Vaginal natural orifice transluminal endoscopic surgery (vNOTES) right hemicolectomy with intracorporeal anastomosis for cecal cancer.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) for colorectal cancer utilizes transvaginal access for bowel mobilization, vascular pedicle ligation, oncological resection, and bowel anastomosis, along with subsequent transvaginal natural orifice specimen extraction (NOSE), reducing or eliminating the need for transabdominal access. In this report, we describe the technique of vNOTES right hemicolectomy for cecal cancer, with intracorporeal anastomosis and transvaginal NOSE, including a step-by-step operative video. The patient was a 59-year-old Chinese female (body mass index 32.0 kg/m2) with a cT3N0M0 3 cm cecal adenocarcinoma. Posterior colpotomy was created with insertion of a dual-ring wound protector. vNOTES D2 right hemicolectomy with a fully stapled intracorporeal anastomosis was performed via a homemade transvaginal glove port, using extra-long rigid instruments. A 10 mm, 30° rigid laparoscope was used for operative visualization through a transumbilical port, without additional percutaneous trocars. Operative difficulties pertained to suboptimal instrument reach, lack of triangulation, and frequent clashing within the restricted access space. Surgical duration was 300 min, with 50 ml of blood loss. There was minimal postoperative pain. Return of bowel function occurred on postoperative day 2, with discharge from hospital on postoperative day 3. The patient resumed normal daily activities and regular diet by 1-week post-surgery. Self-reported cosmetic satisfaction score was excellent. No operative complications were observed at 2 months' follow-up. vNOTES right hemicolectomy with intracorporeal anastomosis is safe and feasible in highly selected colon cancer patients. Operators should be proficient in conventional laparoscopic colectomy and transvaginal NOSE. More experience with the vNOTES technique is required to ascertain best practices.

Robot-Assisted Surgery for Reversed Intestinal Malrotation with Concurrent Cecal Carcinoma: A Case Report.

BACKGROUND Reversed intestinal malrotation is an extremely rare disease, with an incidence of 1 in 250 000. In Japan, application of robotic-assisted colorectal cancer surgery is expected to increase. There are no reports of robot-assisted surgery for cecal cancer with reversed intestinal malrotation. CASE REPORT An 84-year-old Japanese man with epigastric pain and abdominal distention was referred to our hospital's Department of Gastroenterology for thorough examination. Colonoscopy revealed a semicircumferential type 2 tumor in the cecum and ascending colon. Gastrografin contrast study showed that the large intestine was entirely on the patient's right side and the small intestine was shifted to the left side. Contrast-enhanced computed tomography revealed enlarged lymph nodes near the tumor, and masses were observed at the liver, which were believed to be metastases. Following examination, reversed intestinal malrotation and concurrent cecal cancer was diagnosed. The patient was referred to our department for surgery and underwent robot-assisted ileocecal resection with D3 lymphadenectomy. The postoperative course was favorable, and patient was discharged on the sixth postoperative day, without complications. According to the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma 9th edition, the pathological diagnosis was pT4b (ileum), pN1b, cM1a (H1 [grade A]), and pStage IVa cancer. After considering tumor stage and patient's overall condition in consultation with his family, we decided against palliative systemic therapy. The patient was provided with best supportive care. CONCLUSIONS Robot-assisted surgery might be useful in manipulation of the dissection of adhesions, owing to its capacity for high-resolution 3-dimensional imaging and forceps manipulation, using articulated functions.

[A Case of BRAF Mutant Cecal Cancer Treated with Encorafenib, Binimetinib, and Cetuximab Triple Therapy].

A Japanese woman in her early 70's presented to our hospital with abdominal pain and nausea. Abdominal computed tomography showed irregular wall thickening of the ileocecal region and small intestine dilatation. Colonoscopy revealed a tumor lesion at the ileocecal valve and adenocarcinoma was detected in the biopsy specimen. Accordingly, the diagnosis was cecal cancer and bowel obstruction. Right hemicolectomy was performed as palliative surgery, and laparotomy findings revealed peritoneal dissemination. The final staging was pT4a, pN2b, pM1c, pStage Ⅳc, harboring a BRAFV600E mutation. Rapid postoperative tumor progression occurred, leading to multiple liver metastases and ascites. Encorafenib, binimetinib, and cetuximab triple therapy was started as a second line regimen. The therapy was extremely effective. CA19-9 level decreased to within normal range, and the liver tumor size was visibly diminished. After receiving treatment for 2 months in outpatient care, she had to discontinue the treatment due to carcinomatous peritonitis. Unfortunately, she died 6 months after initial diagnosis. BRAF-mutated colon cancer is associated with poor prognosis. In Japan, encorafenib, binimetinib, and cetuximab triple therapy is a new BRAF targeting regimen approved in 2020. We report this clinical course in hopes of eventually achieving better outcomes for patients with this aggressive disease.

FAK loss reduces BRAFV600E-induced ERK phosphorylation to promote intestinal stemness and cecal tumor formation.

BRAFV600E mutation is a driver mutation in the serrated pathway to colorectal cancers. BRAFV600E drives tumorigenesis through constitutive downstream extracellular signal-regulated kinase (ERK) activation, but high-intensity ERK activation can also trigger tumor suppression. Whether and how oncogenic ERK signaling can be intrinsically adjusted to a 'just-right' level optimal for tumorigenesis remains undetermined. In this study, we found that FAK (Focal adhesion kinase) expression was reduced in BRAFV600E-mutant adenomas/polyps in mice and patients. In Vil1-Cre;BRAFLSL-V600E/+;Ptk2fl/fl mice, Fak deletion maximized BRAFV600E's oncogenic activity and increased cecal tumor incidence to 100%. Mechanistically, our results showed that Fak loss, without jeopardizing BRAFV600E-induced ERK pathway transcriptional output, reduced EGFR (epidermal growth factor receptor)-dependent ERK phosphorylation. Reduction in ERK phosphorylation increased the level of Lgr4, promoting intestinal stemness and cecal tumor formation. Our findings show that a 'just-right' ERK signaling optimal for BRAFV600E-induced cecal tumor formation can be achieved via Fak loss-mediated downregulation of ERK phosphorylation.

A case of robot-assisted resection for cecum cancer with anomalous venous confluence.

There are many reports on the positional relationship between the ileocolic artery and superior mesenteric vein (SMV). However, there have been no reports of anomalous venous confluence in the ileocecal vessel area. A 69-year-old man was diagnosed with cecal cancer on a preoperative examination of a lung tumor. We planned to perform surgery for the cecal cancer. Computed tomography angiography revealed an anomalous vein confluence in the ileocolic region. We performed robot-assisted ileocecal resection. Although the small intestinal vein was misidentified as the SMV at first, we confirmed the misidentification, identified the SMV on the dorsal side of the ileocolic artery, and ligated the ileocolic vessels with precise forceps manipulation during robotic surgery. Especially for cases with vascular anomalies revealed by preoperative computed tomography angiography, robotic surgery may be useful, as flexible forceps manipulation prevents vascular injury.

Successful multidisciplinary treatment for synchronous advanced esophageal and cecal cancers after total gastrectomy with reconstruction by jejunal interposition.

BACKGROUND: Esophageal squamous cell carcinoma is characterized by field cancerization, wherein multiple cancers occur in the esophagus, head and neck, and stomach. Synchronous esophageal and colorectal cancers are also encountered with a certain frequency. A good prognosis can be expected if the tumors in both locations can be safely and completely removed. For patients with multiple cancers that occur simultaneously with esophageal cancer, it is necessary to perform a staged operation, taking into consideration the associated surgical invasiveness. It is also necessary to select multidisciplinary treatment depending on the degree of progression of the multiple lesions. We report our rare experience with a staged operation for a patient with synchronous advanced cancers of the esophagus and cecum who had previously undergone total gastrectomy with reconstruction by jejunal interposition for gastric cancer. CASE PRESENTATION: A 71-year-old man with a history of reconstruction by jejunal interposition after total gastrectomy was diagnosed as having multiple synchronous esophageal and cecal cancers. After neoadjuvant chemotherapy, we performed a planned two-stage operation, with esophagectomy and jejunostomy in the first stage and ileocecal resection and jejunal reconstruction with vascular anastomosis in the second. Postoperatively, the patient was relieved without major complications, and both tumors were amenable to curative pathologic resection. CONCLUSIONS: Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with simultaneous advanced esophageal and cecal cancer after total gastrectomy.

Sidedness is not a prognostic factor in an unselected cohort of patients with colon cancer but prognosis for caecal carcinoma is worse - A multivariate analysis of a large single institution database.

PURPOSE: Sidedness has emerged as a prognostic factor for metastatic colorectal cancer treated with modern systemic therapies. This study investigates whether it is also relevant for an unselected patient cohort including all stages. METHODS: All consecutive patients admitted with colon cancer between 1995 and 2018 were retrieved from an institution-held database. Patients were divided into two cohorts. The first cohort included patients without distant metastases who were able to undergo curative resection. The second cohort presented with distant metastases (stage IV). Potentially prognostic factors were subjected to multivariate Cox Regression analysis. RESULTS: Overall, 1,606 patients met the inclusion and exclusion criteria. An R0-resection was achieved in 1,222 patients without distant metastases. Five-year cause-specific survival rate was 89.3% for this group. There was no difference between right- and left-sided cancers (88.2% vs. 90.1%, p = 0.220). However, prognosis of caecal carcinoma was significantly worse than that of all other sites combined (83.5% vs. 90.2%, p = 0.007). In multivariate analysis, pT-category, pN-category, grading, vascular invasion, emergency operation, adjuvant chemotherapy, and caecal carcinoma remained as independent prognostic factors. In the 384 patients with stage IV-disease, 3-year overall survival for right- vs. left-sided cancers differed only in univariate analysis (17.7% vs. 28.6%, p = 0.013). CONCLUSION: In non-metastatic colon cancer, location in the caecum is an independent prognostic factor. In unselected patients with stage IV colon cancer, sidedness was not found to be a prognostic factor. Differentiation into right- and left-sided tumors may be simplistic, and further studies on the biological behavior of different colonic sites are warranted.

[A Case of Early-Stage Cecal Cancer with Mesenteric Phlebosclerosis Requiring Laparoscopic Right Hemicolectomy of the Colon].

The patient was a 71-year-old woman diagnosed with mesenteric phlebosclerosis(MP)2 years earlier. CT performed to investigate her abdominal pain revealed an ascending colon obstruction. Colonoscopy(CS)revealed MP extending to the ascending colon hepatic flexure with stenosis and a cecal tumor(biopsy tub1). Although the cancerous lesion itself was potentially curable by endoscopic treatment, it was surgically resected because of the ascending colon stenosis caused by the MP that had also caused intestinal obstruction. Intraoperative findings revealed wall thickening and stiffening from the cecum to the ascending colon hepatic flexure. Postoperative pathological examination revealed cecal carcinoma pTis, N0, M0, pStage 0. The background mucosal tissue was consistent with MP, but no findings suggested a relationship between the MP and tumor. Although the relationship between MP and carcinogenesis is unknown, and no such relationship was identified in this case, we report this case because a further accumulation of cases of MP and carcinoma is necessary, considering the rarity of MP itself and the non-negligible number of cases with carcinoma.

[A Case of Concentrated Ascites Reinfusion Therapy(CART)for Abundant Refractory Ascites in Cecal Cancer with Peritoneal Dissemination Followed by the Readministration of Chemotherapy].

A 66-year-old man underwent laparoscopic ileocecal resection for cecal cancer with liver metastasis(cT3N1M1a, cStage Ⅳa). One month later, combination chemotherapy with capecitabine, oxaliplatin, and bevacizumab was administered for liver metastasis. However, during the treatment, peritoneal dissemination and abundant diuretic-resistant ascites was revealed, resulting in poor dietary intake. One year and 11 months after the surgery, the chemotherapy was interrupted and cell-free and concentrated ascites reinfusion therapy(CART)was undergone as palliative care. The initial volume of retrieved ascites was 6,500 mL, and the volume was increased gradually to a maximum of 14,020 mL without hemodynamic instability. Totally CART was administered 10 times during 7 months without any complications: mean volume of retrieved ascites; 9,780 mL/unit, the interval between therapies; 2-3 weeks. Serum albumin level did not decrease since CART administration. His oral intake and daily activities were improved by CART. These clinical outcomes contributed to the readministration of chemotherapy. We present a recent case of safe and periodical CART for abundant refractory ascites in cecal cancer with peritoneal dissemination, resulting in the improvement of QOL and the readministration of chemotherapy.

Pseudo-submucosal tumor in the colon: seeing is believing.

A 65-year-old woman was admitted to our hospital with complaints of lower abdominal pain. Her physical examination was unremarkable. The results of routine laboratory testing were within the normal limits. In addition, abdominal CT was normal. Colonoscopy showed a cecum submucosal tumor with a pale yellow surface. Endoscopic ultrasound revealed homogeneous hypoechoic lesions originated from submucosal layer. ESD was subsequently performed to remove the submucosal lesion. During the ESD procedure, fecal outflowed from appendix opening . Yellow fecal-like material was visible after submucosal incision. The trap electrocut surface uplift showed more fecal attachment on the lamina propria surface, and myolayer integrity after clean the fecal (Fig1c), The final pathology of the surface bulge suggested hyperplasia (Fig1d). Patients were discharged with relieved lower abdominal pain. The final diagnosis was submucosal fecalith mimicking a submucosal tumor, eventually leads to chronic appendicitis. Common causes of cecal submucosal tumor include neuroendocrine tumors, lipomas, etc. There was few report about fecalith mimicking a submucosal tumor. ERTA is currently an effective endoscopic method for treating appendicitis combined with fecalith blockage. To our knowledge, this is the first report on a case of cecum submucosal fecalith mimicking a submucosal tumor and was successfully removed using endoscopy.

Pathways of lymph node metastasis and prognosis after right hemicolectomy for cecal cancer: results from a retrospective single center.

BACKGROUND: The recommended operation for cecum cancer (CC) is right hemicolectomy (RH) in some Western countries while the principle of D3 lymphadenectomy in Japan recommends resecting approximately 10 cm from the tumor edge. Therefore, the optimal surgical approach for cecum cancer (CC) remains controversial. We conducted this retrospective study to explore the pattern of lymph node metastasis and better surgical procedures for CC. METHODS: A total of 224 cecum cancer patients from January 1, 2014, to December 31, 2021, were retrospectively included in the final study. The pattern of lymph node metastasis (LNM) was investigated. RESULTS: A total of 113 (50.4%, 113/224) patients had pathologically confirmed LNM. The most frequent metastatic site was no. 201 lymph node (46%, 103/224), while 20 (8.9%, 20/224) patients had LNM in no. 202 lymph node, and 8 (3.6%, 8/224) patients had LNM in no. 203 lymph node. Only 1 (0.4%, 1/224) patient had LNM in no. 221 lymph node, four (1.8, 4/224%) patients had LNM in no. 223 lymph node, and no patients had LNM in no. 222 lymph node. LNM in no. 223 lymph node was significantly associated with a poor prognosis. Multivariate analysis indicated that LNM in no. 223 lymph node (HR = 4.59, 95% CI 1.18-17.86, P = 0.028) was the only independent risk factor associated with worse disease-free survival (DFS). CONCLUSIONS: The LNM in no. 223 lymph node for cecum cancer was rare. Therefore, standard right hemicolectomy excision is too extensive for most CC cases.

Is 10 cm ileal resection sufficient in locally advanced caecal cancer surgery?

BACKGROUND: There is no consensus as to how much ileal resection is sufficient when performing a right hemicolectomy for right colon cancers. Locally advanced caecal cancer has the highest incidence of peri-ileal lymph node metastasis. Therefore, this study investigated whether the 10 cm ileum resection suggested by the Japanese Society for Cancer of the Colon and Rectum is oncologically safe in stage II and III caecal cancer. METHODS: The prospectively collected medical records of stage II and III caecal cancer patients who underwent a right hemicolectomy with at least D2 lymph node dissection were reviewed retrospectively. The patients were divided into two groups according to the length of proximal ileal resected: group 1 (≤10 cm) and group 2 (>10 cm). Factors contributing to the 5-year overall survival (OS) were analysed. RESULTS: The study enrolled 89 patients with pathological stage II or III caecal cancer. The >10 cm group tended to be younger (P = 0.0938) with higher pathological N stages (P = 0.0899) than the ≤10 cm group. The 5-year OS did not differ between the two groups. No significant difference was found between the two groups according to stage. Age (HR = 1.06, 95% CI = 1.02-1.10, P = 0.0069) and N2 stage (HR = 5.38, 95% CI = 1.90-15.28, P = 0.0016) were significantly associated with OS in both uni- and multivariate analyses. CONCLUSIONS: There was no OS benefit to resecting >10 cm of ileum in either stage II or III caecal cancer patients. Hence, we suggest that the '10 cm rule' is sufficient for stage II and III caecal cancer patients.

[A Case of Inguinal Hernial Sac Metastasis of Cecal Cancer Resected with TAPP Approach].

Malignant tumor occurring in the inguinal region are relatively infrequent, and metastatic tumor is extremely rare. We report a case of inguinal hernial sac metastasis of cecal cancer resected with TAPP approach. The case is a 80's man. One year and 6 months after cecal cancer surgery, contrast-enhanced computer tomography(CT)examination revealed a solitary tumor in the right inguinal canal. We diagnosed inguinal hernia sac metastasis of cecal cancer and performed surgery. The mass in the hernia sac was resected with the TAPP approach. Histopathological findings were consistent with peritoneal metastasis directly to the inguinal hernia sac. The patient has been alive without 2 years after metastasectomy. It is necessary to treat patients with a history of malignant disease with keeping the possibility of inguinal hernia sac metastasis in mind.

Ascending colon cecal junction carcinoma with prostate metastasis: A case report and literature review.

RATIONALE: Colon carcinoma is the most common type of cancer, and a leading cause of cancer-related death. Clinically, the most common sites of metastases from colon carcinoma are the liver, lungs, peritoneum, and lymph nodes, while the incidence of metastases to the prostate is low. There are few relevant studies on colon carcinoma, most of them being case reports. PATIENT CONCERNS: A 76-year-old man treated with radical resection of right colon carcinoma due to primary poorly differentiated adenocarcinoma of the cecum. Postoperative pathological examination suggested that he had cancer at the junction of the ascending colon and the cecum. He had received adjuvant chemotherapy after surgery. One year later, he received transurethral plasma resection of the prostate due to urinary system discomfort. Postoperative pathological immunohistochemistry suggested prostate metastasis of colorectal carcinoma, and he received individualized treatment, but this produced no clear survival benefit. DIAGNOSES: Ascending colon cecal junction carcinoma with prostate metastasis. INTERVENTIONS: Radical resection, chemotherapy, anti-androgen therapy, surgery to relieve primary lesion obstruction symptoms, and local radiotherapy of the prostate. OUTCOMES: At present, clinical cases of colon carcinoma with prostate metastasis are rare. By sharing a rare case of ascending colon cecal junction carcinoma with prostate metastasis and reviewing the relevant literature, this paper explores and optimizes the clinical treatment of colon carcinoma with prostate metastasis.