[A Case of Rectal Cancer in Which Total Pelvic Organ Excision Could Be Avoided by TNT Therapy and Robotic Surgery].

The patient is a 50s year old man. He visited his local doctor with complaints of anal pain and bloody stools, and a rectal examination revealed a tumor on the anterior wall of the rectal canal. CT imaging showed tumors invading the prostate, urethra, and anorectal muscles, and a 3 mm-sized nodule was found in the lungs. The patient was diagnosed as cT4bN1M1a, Stage Ⅳ, and total neoadjuvant chemotherapy was planned as preoperative treatment. The 5 Gy×5 times radiation therapy followed by 5 courses of CAPOX plus BEV as preoperative chemotherapy and CAPOX. CAPOX was administered. After completion of treatment, the colonoscopy showed PR, and MRI showed clear boundary between the prostate and tumor but invasion into the anorectal muscles; CT showed no lung metastasis, and preoperative diagnosis was ycT4bN0M0, ycStage Ⅱ. Robotic-assisted rectal amputation and left lateral lymph node dissection were performed under general anesthesia. Pathologically, the patient was diagnosed as ycT4bN0M0, Stage Ⅱ, and the efficacy was determined as TRG 1(AJCC). Vertical dissection was negative and radical resection was possible.

[A Case of Rectal Cancer with Enlarged Lateral Lymph Nodes Treated with Total Neoadjuvant Therapy and Robotic Surgery].

A 70s woman with advanced rectal cancer(AV 3 cm, type 2)was diagnosed as cT3N2M1a, Stage Ⅳ(UICC, TNM 8th) and underwent total neoadjuvant therapy(TNT)consisted of preoperative 5 Gy×5 short course RT followed by 5 courses of CAPOX plus BEV and CAPOX. Post-treatment endoscopy revealed nearCR, MRI failed to identify the primary tumor, and the mesenteric and lateral lymph node enlargement had disappeared. The patient underwent robot-assisted low anterior resection, bilateral lymph node dissection, and temporary ileal colostomy. Postoperative pathological findings were ypT0N0M0, Stage 0, and the efficacy evaluation was TRG 0(AJCC)with no residual tumor including lateral lymph nodes. The patient was discharged on the 16th day without any postoperative complications and is currently alive 6 months postoperatively without recurrence.

[Risk Factors for Recurrence in Patients with Pathological Stage â ¡ Colorectal Cancer].

BACKGROUND: The risk factors for recurrence in patients with pStage Ⅱ colorectal cancer still remains controversial. The aim of this study was to investigate the risk factors for recurrence after surgery in patients with pStage Ⅱ colorectal cancer. METHOD: We retrospectively reviewed 311 patients with primary pStage Ⅱ colorectal cancer who underwent radical resection without neoadjuvant therapy at our institute between January 2014 and December 2019. RESULTS: Of 311 patients, 32 patients(10.3%)developed recurrences after surgery at a median follow-up of 32.9(0.23-74.2)months. The 3-year and 5-year recurrence-free survival(RFS)rate was 88.4% and 87.6%, respectively. A multivariate analysis for RFS showed that only pT4 (HR: 4.06, 95%CI: 1.60-10.29, p=0.003) was an independent risk factor. CONCLUSION: This study revealed that pT4 was an independent risk factor for recurrence after surgery in patients with pStage Ⅱ colorectal cancer.

[Robot Assisted Lower Anterior Resection for Anastomotic Recurrence of Colorectal Cancer-A Case Report].

Patient undergoing R0 resection have the good survival advantage following surgery for recurrent rectal cancer. Robotic surgery for anastomotic local recurrence of rectal cancer has never been reported before. An 80-year-old woman who had undergone high anterior resection for rectal cancer 1 years previously got colonoscopy. It revealed a 10 mm sized, elevated lesion on the anastomotic site, and a biopsy revealed an adenocarcinoma(tub1). Computed tomography and positron emission tomography-computed tomography showed no signs of distant metastasis, and we decided to conduct radical surgery with robot-assisted laparoscope. Robot-assisted laparoscopic lower anterior resection with resection of left hypogastric nerve was carried out. Histological assessment showed that R0 resection was performed. The patient was discharged on postoperative day 8th without postoperative complication. She is alive without recurrence at 1 year after the last operation.

[A Case of Laparoscopic High Anterior Resection for Rectal Cancer with Autosomal Dominant Polycystic Kidney Disease].

The case was a 61-year-old woman. She was diagnosed with autosomal dominant polycystic kidney disease(ADPKD)at the age of 38 and started hemodialysis at the age of 42. She was diagnosed with rectal cancer(RS)at the age of 61. Laparoscopic high anterior resection and D3 lymphadenectomy were carried out. Although the intra-abdominal space was limited by the huge renal cysts, laparoscopic surgery can be safely performed by arranging the port closer to the midline, taking the patient's position sufficiently, and using some useful tips. Laparoscopic surgery for the patient with ADPKD was considered a useful approach.

[Two Cases of Locally Recurrent Rectal Cancer Undergoing Preoperative Chemoradiationtherapy].

Case 1 is a 68-year-old woman with locally recurrent rectal cancer(LRRC)developed 5 years after resection of primary rectal cancer. The tumor seized right lateral side in pelvic. We performed tumor excision after preoperative chemoradiation comprised external beam radiation with oral S-1(tegafur/gimeracil/oteracil). He has been relapse-free for 3 years 3months after surgery. Case 2 is a 74-year-old man with LRRC developed 2 years after resection of primary rectal cancer. The tumor was located dorsal to anastomosis site in pelvic. We performed abdominoperineal resection for LRRC after preoperative chemoradiation with oral S-1. He has been relapse-free for 2 years. It was suggested that preoperative radiotherapy combined with oral FU for local recurrence after rectal cancer may contribute to distant and local control.

[A Case of Diaphragmatic Metastasis from Adenocarcinoma of the Rectum Treated via Surgical Resection].

A 67-year-oldman underwent lower anterior resection for rectal cancer andresection of liver metastatic tumor 5 years later. Seven years and 2 months after the initial surgery, a soft tissue mass was detected in the left diaphragm. Further retrospective review of CT scan images showedthat the diaphragmatic tumor was present just before the hepatectomy. Partial resection of the left diaphragm was performed, and no relapse has occurred since then for 2 years. Most cases of diaphragmatic metastasis are considered to arise from dissemination, but we considered this case as more likely to be hematogenous. When surgery is chosen to treat metastatic tumors of colorectal cancer, checking for other metastasis via preoperative imaging andperforming curative resection is important.

Chronic intestinal pseudoobstruction ileus in a patient with rheumatoid arthritis: outcome of a stoma construction and its histopathological features.

We report the first case of a chronic intestinal pseudoobstruction (CIPO) in a patient with rheumatoid arthritis (RA) in whom a stoma was constructed at the sigmoid colon to decompress intracolonic pressure. The treatment improved quality of life in this patient, suggesting that surgical resection of the colon to decompress intracolonic pressure would be one of the options for the treatment of intractable CIPO. The resected specimen obtained from the sigmoid colon was found to be palisaded, with nuclei crowded in some areas of the inner circular muscle layer and thickened, with zonal or focal myxoid regions with interstitial fibrosis, composed of collagenous and elastic fibers, in the outer longitudinal muscle layer. Some of the smooth muscle cells in the outer longitudinal muscle layer showed mild degeneration with cytoplasmic vacuolar changes, but no inflammatory changes. However, further studies are required to determine whether these histopathological changes are unique to RA.

Appearance of rectal varices in extrahepatic portal obstruction after treatment for esophago-gastric varices: a case report.

We report a case of rectal varices that developed after endoscopic injection sclerotherapy (EIS) and Hassab's operation for esophageal varices with extrahepatic portal obstruction. A 54-year-old woman was admitted to our hospital in September 1997 for treatment of hematochezia. Emergent colonoscopy revealed tortuous rectal varices with a white plug. Angiography revealed that rectal varices were provided with backward blood flow by the inferior mesenteric vein due to extrahepatic portal obstruction. In this case, previous treatment, EIS and Hassab's operation, for esophago-gastric varices might have inhibited the development of collaterals apart from surface of gastrointestinal tract, such as para-esophageal collateral veins or spleno-renal shunt. Since the thrombus in the extrahepatic portal vein causes strong pressure on inferior mesenteric vein which is connected to the inferior vena cava via the inferior rectal vein, rectal varices might be developed. In this case, it was considered that rectal varices were not treated enough by endoscopic therapy because of regurgitant hyper blood flow against portal venous pressure. Therefore, rectal transection was performed. After the treatment, the patient suffered no further episodes of bleeding from rectal varices.

[Long-term prognosis of hepatocellular carcinoma patients treated with adoptive immunotherapy].

Adoptive immunotherapy was performed for patients with multiple hepatocellular carcinoma (HCC) using LAK cells via the hepatic arterial catheter. One case study: A 45-year-old male patient was performed an absolute-non-cure operation. The operation was a success. However, some residual tumors remained in the liver. After the operation, adoptive immunotherapy was performed for 7 times in 5 weeks. The total inoculated LAK cells were 6.9x10(9). After the adoptive immunotherapy, no residual tumors were detected in the liver. He survived for 7 years in remission. Our results show that adoptive immunotherapy with LAK cells is useful and effective for patients with multiple HCC.

Clinical evaluation of dendritic cells vaccination for advanced cancer patients at Fukushima Medical University.

Dendritic cells (DCs) are powerful antigen-presenting cells (APCs) that have attracted attention in recent years from the viewpoint of DC vaccine therapy against cancer. However, the existence of a strongly immunosuppressed state in cancer-bearing individuals inhibits DC maturation, which is one of the problems facing anti-cancer DC vaccine therapy. Isolated DCs loaded with tumor antigen ex vivo and administered as a cellular vaccine have been found to induce protective and therapeutic anti-tumor immunity in experimental animals. In clinical trials of DC vaccination for cancer patients, induction of anti-tumor immune responses and tumor regression has been observed. In this study, eighty-one advanced cancer patients unsuccessfully treated by established treatment in individual cases were selected between January 2002 and May 2007 at Fukushima Medical University. The usefulness of DC therapy was investigated by intradermal injection of peptide pulsed DCs for an overall objective response rate of 28.0%. Furthermore, direct injection of immature DCs into tumor extracted an overall objective response rate of 35.7%, and especially 40.0% for advanced pancreatic cancer by using endoscopic ultrasound-guided fine-needle injection technique as a novel approach. These results indicate that DC-based vaccination could be a promising treatment modality for various cancers, however multiple hurdles must be cleared before the development of an affordable DC-based vaccination can be used worldwide.