lymph nodes around the rectum. Laparotomy was performed because of severe dyschezia caused by rectal stenosis. Hartmann's operation was performed because of peritoneal metastases. Histopathological examination of the rectal tumor revealed MiNEN containing large-cell NEC, SCC, well-differentiated adenocarcinoma, and tubulovillous adenoma covering the surface of the tumor. The patient died 73 days after surgery due to liver metastases. It is important to consider NEC in the differential diagnosis and tissue sampling should be performed to ensure appropriate management when pathological findings and clinical diagnosis do not match. More research is required to determine the ideal treatment for these rare and aggressive tumors.

Implantation of rectosigmoid cancer in a preexisting anal fissure.

Colorectal cancer (CRC) rarely spreads by implantation. We report a case of implantation of rectosigmoid cancer in an anal fissure. A 70-year-old woman with a 15-year medical history of anal fissure was referred to our hospital with anal pain of 3-month duration. Colonoscopy revealed a rectosigmoid tumor and a 10-mm submucosal tumor at the anal verge. Biopsy of the rectosigmoid and anal tumors revealed that both were moderately differentiated adenocarcinomas, and abdominoperineal resection (APR) was performed. The anal adenocarcinoma was surrounded by squamous cell epithelium and mainly proliferated in the submucosal and muscular layers. The patient was diagnosed as having rectosigmoid cancer with implantation of cancer in a preexisting anal fissure. The patient remains well 43 months post-surgery with no sign of recurrence. Implantation of CRC in anal fissure is a rare occurrence. Nevertheless, performing adequate anal examination of patients with CRC before surgery and during follow-up is necessary. Further, it is important to perform preoperative large bowel examination of patients with benign anal diseases to prevent implantation of CRC.

Rectal cancer with extensive distal intramural spread treated by abdominoperineal resection.

Distal intramural spread refers to microscopic tumor implantation in the intestinal wall, distal to the inferior edge of a macroscopic tumor but rarely beyond 2 cm. We report a case of rectal cancer with preoperatively diagnosed distant intramural spread to approximately 6.5 cm. A 75-year-old woman diagnosed with upper rectal cancer was scheduled to undergo low anterior resection 5 weeks after initial presentation. However, preoperative digital rectal examination and anoscopy under general anesthesia revealed a rectal tumor 4 cm proximal to the anal verge; adenocarcinoma was diagnosed based on frozen section analysis of the rectal tumor. Therefore, abdominoperineal resection was performed, and histopathological examination confirmed a moderately differentiated adenocarcinoma with distal intramural spread of 6.5 cm. The patient died 18 months postoperatively owing to lung metastasis. Although distal intramural spread is rare and can be difficult to detect prior to surgery, repeated rectal examination, with prompt histological examination of suspicious lesions, can ensure earlier diagnosis to achieve better local control by radical surgery including sufficient distal margin.

Surgical management of colorectal cancer for the aging population-A survey by the Japanese Society for Cancer of Colon and Rectum.

OBJECTIVE: The treatment policy of colorectal cancer in elderly patients is controversial due to a lack of specific guidelines. To clarify the present management of colorectal cancer for aged patients, a questionnaire survey was conducted by the Japanese Society for Cancer of the Colon and Rectum. METHODS: Questionnaire forms were sent to the 430 member institutions of the Japanese Society for Cancer of the Colon and Rectum. RESULTS: The response rate of the surgical department to the questionnaire was 39%. Performance status was used for preoperative assessments, and electrocardiogram and ultrasonic cardiograms were conducted for cardiovascular evaluations in many institutions. The same extent of surgical procedures was often adopted for elderly and younger patients, and the frequency of a laparoscopic procedure was the same regardless of a patient's age. A simultaneous hepatectomy for hepatic metastasis was considered in one-third of institutions. In many institutions, intersphincteric resection for patients with possible sphincter-saving surgery was not considered for elderly patients with low rectal cancer. CONCLUSION: Japanese Society for Cancer of the Colon and Rectum member institutions often used the same surgical treatment strategies for both elderly and younger patients with the exception of performing intersphincteric resection.

Successful repair of a rectovaginal fistula caused by a tension-free vaginal mesh (TVM): a case report.

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

[Outcomes of Anal Squamous Cell Carcinoma Treated with Chemoradiotherapy].

We evaluated the effectiveness of chemoradiotherapy(CRT)by reviewing 11 clinicalcases of analsquamous cellcarcinoma( SCC). Radiotherapy(RT)consisted of 40 Gy delivered to pelvic and bilateral inguinal lesions, and a perianal booster dose of 20 Gy in fractions of 2.0 Gy per day, 5 days per week. 5-fluorouracil(5-FU)and mitomycin C were administered twice every 4weeks as standard chemotherapy. On the first day of RT, patients received a single bolus dose of 10mg/m2 mitomycin C, and a continuous 24-hour infusion of 750mg/m2 5-FU for 5 days. One patient with a T3 tumor was orally administered S- 1 during RT because of his poor generalcondition, and 1 patient with a T2 tumor did not receive 1 course of 5-FU and MMC owing to an adverse event. Grade 3 adverse effects occurred in 3 patients, but all 11 patients completed CRT. The anal lesions of 10 patients had complete response after CRT. Recurrence of anal lesions occurred in 4 patients, including 2 patients who were not treated with standard CRT. Of 8 patients who received CR via standard CRT, 2 patients had recurrence of anal lesions more than 60 months after completion of CRT. CRT is believed to be safe and effective for improving the prognosis of anal squamous cell carcinoma; however, sufficient and appropriate follow-up is necessary after complete response.

[Results of Neoadjuvant Chemoradiotherapy for Rectal Cancer with Invasion to the Adjacent Organs].

We reviewed the clinical records of 14 cases who received neoadjuvant chemoradiotherapy(CRT)to evaluate the clinical effectiveness of the CRT for T4b rectal cancer. The preoperative radiotherapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day, 5 days per week. A treatment with intravenous 5-fluorouracil, or oral tegafur-uracil(UFT)with l-leucovorin, or oral S-1, or capecitabine or intravenous irinotecan with oral S-1, was administered during radiotherapy. One patient died due to pelvic abscess at 69 days after CRT. Complete response(CR)or partial response(PR)was observed in 8 cases, 1 month after CRT. Curative surgery was performed in 10 patients. Among 10 patients who underwent curative surgery, both urinary and anal function were preserved in 5 patients. Although no lymph node metastasis was found in 9 patients of 10 patients who underwent curative surgery, recurrence was found in 5 patients, and local recurrence was found in 4 of these patients. Recurrence occurred in all patients who had recurrence within 1 year. Preoperative CRT was expected to be an effective treatment to improve the resection rate and prognosis for T4b rectal cancer. However, it was thought that it was necessary to be careful about local recurrence, especially within 1 year after surgery.

[Treatment Outcome of Anal Squamous Cell Carcinoma Treated with Radical Chemoradiotherapy].

We reviewed the clinical records of 7 patients with anal squamous cell carcinoma(SCC)to evaluate the effectiveness of radical chemoradiotherapy(CRT). The radiotherapy(RT)consisted of 40 Gy delivered to the pelvis and bilateral inguinal lesions, and a perianal booster dose of 20 Gy, in fractions of 2.0 Gy per day, 5 days per week. 5-fluorouracil(5-FU)and mitomycin C(MMC)were administered 3 times every 4weeks as standard chemotherapy. On the first day of RT, 750mg/m2 of 5-FU in the form of a continuous 24-hour infusion, for 5 days was administered. On the first day of chemotherapy, 10mg/ m2 of MMC was also administered as a single bolus infusion. One patient with a T3 tumor was administered oral TS-1 during RT because of advanced age. In the CRT group, there was 1 case each of T1 and T3, and the others were T2. Grade 2 adverse effects occurred in 5 patients, and Grade 3 in 2, but completion of CRT was achieved in all 7 patients. All patients had a complete response in the anal lesion after CRT. Three patients, including those with the T3 tumor treated with TS-1, developed recurrence of the anal lesion. Two patients with T2 tumors, who were treated with CRT comprising 5-FU and MMC, developed recurrence of the anal lesion more than 60 months after CRT. CRT is expected to be a safe and effective treatment to improve the prognosis for anal squamous carcinoma; however, sufficient and appropriate follow-up is necessary after a complete response.

Clinical characteristics of ischemic colitis after surgery for colorectal cancer.

PURPOSE: This study was performed to clarify the clinical features of ischemic colitis (IC) after colorectal cancer surgery. METHODS: This study retrospectively reviewed the medical records of 35 patients with IC. Patients were divided into two groups: those who had undergone colorectal cancer surgery (POIC group, n = 13) and those who had not undergone colorectal cancer surgery (NOIC group, n = 22). Gangrenous colitis was seen in one patient in the POIC group, and transient colitis was seen in the remaining 34 patients. RESULTS: Among the patients with transient colitis, there were significantly more patients without underlying diseases or promoting factors in the POIC group than in the NOIC group (P = 0.01). Abdominal pain was more frequently reported in the NOIC group than in the POIC group as both the initial symptom (P = 0.02) and throughout the disease course (P = 0.02). Ischemic changes occupying more than half the circumference of the intestinal wall were more frequently found in the NOIC group than in the POIC group (P = 0.03). CONCLUSIONS: Although transient POIC may occur without any underlying disease, severe symptoms rarely occur. However, if POIC occurs in a patient with severe underlying disease, then the occurrence of severe colitis should be considered.

[Treatment outcome in nine cases of anal squamous cell carcinoma].

We reviewed the clinical records of 9 patients with anal squamous cell carcinoma (SCC) chiefly to evaluate the effectiveness of chemoradiotherapy (CRT). Surgery was performed in 1 patient; radiotherapy (RT), in 2; and CRT, in 6. RT consisted of 40 Gy delivered to the pelvic and bilateral inguinal lesions, and a perianal booster dose of 20 Gy in fractions of 2.0 Gy/day, 5 days a week. 5-fluorouraci (l 750 mg/m², administered through a 24-h continuous infusion for 5 days) and mitomycin C (10 mg/m², administered as a single bolus infusion)were administered 3 times every 4 weeks as standard chemotherapy. One patient with a T3 tumor received oral TS-1 during RT because of advanced age. In the CRT group, 1 patient had a T1 tumor, another had a T3 tumor, and the others had a T2 tumor. Grade 2 adverse effects occurred in 3 patients, and grade 3 adverse effects occurred in 1 patient. Nevertheless, CRT was completed in all of the 6 patients. All the patients had complete response after CRT for the anal lesion. Two patients, one of whom had a T3 tumor treated with oral S-1, had recurrence of the anal lesion. The 2 patients (T2 and T3) who underwent RT and needed surgery because of residual tumor died of recurrent disease. The patient with a T4 tumor who underwent abdominoperineal resection also died of recurrent disease. CRT is considered a safe and effective treatment option to improve prognosis in anal SCC.

[Outcomes of preoperative chemoradiotherapy for rectal cancer with invasion to the adjacent organs].

We reviewed the clinical records of 13 patients who received preoperative chemoradiotherapy(CRT)to evaluate the clinical effectiveness of CRT for T4b rectal cancer. Preoperative radiotherapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day, 5 days per week. Treatment with intravenous 5-fluorouracil, oral tegafur-uracil(UFT-E)with l-leucovorin, oral S-1, or intravenous irinotecan(CPT-11)with oral S-1 was administered during radiotherapy. At 63 days after CRT, 1 patient died because of pelvic abscess. Complete response(CR)or partial response(PR)was observed in 7 patients, 1 month after CRT. Curative surgery was performed in 9 patients. Among 10 patients who underwent surgery 70 days after CRT, 5 who showed PR 1 month after CRT underwent curative surgery; both urinary and anal function were preserved in 4 of these patients. Histological invasion to the adjacent organs was not observed in 6 patients, and 1 patient achieved histological CR. Of the 9 patients who underwent curative surgery, recurrence was observed in 2; however, the other patients survived without recurrence. Preoperative CRT was considered to be effective in improving the resection rate and prognosis in patients with T4b rectal cancer. However, careful attention should be paid to the severe toxicities associated with CRT, such as pelvic abscess.

[Our experiences of anal squamous cell carcinoma treated by chemoradiotherapy].

We reviewed the clinical records of 6 cases with anal squamous cell carcinoma to evaluate the clinical effectiveness of chemoradiotherapy (CRT). The radiotherapy consisted of 40 Gy delivered to the pelvis and bilateral inguinal lesion, and a perianal booster dose of 20 Gy, in fractions of 2.0 Gy per day, 5 days per week. 5-FU and mitomycin C were administrated 3 times every 4 weeks as standard chemotherapy. On the first day of radiation therapy, 750 mg/m2 of 5-FU in the form of a continuous 24-hour infusion for 5 days was given. On the first day of chemotherapy, 10 mg/m2 of mitomycin C was also given as a single bolus infusion. One aged patient with a T3 tumor was administrated oral S-1 during radiotherapy. Four patients had a T2 tumor, 1 had a T1 tumor, and 1 had a T3 tumor. One patient had metastases in the Virchow lymph node that originated from synchronous vaginal cancer. No patient had hematogenous metastases. Grade 2 adverse effects occurred in 3 patients, and Grade 3 in 1 patient, during CRT, but the completion of CRT was achieved in all 6 patients. All patients had complete response (CR) in the anal lesion after CRT. Only the patient with a T3 tumor who was administrated S- 1 showed signs of recurrence in the anal lesion. CRT is expected to be a safe and effective treatment for improving the prognosis of anal squamous carcinoma.

[Results of preoperative chemoradiotherapy for T4 rectal cancer].

We reviewed clinical records of 11 cases with preoperative chemoradiotherapy to evaluate the clinical effectiveness of chemoradiotherapy for T4 rectal cancer. The preoperative radiotherapy consisted of 40-50 Gy delivered in fractions of 1 .8- 2.0 Gy per day, five days per week. A treatment of 5-fluorouracil, 500 mg/body per day intravenously, or oral UFT-E (300 mg/m²) with l-leucovorin (75 mg) per day, or oral S-1 (80 mg/m²) per day five days per week, was given during radiotherapy. One patient died due to pelvic abscess in 63 days after chemoradiotherapy. Invasive findings to the adjacent organs identified by CT and MRI disappeared in 6 cases with complete or partial response 1 month after chemoradiotherapy. Curative surgery was performed in 7 patients. Although the adjacent organs were also removed during surgery in 7 patients, there was no histological invasion to the adjacent organs in 4 patients, and one patient had histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. Two of 7 patients with curative surgery had recurrence, but the rest of them survived without recurrence. Preoperative chemoradiotherapy was expected to be an effective treatment to improve the resection rate and prognosis for T4 rectal cancer. However, it was thought that it was necessary to be careful about severe toxicity, such as pelvic abscess.

[HAI chemotherapy for liver metastases of colorectal cancer].

We evaluated the effect of hepatic arterial infusion(HAI)chemotherapy for liver metastases from colorectal cancer. A total of 65 patients received HAI chemotherapy. The chemotherapy regimen consisted of weekly 5-FU (1, 500 mg/body) or 5-FU (400 mg/mm2) and l-LV (200mg/mm2). The survival and response rates were assessed according to RECIST. Median survival time with HAI chemotherapy was 13. 5 months, 5-year survival rate 8% and response rates 55%. There was no evidence of myelosuppression, and HAI could be continued for a long time even for poor PS patients. There were no differences in survival time between synchronous, metachronous and postoperative metachronous liver metastases. In the patients who underwent curative hepatectomy after HAI chemotherapy, the 5-year survival rate was 21%, which was better than in patients with HAI chemotherapy alone. HAI chemotherapy could thus be an option for unresectable liver metastases, which could be well tolerated.

[Four cases of anal squamous cell carcinoma treated by chemoradiotherapy].

We reviewed clinical records of 4 cases with squamous cell carcinoma in anus to evaluate the clinical effectiveness of the chemoradiotherapy. The radiation therapy consisted of 40 Gy was delivered to pelvis and bilateral inguinal lesion, and perianal booster dose of 20 Gy, in fractions of 2.0 Gy per day, was given five days a week. On the first day of radiation therapy, 750 mg/m2 of 5-FU in the form of a continuous 24-hour infusion for 5 days was given. On the first day of chemotherapy, 10 mg/m2 of MMC was also given as a single bolus infusion. 5-FU and MMC were administered 4 times every 4 weeks. Three patients had T2 tumor, and one patient had T1 tumor. One patient had metastases in para-aortic and Virchow lymph node. No patients had hematogenous metastases. Grade 1 or 2 adverse effects occurred in 3 patients during chemoradiotherapy, but the completion of chemoradiotherapy was achieved in all of the 4 patients. All patients had complete response in the anal lesion after chemoradiotherapy. No patients had any sign of recurrence in anal lesion. Chemoradiotherapy was expected to be a safe and effective treatment to improve prognosis for anal squamous carcinoma.

[Our experiences of preoperative chemoradiotherapy for rectal cancer with invasion to adjacent organs].

We reviewed clinical records of 10 cases with preoperative chemoradiotherapy to evaluate the clinical effectiveness of the chemoradiotherapy for T4 rectal cancer. The preoperative radiation therapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day for five days per week. A treatment of 5-fluorouracil (500 mg/body) per day intravenously, or oral UFT-E (300 mg/m2) with l-leucovorin (75 mg/body) per day, or oral S-1 (80 mg/m2) per day for five days per week, was given during radiotherapy. Grade 1 or 2 adverse effects occurred in 3 patients during chemoradiotherapy, but a completion of chemoradiotherpy was achieved in all of the 10 patients. Invasive findings to the adjacent organs identified by CT and MRI disappeared in 6 cases with complete or partial response 1 month after chemoradiotherapy. Although the adjacent organs were also removed during surgery in 7 patients, curative surgery was performed in 7 patients. There was no histological invasion to the adjacent organs in 4 patients, and one patient had a histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. Two of 7 patients with curative surgery had recurrence, but the rest of them survived without recurrence. Preoperative chemoradiotherapy was expected to be a safe and effective treatment to improve the resection rate and prognosis for T4 rectal cancer.

[Our experiences of preoperative chemo-radiotherapy for T4 primary rectal cancer].

We reviewed 7 cases of clinical record with preoperative chemo-radiotherapy to evaluate the clinical effectiveness of the chemo-radiotherapy for T4 rectal cancer. The preoperative radiation therapy consisted of 40-45 Gy delivered in fractions of 1.8-2.0 Gy per day, five days a week. A treatment of 5-fluorouracil, 500 mg/body per day intravenously, or oral UFT-E (300 mg/m2) with l-leucovorin (75 mg) per day, or oral S-1 (80 mg/m2) per day five days a week, was given during radiotherapy. Grade 1 or 2 adverse effects occurred in 3 patients during chemo-radiotherapy, but the completion of chemo-radiotherapy was achieved in all of the 7 patients. Tumor invasion identified by CT and MRI to other organs in the pelvis disappeared in four cases with complete or partial response after a month of chemo-radiotherapy. Although the other organs were also removed during surgery in 4 patients, curative surgery was performed in 5 patients. There was no histological invasion seen to other organs in 4 patients, and one patient had histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. One of 4 patients with curative surgery had liver and local recurrence, but others survived without recurrence. Preoperative chemo-radiotherapy was expected to be a safe and effective treatment to improve the resection rate and prognosis for T4 rectal cancer.