Prediction of Lateral Pelvic Lymph-Node Metastasis in Low Rectal Cancer by Magnetic Resonance Imaging.

OBJECTIVE: This study was designed to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for lateral pelvic lymph-node metastasis. PATIENTS: Eighty-four patients with primary lower rectal cancer were examined by MRI and subsequently underwent radical surgery with lateral pelvic lymph-node dissection, without preoperative treatment. Lateral lymph-node metastases were assessed preoperatively by MRI, and the results were compared with the histopathological findings. The criterion for lateral lymph-node metastasis was any recognizable lymph node in the pelvic wall, regardless of diameter. RESULT: Lateral pelvic lymph-node metastasis was diagnosed on preoperative MRI in 16 patients (19.9 %). The overall patient-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI were 75, 69.1, 36.4, 92.2, and 70.2 %, respectively. When a cut-off value of 10 mm was used for diagnosis, the corresponding values were 43.8, 98.5, 87.5, 88.1, and 88.1 %, respectively. The mean diameter of metastatic nodes (14.7 mm) was significantly larger than that of negative nodes (5.7 mm; P < 0.01). CONCLUSION: MRI is an effective technique for predicting lateral pelvic node involvement and thus may facilitate preoperative decision-making in rectal cancer treatment. A cut-off value of 10 mm is useful for avoiding unnecessary lateral lymph-node dissection.

[Safety and Feasibility of Pancreatic Surgery for Pancreatic Cancer in Elderly Patients].

PURPOSE: This study aimed to evaluate the safety and feasibility of pancreatic surgery for pancreatic cancer in elderly patients. PATIENTS AND METHODS: In total, 9 patients underwent pancreatic surgery for pancreatic cancer between April 2005 and March 2014. The surgical complications were evaluated by Clavien-Dindo classification. RESULTS: The median operating time was 420(range: 354-503)min and the median blood loss was 640(range: 350-1,170)mL. Grade 2 or higher complications were observed in 3 patients. Pancreatic fistula(Grade 3b)was observed in 1 patient, delirium was observed(Grade 2)in 1 patient, and portal vein thrombosis(Grade 2)was observed in 1 patient. No surgical mortality was observed. DISCUSSION: Our results suggest that pancreatic surgery is a safe and feasible treatment for pancreatic cancer in elderly patients.

[A Case of Primary Splenic Inflammatory Myofibroblastic Tumor].

Inflammatory myofibroblastic tumor(IMT)is a rare neoplasm. IMTs are found in a number of locations throughout the body, but splenic involvement is uncommon. One case of splenic IMT is described. A 42-year-old woman presented with anterior chest pain and was found to have a splenic mass by computed tomography(CT). Fluorine-18-FDG-PET showed no FDG accumulation in the spleen. Magnetic resonance imaging(MRI)at 6 months follow-up showed an increase in the size of the tumor. We performed splenectomy for a suspected malignant tumor. The surgical specimen was a gray-white mass in the spleen. The mass was histopathologically diagnosed as primary splenic IMT because it consisted of desmin- and SMA-positive spindle-shaped cells with various inflammatory cells. In Japan, only 6 cases(including this case)of primary splenic IMT have been reported. Surgery is the only curative approach, but recurrences occur in around 5% of cases of pulmonary IMT, and around 25% of cases of extrapulmonary IMT. This patient needs to be carefully followed up.

Impact of S-1 plus Cisplatin Neoadjuvant Chemotherapy on Scirrhous Gastric Cancer.

OBJECTIVE: This retrospective study aimed to address the therapeutic outcome for scirrhous gastric cancer patients by evaluating the effect of neoadjuvant chemotherapy prior to gastrectomy. METHODS: Two cycles of a 3-week regimen of fluoropyrimidine S-1 (40 mg/m(2), orally, twice daily), together with cisplatin (60 mg/m(2), intravenously, day 8), were administered to patients, separated by a 2-week rest period. Surgery was performed 3 weeks later in the neoadjuvant group (n = 27). We retrospectively evaluated overall survival and prognostic factors in these patients. RESULTS: Univariate analysis showed that positive lavage cytology indicated significantly worse prognoses. In the 15 patients who also underwent curative gastrectomies after S-1 plus cisplatin chemotherapy, the pathological response grade was a significant prognostic factor for 5-year survival. Additionally, lymph node metastasis tended to be an adverse prognostic factor. CONCLUSION: After S-1 plus cisplatin neoadjuvant chemotherapy, a grade 2-3 pathological response may predict favorable outcomes in scirrhous gastric cancer patients receiving curative gastrectomy, but further studies are needed to confirm these results.

The short- and long-term outcomes of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas.

BACKGROUND: Radical antegrade modular pancreatosplenectomy (RAMPS) is a relatively new modification of the standard distal pancreatosplenectomy. In this method, dissection proceeds from right-to-left to achieve negative posterior resection margins. However, short-term and long-term outcomes of RAMPS for pancreatic cancer have not yet been clarified. The aim of this study is to evaluate short-term and long-term outcomes in the patients who have undergone RAMPS. METHODS: Consecutive 49 patients were selected from the retrospective database of the Kanagawa Cancer Center from 2000 to 2014. Data from the operative notes, pathology reports, postoperative data, and outpatient data (recurrence and survival) were entered into the database. RESULTS: All patients were undergone anterior RAMPS. The median operation time was 278 min (range from 140 to 625 mins). The median blood loss in operation was 850 ml (range from 60 to 2790 ml). The overall incidence of morbidity was 51.4% and the incidence of mortality was 0%. Forty-one patients (83.7%) had negative resection margins. The mean number of lymph nodes harvested was 15 and 27 patients had lymph node metastasis. After the median follow-up period was 41.1 months, 1-year and 3-year overall survival rates were 84.1 and 38.6%, respectively. Median overall survival was 22.6 months. CONCLUSIONS: The present study results suggested that RAMPS procedure might be safe and feasible without an increase in morbidity and morbidity and have survival benefit compared with standard DP.

[The Safety and Feasibility of Conversion Surgery for Initially Unresectable Pancreatic Cancer].

BACKGROUND: By remarkable progress of chemotherapy for pancreatic cancer, we sometimes achieve resection of initially unresectable pancreatic cancer after chemotherapy. Otherwise, the safety and feasibility of radical pancreatic resection after chemotherapy is not still clear. In this report, we evaluated the safety and feasibility of conversion surgery for initially unresectable pancreatic cancer in our center. PATIENTS AND METHODS: Between 2009 and 2014, approximately 500 patients were diagnosed with unresectable pancreatic cancer and received chemotherapy, and after chemotherapy, 10 patients were found to have resectable tumors on computed tomography. We evaluated surgical complications using the Clavien-Dindo classification. Clinicopathological data were reviewed by using UICC, seventh edition, and the chemotherapeutic effect was measured by using Evans classification. RESULTS: The mean age of patients was 68 years, with 4 men and 6 women. The preoperative chemotherapy regimens were S-1 chemotherapy in 2 patients, gemcitabine in 5 patients, and gemcitabine plus S-1 chemotherapy in 3 patients. Nine patients underwent pancreatoduodenectomy, and 1 underwent distal pancreatosplenectomy. The mean operative time was 527.5 minutes, and the mean estimated blood loss was 875 mL. Surgery-related morbidity more than Grade 2 based on Clavien-Dindo classification occurred in 6 patients. Mortality was 0%. CONCLUSION: Our study suggests that conversion surgery for initially unresectable pancreatic cancer is safe and feasible.

[Safety and Feasibility of the Bioabsorbable Staple Line Reinforcement in Distal Pancreatic Resections].

PURPOSE: The aim of this study was to evaluate the safety and feasibility of the bioabsorbable staple line reinforcement in distal pancreatic resection. PATIENTS & METHODS: Thirteen patients underwent distal pancreatic resection using the bioabsorbable staple line reinforcement between May 2014 and December 2014. Surgical complications were evaluated by Clavien-Dindo classification. RESULT: Median age was 64 years. Median operation time was 219 minutes and median blood loss was 490 mL. Complications>Grade 2 were observed in 3 patients. Among them, pancreatic fistula (Grade 2) was found in 2 patients and ileus (Grade 2) in 1. No surgical mortality was observed. DISCUSSION: Our results may suggest that the bioabsorbable staple line reinforcement is safe and feasible in distal pancreatic resection.

[A case of stage IV gastric cancer resected after chemotherapy with capecitabine plus cisplatin].

A 64-year-old woman was diagnosed with Stage IV gastric cancer with lymph node and multiple liver metastases. She was treated with 6 courses of chemotherapy, in 3-week courses, with capecitabine (1,000 mg/m/(2)) plus cisplatin(80 mg/m(2)) administered for 2 weeks, followed by a drug-free week. She underwent curative total gastrectomy with D2 lymph node dissection and reconstruction by using the Roux-en-Y method. The postoperative pathological findings revealed a T3 (SE), N1M1, Stage II B tumor; the tumor was determined to be Grade 1b owing to the chemotherapeutic effect. Postoperatively, only S-1 therapy was administered, because of the development of Grade 3 hand-foot syndrome. The patient is alive 1 year and 8 months after the initial gastrectomy.

Short-term results of a randomized study between laparoscopic and open surgery in elderly colorectal cancer patients.

BACKGROUND: In surgical treatment of elderly patients, securing the safety of surgery and radical cure must be balanced. Our purpose was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients. METHODS: Patients with cTis­T4a colorectal cancer who were 75 years or older were randomized to receive open or laparoscopic surgery. Exclusion criteria were patients who had a bulky tumor, rectal cancer that required pelvic side wall lymphadenectomy, and history of colon resection. Patients were divided according to tumor location (right colon, left colon, and rectum). The short-term outcomes were compared between the two groups. RESULTS: One hundred patients (right 43, left 28, and rectum 29) were registered in each group from August 2008 to August 2012. There were no differences in patient characteristics between the two groups. Three patients were converted from laparoscopic to open, because of bleeding, excision of peritoneum metastasis, and patient's desire, respectively. In the short-term results (open:laparoscopic), there were significant differences in the rates of complications (36:23 %) and ileus (12:4 %), amount of blood loss (157:63 mL), and duration of surgery (150:172 min). There were no significant differences in the pathological margins, and the number of dissected lymph nodes. In the subgroup analysis according to the tumor location, there were significant differences in the rate of complications (39.4:22.5 %), amount of blood loss (135:42 mL), duration of surgery (139:160 min), and length of postoperative stay (13.0:10.0 days) in the colon cancer. There were no significant differences in short-term results in the rectal cancer. CONCLUSIONS: Laparoscopic surgery in elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for elderly patients with colorectal cancer, especially colon cancer.

Perivascular epithelioid cell tumor of the rectum: report of a case and review of the literature.

We report a case of perivascular epithelioid cell tumor arising in the rectum of a 55-year-old woman. The tumor was treated by transanal endoscopic microsurgery. After 1 year follow-up, the patient is alive with no radiologic or endoscopic evidence of recurrence. Perivascular epithelioid cell tumor is a rare mesenchymal tumor characterized by co-expression of melanocytic and smooth muscle markers. This rare tumor can arise in various organs, including the falciform ligament, uterus, uterine cervix, liver, kidney, lung, breast, cardiac septum, pancreas, prostate, thigh, and gastrointestinal tract. Perivascular epithelioid cell tumor of the gastrointestinal tract is very rare, with only 23 previously reported cases. We review the literature on perivascular epithelioid cell tumors arising in the gastrointestinal tract.

Daikenchuto, a traditional Japanese herbal medicine, for the maintenance of surgically induced remission in patients with Crohn's disease: a retrospective analysis of 258 patients.

PURPOSE: Despite numerous studies, the best postoperative therapy for Crohn's disease is still undefined. We retrospectively evaluated the effects of postoperative maintenance therapy with daikenchuto, a traditional Japanese Kampo medicine, on the reoperation rate at 3 years in patients with Crohn's disease. METHODS: A total of 258 patients who underwent surgery for Crohn's disease were identified for the study. For the prevention of postoperative recurrence, patients were stratified to receive 5-aminosalicylic acid, azathioprine or daikenchuto, and their effects on preventing reoperation at 3 years were evaluated. RESULTS: Of the 258 patients, 44 required reoperation with intestinal resection within 3 years due to disease recurrence. The 3-year reoperation rate was significantly lower in the postoperative daikenchuto group than in the non-daikenchuto group (11.3 vs. 24.5 %, P = 0.01), and was similarly significantly lower in the postoperative 5-aminosalicylic acid group than in the non-5-aminosalicylic acid group (14.8 vs. 29.6 %, P = 0.0049). A multivariate Cox analysis showed that postoperative daikenchuto (P = 0.035) and postoperative 5-aminosalicylic acid (P = 0.022) were significantly and independently associated with the rate of reoperation at 3 years in patients with Crohn's disease. CONCLUSION: We propose that continuous daikenchuto therapy is a clinically useful and feasible maintenance therapy for the prevention of postoperative reoperation in patients with Crohn's disease.

[A case of gastric small cell carcinoma with liver and lymph node metastases responding to CPT-11 plus CDDP chemotherapy].

We report a case of gastric small cell carcinoma with liver and lymph node metastases responding to CPT-11 plus cisplatin (CDDP) chemotherapy. The patient was a 77-year-old woman with advanced gastric cancer, clinically diagnosed as P0H1M1CY0T4aN3. The immunostaining and pathological analysis of a biopsied specimen obtained during a gastrointestinal tract endoscopy indicated small cell carcinoma of the stomach. The patient received the following chemotherapy treatments: 11 courses of CPT-11 plus CDDP, 8 courses of docetaxel plus S-1, and 2 courses of paclitaxel. The patient is alive 2 years after the first chemotherapy treatment. We conclude that the combination of chemotherapy used was effective for treating the patient's small cell carcinoma of the stomach, which is considered to have a poor prognosis.

Risk factors for postoperative intra-abdominal septic complications after bowel resection in patients with Crohn's disease.

BACKGROUND: Postoperative intra-abdominal septic complications are a serious concern with regard to postoperative morbidity and mortality in Crohn's disease. OBJECTIVE: The aim of this study was to identify the clinical variables that potentially impact the risk of intra-abdominal septic complications in patients with Crohn's disease, as well al analyze the short-term prognosis in patients with postoperative intra-abdominal septic complications. DESIGN: This study is a retrospective review with the use of hospital medical records. SETTINGS: This investigation was conducted at a single-institution, tertiary referral center in Tokyo, Japan. PATIENTS: We reviewed 550 patients that had undergone 728 intestinal anastomoses during 633 operations for primary or recurrent Crohn's disease between January 2005 and December 2010. Postoperative intra-abdominal septic complications were defined as anastomotic leakage or intra-abdominal abscesses occurring within 1 month after surgery. MAIN OUTCOME MEASURE: Twenty-four clinical variables were evaluated as potential risk factors for postoperative intra-abdominal septic complications. These factors were analyzed by use of univariate and multivariate methods. RESULTS: Postoperative intra-abdominal septic complications occurred in 17 cases (2.7%), with no fatalities. Of the 17 patients, 13 had anastomotic leakage and 4 had intra-abdominal abscesses. In the univariate and multivariate analyses, penetrating type (p = 0.014), operation time >180 minutes (p = 0.004), and handsewn anastomoses (p = 0.005) were significantly independent risk factors for postoperative intra-abdominal septic complications. Patients experiencing intra-abdominal septic complications had significantly higher 1-year reoperation rates (41.2%) than patients without intra-abdominal septic complications (2.3%, p < 0.0001). LIMITATIONS: This study was limited by being a retrospective review, and the details regarding postoperative complications other than intra-abdominal septic complications were not completely available. CONCLUSIONS: Penetrating type, operation time >180 minutes, and handsewn anastomoses significantly increased the risk of postoperative intra-abdominal septic complications in Crohn's disease. Postoperative intra-abdominal septic complications had a negative influence on the short-term outcome in Crohn's disease.

[Retroperitoneal metastasis of hepatocellular carcinoma - a case report].

The patient was a 54-year-old man. He was an HBV carrier, and hepatocellular carcinoma (HCC) was detected for the first time in 2000. An operation was performed, but HCC recurred. After repeating the operation and transarterial chemo-embolization (TACE) for the recurrent HCC, a tumor was found in January 2009 on the ventral side of the right kidney, and we thought it was a retroperitoneal metastasis of HCC or peritoneal dissemination. He was enrolled in a trial of systemic chemotherapy, called "S-1 monotherapy for extrahepatic metastasis of HCC", but the tumor seemed progressive. Since he showed no other lesion, he was indicated for surgical resection. Intraoperatively, the tumor was localized between the duodenum and the right kidney, and was covered by the retroperitoneum. Pathological examination of the resected specimen revealed retroperitoneal metastasis of HCC. Intrahepatic recurrence was detected 6 months after the resection. Therefore, he underwent TACE, and he is currently (1 year after surgery) alive without any extrahepatic metastasis. We describe herein this case because retroperitoneal metastasis of HCC is very rare.

Relation of MT1-MMP gene expression to outcomes in colorectal cancer.

BACKGROUND: Matrix metalloproteinases are members of a large family of endopeptidases that participate in the extracellular-matrix degradation that accompanies cancer cell invasion, metastasis and angiogenesis. The membrane-type 1 matrix metalloproteinase (MT1-MMP) gene has been reported in various cancers and is associated with tumor invasion and metastasis. This study examined the relation of the relative expression of MT1-MMP gene to clinicopathological factors and outcomes in patients with colorectal cancer (CRC). METHODS: We studied surgical specimens of cancer tissue and adjacent normal mucosa obtained from 202 patients with untreated CRC. The relative expression levels of MT1-MMP mRNA in cancer and in normal adjacent mucosa were measured by quantitative real-time reverse-transcriptase polymerase chain reaction. RESULTS: MT1-MMP gene expression was higher in cancer tissue than in adjacent normal mucosa. The level of MT1-MMP gene expression was not related to any clinicopathological factor. Overall survival at 5 years differed significantly between patients with high MT1-MMP gene expression and those with low expression. CONCLUSIONS: Overexpression of the MT1-MMP gene is considered a useful independent predictor of outcomes in patients with CRC.

Risk factors for intrahepatic recurrence after curative surgical treatment of colorectal liver metastases.

BACKGROUND/AIM: Hepatic resection has been regarded as the only curative treatment for colorectal liver metastases. After a first hepatectomy, 30% to 70% of patients develop intrahepatic recurrence. In this study, we retrospectively analyzed risk factors for intrahepatic recurrence. METHODS: From April 1990 to December 2006, 86 patients with colorectal liver metastases underwent curative hepatic resection at Kanagawa Cancer Center. Clinicopathological characteristics of 35 patients in the intrahepatic recurrence group were compared with those of 30 patients in the no recurrence group. RESULTS: The 5-year survival rate was 18.7% for patients in the intrahepatic recurrence group. Lymph node metastases of primary colorectal cancer and synchronous liver metastases were found to be independently associated with intrahepatic recurrence. CONCLUSION: We suggest that neoadjuvant chemotherapy before hepatectomy should be considered as feasible treatment for reducing intrahepatic recurrence in two cases; One case is resectable synchronous liver metastases from colorectal cancer, and the other is resectable metachronous liver metastases with primary regional lymph node metastases from colorectal cancer.

Predictive factors for surgical complications of laparoscopy-assisted distal gastrectomy for gastric cancer.

BACKGROUND: Some studies have found high incidences of intraoperative and postoperative complications for patients with gastric cancer. To determine the predictive factors for the surgical complications of laparoscopic gastric surgery, surgical outcomes were evaluated. METHODS: Between April 2002 and December 2007, 152 patients with preoperatively diagnosed early gastric cancer who underwent laparoscopy-assisted distal gastrectomy (LADG) were enrolled. Visceral (VFA) and subcutaneous fat areas (SFA) were assessed by Fat Scan software. The predictive factors for surgical complications of LADG were evaluated by univariate and logistic regression analyses. RESULTS: Of 152 patients, conversion to open surgery due to uncontrollable bleeding was observed in nine male patients, and postoperative complications were detected in seven male and one female patient (four anastomotic leakage, two intraabdominal abscess, one pancreatic fistula, and one lymphorrhea). High body mass index (BMI) and high VFA independently predicted conversion to open surgery and postoperative complications. VFA was significantly higher, operation time was longer, blood loss was greater, and SFA was lower in male than in female patients, whereas no significant difference was observed in BMI between male and female patients. CONCLUSIONS: High BMI and high VFA can predict technical difficulties during laparoscopic gastric surgery and postoperative complications. Particularly, LADG should be performed cautiously to prevent surgical complications for male patients with high VFA. Predictive impact of VFA should be further determined in a larger set of patients.

[A case of interstitial pneumonia after S-1 administration for gastric cancer].

An 80-year-old man with no history of thoracic radiotherapy nor interstitial pneumonia was administered S-1 for gastric cancer in June 2007. Twenty-two days after starting S-1, he had dyspnea, and X-rays showed reticular shadows in both lung fields, yielding a diagnosis of interstitial pneumonia. Drug lymphocyte stimulating test (DLST) was positive against S-1. The total dose of S-1 was 2,200 mg to the symptom onset. We immediately started steroid pulse therapy after emergency hospitalization, and it revealed improved condition and he was able to leave the hospital. S-1 administration is becoming frequent because RCTs supported the efficacy of S-1 for gastric cancer. Interstitial pneumonia as a side effect of S-1 is not frequent, but it is necessary to pay attention to dyspnea throughout the duration of administration.

Clinical implications of dihydropyrimidine dehydrogenase expression in patients with pancreatic cancer who undergo curative resection with S-1 adjuvant chemotherapy.

The predictive roles of dihydropyrimidine dehydrogenase (DPD) in patients who undergo curative resection and adjuvant chemotherapy with S-1, which is the oral 5-fluorouracil prodrug tegafur combined with oteracil and gimeracil, remain unclear. In the present study, the clinical data from 66 consecutive patients who underwent curative resection and received adjuvant chemotherapy with S-1 for the treatment of pancreatic cancer at Kanagawa Cancer Center (Yokohama City, Japan) from April 2005 to March 2014 were retrospectively analyzed. The association between the DPD status and the survival and clinicopathological features were investigated. Of the 66 patients, 34 patients exhibited positive DPD expression (51.5%). Although a significant increase in DPD expression in male patients was observed, no significant differences were identified for other clinicopathological parameters, including tumor factor or node factor, between the DPD-positive expression group and the DPD-negative expression group. The median follow-up period of the present study was 29.2 months. There was no significant difference in the 3-year overall survival (OS) rates following surgery, which were 12.6 and 14.5% in the DPD-positive and DPD-negative expression groups, respectively (P=0.352). However, in a subgroup analysis, a significant difference in the 3-year OS rates following surgery was noted, which were 58.9 and 14.5% in the DPD-high and DPD-low expression groups, respectively (P=0.019). The intratumoral DPD expression in curatively resected pancreatic cancer patients treated with S-1 adjuvant chemotherapy was identified to not be useful as a predictive marker, whereas the level of DPD expression is a potential predictive marker. The results of the present study require confirmation in another cohort or in a prospective multicenter study.