Endoscopic treatment of anastomotic leakage after colorectal surgery by using polyglycolic acid sheets and fibrin glue.

We describe the case of a 66-year-old man with an anastomotic fistula after rectal surgery, which was treated colonoscopically using polyglycolic acid sheets and fibrin glue. Polyglycolic acid sheets and fibrin glue have been used in thoracic surgery and otolaryngology to reinforce sutures and prevent air leakage. There have been recent reports of their use in endoscopic surgery for the closure of intraoperative perforations after endoscopic submucosal dissection and for fistula closure after upper gastrointestinal tract surgery. However, anastomotic fistulas in colorectal surgery are difficult to visualize endoscopically and may be difficult to suture with clips due to fibrosis. Polyglycolic acid sheets can be easily trimmed, and the fistula can be easily filled using these sheets; moreover, using fibrin glue to fix the sheets may enable fistula closure in areas that are difficult to visualize endoscopically.

New Scale Predicting Distant Recurrence in Locally Advanced Lower Rectal Cancer Patients After Neoadjuvant Chemoradiotherapy.

BACKGROUND/AIM: Neoadjuvant chemoradiotherapy (nCRT) for locally advanced lower rectal cancer (LALRC) is effective in preventing locoregional recurrence; however, it is less effective for preventing distant recurrence. This study aimed to evaluate a new scale for predicting distant recurrence before administering nCRT. PATIENTS AND METHODS: Sixty-three patients underwent nCRT for LALRC between 2009 and 2016 at the Tokyo Women's Medical University. Of these, 51 consecutive patients who underwent curative surgery were enrolled in this study. Patients with ≥cT3 status or cN-positive LALRC were classified into three groups before nCRT based on the neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR): high-risk, NLR ≥3.2 and LMR <5.0; intermediate-risk, NLR <3.2 and LMR ≥5.0 or NLR ≥3.2 and LMR <5.0; and low-risk, NLR <3.2 and LMR ≥5.0. Independent risk factors associated with distant relapse-free survival were analysed using the Cox proportional hazards model. Relapse-free survival from distant metastasis was evaluated using the log-rank test. RESULTS: Patient characteristics and tumour-associated factors were not significantly different between the groups. Distant recurrence in the high-, intermediate-, and low-risk groups was 61.5%, 42.9%, and 20.8% (p=0.046), respectively. In the multivariate analysis, the new scale was an independent risk factor for distant relapse-free survival (high-risk vs. low-risk groups, p=0.004 and intermediate-risk vs. low-risk groups, p=0.055). The 3-year distant relapse-free survival rate in the high-, intermediate-, and low-risk groups was 38.5%, 56.3%, and 81.7% (p=0.028), respectively. CONCLUSION: A new scale combining the pre-nCRT NLR and LMR was independently associated with distant relapse-free survival. The new scale for LALRC may aid selection for total neoadjuvant chemotherapy.

Prognostic risk factors for pT4 colon cancer: A retrospective cohort study.

The present study aimed to clarify the prognostic risk factors for pathological T4 (pT4) colon cancer and provide a basis for improved treatment in affected patients. The current retrospective cohort study included 83 consecutively enrolled patients who underwent curative surgery for primary pT4 colon cancer between January 2014 and December 2021 at Tokyo Medical Women's University (Tokyo, Japan). Oncological outcomes, including recurrence pattern, were compared between patients with pT4a and pT4b colon cancer. Independent risk factors associated with overall survival (OS) and relapse-free survival (RFS) were analyzed using a multivariate Cox regression model. The 3-year OS rates were 85.1 and 95.0% in the pT4a and pT4b groups (P=0.089) and 3-year RFS rates were 64.1 and 60.5% (P=0.589), respectively. Moreover, the 3-year peritoneal recurrence-free survival was 71.0 and 90.2% (P=0.085) in these groups, respectively. Independent risk factors for OS were histology (mucinous or poorly differentiated adenocarcinoma), tumor location (right-sided) and pN status (positive). The risk factors for RFS were histology and pN status. Patients with pT4b colon cancer and R0 resection may not have a poorer prognosis compared with those with pT4a colon cancer. However, patients with pT4a colon cancer tended to have more peritoneal recurrence patterns. Histology and pN status were associated with OS and RFS, and right-sided colon cancer was also a risk factor for OS.

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy complicating laparoscopic low anterior resection of rectal cancer: Case report.

INTRODUCTION: Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy is increasingly popular for treating internal hemorrhoids. This injectable compound incites inflammation to dampen hemorrhoidal blood flow and inflict secondary fibrosis. Herein, we detail the implications of ALTA treatment for laparoscopic low anterior resection of rectal cancer. PATIENT PRESENTATION: A 72-year-old man receiving ALTA sclerotherapy for internal hemorrhoids thereafter required laparoscopic low anterior resection for newly discovered early rectal cancer. Observed changes of anal canal resembled those of radiochemotherapy and proved problematic. There was mural thickening and sclerosis at the planned resection site. To ensure proper removal, the bowel was compressed and stapled slowly. A two-shot resection took place (without straining), anastomosis was performed, and a covering stoma was constructed. Recovery was uneventful, allowing discharge on postoperative Day 10. The ileostomy was closed at a later time. DISCUSSION: Although little information is available on long-term rectal pathology after ALTA therapy, existing data suggest that sclerosis persists well beyond injection timeframes. Hence, caution is required in dissecting and debriding sclerotic remnants. We have identified only four earlier reports in this setting, the present case providing added perspective. CONCLUSION: Colonoscopy is highly advisable prior to ALTA therapy. A thorough work-up before rectal surgery is also essential, documenting any past treatments for anorectal disease, especially ALTA.

Multiple intestinal lymphangiomas with episodic hemorrhage requiring partial laparoscopic resection: a case report.

BACKGROUND: Lymphangioma is a non-epithelial tumor marked by aggregates of abnormally dilated lymphatics. Mesenteric occurrences account for < 1% of all cases, and < 0.05% involve the gastrointestinal tract. Most are confined to children, rarely affecting adults. CASE PRESENTATION: Herein, we describe an elderly Japanese woman with anemia, hypoalbuminemia, and episodic bleeding due to multiple intestinal lymphangiomas. Abdominal computed tomography revealed multiple low-density defects of mesentery, with areas of intermediate (T1 images) or high (T2 images) signal intensity similarly dispersed in magnetic resonance scanning sequences. Single-balloon enteroscopy was undertaken, enabling identification and tattooing of a small intestinal bleeding source. Laparoscopy-assisted resection at this site served to control related hemorrhage, removing a histologically confirmed hemolymphangioma. Having recovered uneventfully, the patient remained stable 2 months postoperatively. CONCLUSIONS: Although rare in adults, mesenteric or gastrointestinal lymphangiomas must be considered in a setting of anemia and hypoalbuminemia. Complete resection is advantageous to improve patient symptoms, but limited resection of multiple lesions may be equally effective.

Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management.

The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer are described in this review. Magnetic resonance imaging (MRI) is recommended for the diagnosis of LPLN metastasis. A LPLN-positive status on MRI is a strong risk factor for metastasis, and evaluation by MRI is important for deciding treatment strategy. LPLN dissection (LPLD) has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications; therefore, LPLD may not be appropriate for cases that are less likely to have LPLN metastasis. Radiation therapy (RT) and chemoradiation therapy (CRT) have limited effects in cases with suspected LPLN metastasis, but a combination of preoperative CRT and LPLD may improve the treatment outcome. Thus, RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.

Pedunculated early colorectal cancer with nodal metastasis: a case report.

BACKGROUND: Pedunculated polyps are more likely to be amenable to complete resection than non-pedunculated early colorectal cancers and rarely require additional surgery. We encountered a patient with a pedunculated early colorectal cancer that consisted of poorly differentiated adenocarcinoma with lymphatic invasion. We performed an additional bowel resection and found nodal metastasis. CASE PRESENTATION: A 43-year-old woman underwent colonoscopy after a positive fecal occult blood test. The colonoscopist found a 20-mm pedunculated polyp in the descending colon and performed endoscopic resection. Histopathologic examination revealed non-solid type poorly differentiated adenocarcinoma. The lesion invaded the submucosa (3500 µm from the muscularis mucosa) and demonstrated lymphatic invasion. In spite of the early stage of this cancer, the patient was considered at high risk for nodal metastasis. She was referred to our institution, where she underwent bowel resection. Although there was no residual cancer after her endoscopic resection, a metastatic lesion was found in one regional lymph node. The patient is undergoing postoperative adjuvant chemotherapy, and there has been no evidence of recurrence 3 months after the second surgery. CONCLUSIONS: Additional bowel resection is indicated for patients with pedunculated polyps and multiple risk factors for nodal metastasis, such as poorly differentiated adenocarcinoma and lymphatic invasion. We encountered just such a patient who did have a nodal metastasis; herein, we report her case history with a review of the literature.

Is prophylactic lateral lymph node dissection needed for lower rectal cancer? A single-center retrospective study.

BACKGROUND: The effectiveness of prophylactic lateral lymph node dissection (LLND) in treating patients with lower rectal cancer remains controversial and has not been clearly established. Therefore, we aimed to retrospectively analyze the survival impact of prophylactic LLND in patients with lower rectal cancer. METHODS: Data of 301 patients with lower rectal cancer (tumor's lower edge on the anal side of the peritoneal reflexion) with clinical T3 disease and negative preoperative lateral lymph node metastasis, who underwent radical resection (R0) at our hospital between April 2007 and March 2017, were included in this study. Patients who received preoperative chemotherapy or radiotherapy were excluded. The relapse-free survival (RFS) and overall survival (OS) rates were compared between the dissection (prophylactic LLND, n = 37) and non-dissection (no prophylactic LLND, n = 264) groups. RESULTS: Significantly fewer men and younger patients were noted in the dissection group than in the non-dissection group. Post-surgery 3- and 5-year RFS rates were 69.6% and 66.8% in the dissection group and 75.1% and 72.5% in the non-dissection group, respectively (5-year post-surgery RFS, p = 0.58). In the dissection and non-dissection groups, the 5-year OS rates were 86.5% and 79.7%, respectively (p = 0.29), and the 5-year cancer-specific survival rates were 88.9% and 86.0%, respectively (p = 0.29), with no significant differences. Lateral lymph node recurrence was observed in one (2.7%) and 10 patients (3.8%) in the dissection and non-dissection groups, respectively, and there was no significant difference between the groups. CONCLUSIONS: In this study, the effectiveness of prophylactic LLND was limited in patients with > T3 lower rectal cancer with no evidence of preoperative lymph node metastasis. Prophylactic LLND may not be necessary if there is no preoperative lymph node metastasis, even if the invasion depth is T3 or higher.

Resection of solitary abdominal wall metastasis of ascending colon cancer along the ventriculoperitoneal shunt: A case report.

INTRODUCTION: Ventriculoperitoneal (VP) shunt is often placed as a treatment for hydrocephalus. Additionally, it is also not uncommon to perform laparoscopic surgery for colon cancer with a VP shunt in place. It is very rare for colorectal cancer to metastasize to an implanted VP shunt. We report a case of VP shunt-related metastasis of the ascending colon that was successfully resected. PRESENTATION OF CASE: A 79-year-old man who had a VP shunt for hydrocephalus two years earlier underwent laparoscopic right colectomy for ascending colon cancer. Six months after the colectomy, imaging examinations showed mass formation in the subcutaneous tissue of the abdominal wall along the VP shunt. Because of the possible metastasis of colorectal cancer and the fact that it was a solitary lesion, a tumor resection with replacement of the VP shunt was performed. Histopathological examination revealed that the mass was a metastasis of colon cancer. DISCUSSION: This case involves the metastasis of colorectal cancer in the subcutaneous tissue of the abdominal wall after laparoscopic surgery, and since the tumor had reached the serosa, the possibility of metastasis by pneumoperitoneum was considered. Careful intraoperative manipulation is considered to be important for prevention. CONCLUSION: Metastasis of colorectal cancer to the VP shunt is extremely rare, but possible. In such cases, intraoperative prevention and careful postoperative follow-up are required.

First experience using the Senhance surgical system in laparoscopic local gastrectomy for gastrointestinal stromal tumor.

Various innovative robotic systems have been developed to improve surgery precision. The Senhance Surgical System (SSS) is a digital laparoscopic system offering eye tracking and haptic feedback. Several reports have described application of the SSS to general surgeries, including cholecystectomy and colectomy. However, use of the SSS for gastric tumor has not been reported. We experienced a case of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) with the SSS. A 74-year-old man diagnosed with GIST underwent LLG with the SSS. Operation, docking, and console times were 117, 11, and 59 minutes, respectively. No perioperative complications were encountered. This study is the first to report LLG for GIST with the SSS. LLG with the SSS was safe and feasible. The SSS can use reusable forceps and contribute to reducing medical costs. The development of instruments is also progressing, and various kinds of surgery are likely to be indicated.

Robot-assisted surgery with Senhance robotic system for colon cancer: our original single-incision plus 2-port procedure and a review of the literature.

BACKGROUND: The Senhance robotic system provides such advantages as an eye-tracking camera control system, haptic feedback, operator comfort, and reusable endoscopic instruments. The aim of this small study was to assess the feasibility and safety of performing a reduced-port robot-assisted colectomy for colon cancer with the use of a novel robotic system. METHODS: This was a single-center retrospective study of eight patients with colon cancer who underwent single-incision plus 2-port robot-assisted colectomy with the Senhance robotic system (SILS+2-S) between December 2019 and March 2020 at our hospital. Data on perioperative outcomes, which included operative time, operative blood loss, length of hospitalization, postoperative complications, and histopathological results, were collected prospectively. RESULTS: The mean patient age was 70.9 years and the mean body mass index was 24.4 kg/m2. One patient was converted to laparoscopy due to a damaged scope holder. The mean operative and console times were 229.1 and 139.1 min, respectively. The mean intraoperative blood loss was 49.4 ml. The mean length of the umbilical incision was 3.0 cm. The mean number of harvested lymph nodes was 18.3. The surgical margins were negative in all eight patients. There was neither morbidity nor mortality associated with the procedure, and no Clavien-Dindo classification Grade II-IV complications occurred. CONCLUSIONS: SILS+2-S is a safe and feasible approach for patients with colon cancer. Further studies are needed to validate the advantages of SILS+2-S and to evaluate the long-term oncological outcomes.

Impact of Lymphovascular Invasion in Patients With Stage II Colorectal Cancer: A Propensity Score-matched Study.

BACKGROUND/AIM: Whether lymphovascular invasion (LVI) is a high-degree risk factor in stage II colorectal cancer has not been fully clarified, as different results have been reported in the literature. If LVI is a risk factor, postoperative chemotherapy may be recommended. The purpose of this study was to evaluate the impact of lymphovascular invasion on disease recurrence and patient prognosis in conjunction with stage II colorectal cancer (CRC). PATIENTS AND METHODS: A total of 636 patients with stage II CRC, each undergoing radical resection between April 2007 and December 2015, were selected for the study. Subjects with or without venous or lymphatic invasion were assigned to positive and negative groups, respectively. We then compared overall survival (OS) and disease-free survival (DFS) using propensity score matching. RESULTS: After matching (n=226, each group), OS and DFS were found to be significantly lower (OS: p=0.047; DFS: p=0.004) in patients positive (vs. negative) for venous invasion. However, the same was not true of lymphatic invasion. After matching, positive and negative groups (n=92, each) did not significantly differ in terms of OS (p=0.951) or DFS (p=0.258). CONCLUSION: In patients with stage II CRC, venous invasion proved to be a significant high-degree risk factor that may warrant adjuvant chemotherapy.

Laparoscopic Surgery for Colorectal Cancer in Patients on Hemodialysis: A Propensity Score-matched Analysis.

BACKGROUND/AIM: Surgery on hemodialysis patients requires special attention, as the tissue of these patients is vulnerable and hemorrhagic. This study explored the feasibility of laparoscopic surgery for colorectal cancer in hemodialysis patients. PATIENTS AND METHODS: This was a retrospective study of patients who underwent laparoscopic surgery for colorectal cancer in a single institute from April 2007 to December 2016. RESULTS: A total of 2668 patients were included: 24 (0.9%) were on hemodialysis, and 2644 (99.1%) were not. After 1:1 propensity score matching, there were no significant differences in the short-term postoperative results, the disease-free survival rate (p=0.0813) or the cancer-specific survival rate (p=0.555). However, the overall survival rate was significantly lower in hemodialysis patients than in non-hemodialysis patients (p=0.0135). CONCLUSION: Standard laparoscopic operative procedures can be safely performed for hemodialysis patients, and there was no marked difference in the long-term oncological outcomes between the two groups.

Single-incision plus two-port robotic surgery for sigmoid colon cancer using the Senhance robotic system.

Informed by our experiences with reduced-port surgery for colorectal cancer, we performed the first single-incision plus two-port robotic sigmoidectomy for cancer with the Senhance robotic system. A 70-year-old woman presented to our department for the treatment of sigmoid colon cancer. We performed single-incision two-port robotic sigmoidectomy. A wound protector was inserted through a 3.0-cm transumbilical incision, a multiport access device was mounted on top of it, and then a camera port and a 5-mm assistant's port were placed in the multiport access device. Two extra ports were placed on the central line of the abdomen. Lymph node dissection around the inferior mesenteric artery and mobilization of the left-sided colon were completed without any perioperative complications. The total operative time was 204 minutes, and the console time was 113 minutes. The estimated blood loss was 75 mL. The patient was discharged on postoperative day 8 without any complications.

Does signet ring cell carcinoma component signify worse outcomes for patients with colorectal cancer?

AIM: The purpose of this study was to elucidate the differences in clinical pathology and prognosis between signet ring cell carcinoma component and adenocarcinoma in colorectal cancer. MATERIALS AND METHODS: From April 2007 to December 2016, a total of 4348 patients with colorectal cancer underwent surgery, of which 3283 were included in the study. One patient was diagnosed with signet ring cell carcinoma (SRCC); 16 were diagnosed with signet ring cell carcinoma component (SRCCc); and 3266 patients were diagnosed with adenocarcinoma (ADC). We matched SRCCc and ADC with a propensity score of 1:3 and analyzed overall survival rates (OS) and cancer-specific survival rate (CSS) between the 2 groups before and after matching. RESULTS: Before matching, patients in the SRCCc group had more advanced cancer (stage III-IV: 87.5% vs 45.6%; P < .001), more perineural invasion (75.0% vs 44.2%; P = .013), and higher lymphatic invasion (87.5% vs 42.4%; P < .001) than those in the ADC group. Consequently, the OS (P < .001) and CSS (P = .049) of the SRCCc group were worse than the ADC group. Peritoneal metastasis was found in 4 (57%) patients with stage IV disease. However, after tumor staging and all background factors were matched, there were no significant differences in prognosis for OS (P = .127) and CSS (P = .932) between the 2 groups. CONCLUSION: SRCCc is more likely to be associated with lymphatic invasion and perineural infiltration than ADC, leading to significantly poorer survival outcomes. However, when all background factors are matched with ADC, the prognosis of SRCCc is not worse than ADC. Improving the treatment outcomes of peritoneal metastasis may be pivotal in the treatment of SRCCc.

The Significance of Lateral Lymph Node Metastasis in Low Rectal Cancer: a Propensity Score Matching Study.

BACKGROUND: The indications for lateral lymph node dissection (LLND) in rectal cancer have been controversial. The purpose of this study was to clarify the significance of lateral lymph node metastasis in low rectal cancer. METHODS: This was a retrospective study at a high-volume cancer center in Japan. In this study, 40 patients with pathologically positive LLN (LLN+) were matched with 175 negative (LLN-) patients by propensity score matching (PSM). COX regression analysis was used to identify independent risk factors related to prognosis. The relapse-free survival rate (RFS) and overall survival rate (OS) of the 2 groups before and after matching were analyzed. RESULTS: Of the 64 patients undergoing LLND, 40 (62.5%) patients had LLN+ disease. The LLN+ patients showed deeper infiltration of the primary tumor than the LLN- patients (T3-T4: 87.5% vs. 72.0%; p = 0.044), a greater number of metastatic lymph nodes (N2: 75.0% vs. 35.4%; p < 0.001), and a higher rate of local recurrence (30% vs. 9.1%; p < 0.001). Adjuvant chemotherapy was more common in the 40 LLN+ patients than in the 175 LLN- patients (70.0% vs. 46.8%; p = 0.008). After relapse, the rate of first-line chemotherapy administration for LLN+ patients was higher than that for the LLN- patients (62.5% vs. 29.5%; p = 0.005). The RFS of LLN+ patients was shorter than that of the LLN- patients (p = 0.005). After PSM, although more LLN+ patients received adjuvant chemotherapy than the LLN- patients (70.0% vs. 40.0%; p = 0.007), the local recurrence rate remained higher (30% vs. 10%; p = 0.025). The differences between RFS (p = 0.655) and OS rates (p = 0.164) of the 2 patient groups were not significant. CONCLUSION: Even after LLND, patients with LLN+ low rectal cancer still showed an elevated local recurrence rate. Controlling local recurrence by adjuvant chemotherapy alone is difficult, and the additional strategic treatments are needed.

A long-term survivor of clear cell sarcoma-like tumor of the gastrointestinal tract with liver metastasis: a case report.

BACKGROUND: Clear cell sarcoma-like tumor of the gastrointestinal tract (CCSLTGT) is extremely rare. It is a mesenchymal neoplasm that usually forms in the small intestine of adolescents and young adults, is prone to local recurrence and metastasis, and has a high mortality rate. We report a patient with CCSLTGT with lymph node- and liver metastases, who continues to survive 6 years after initial surgical resection. CASE PRESENTATION: A 38-year-old woman presented with lightheadedness. Laboratory analysis revealed anemia (hemoglobin, 6.7 g/dL), and enhanced computed tomography (CT) demonstrated a mass in the small intestine, about 6 cm in diameter, with swelling of 2 regional lymph nodes. Double-balloon small intestine endoscopic examination revealed a tumor accompanied by an ulcer; the biopsy findings suggested a primary cancer of the small intestine. She was admitted, and we then performed a laparotomy for partial resection of the small intestine with lymph node dissection. Pathologic examination revealed CCSLTGT with regional lymph node metastases. About 3 years later, follow-up CT revealed a single liver metastasis. Consequently, she underwent a laparoscopic partial liver resection. Histopathologic examination confirmed that the liver metastasis was consistent with CCSLTGT. It has now been 3 years without a recurrence. CONCLUSION: Repeated radical surgical resection with close follow-up may be the only way to achieve long-term survival in patients with CCLSTGT.

Right hemicolectomy with D3 lymph node dissection for right-sided transverse colon cancer using the Senhance robotic system: a case report.

BACKGROUND: The evolution of remote systems and artificial intelligence technology has led to increase in robotic surgeries. One system used in this case report is the Senhance robotic system. The most important premise for using robotic surgery in cancer therapeutics is to ensure oncological safety. Similar to conventional laparoscopic surgery, robotic surgery needs to be a reliable and secure surgical procedure, such as complete mesocolic excisions with central vascular ligations in Western countries or D3 lymph node dissections (dissection of the lymph nodes that locates from the origin to the terminal branch of the main feeding artery of cancer) in Japan. CASE PRESENTATION: A 76-year-old man underwent clinical examination for severe anemia. He was diagnosed with transverse colon cancer of tumor (T)3, node (N)1a, metastasis (M)0 cancer stage IIIA. A right hemicolectomy with D3 lymph node dissection using the Senhance surgical system was performed. The operative time was 313 min and the estimated blood loss was 5 ml. He was discharged from our hospital 12 days after the surgery without any complications. What is the remarkable of this report, not only mobilization of right colon but also D3 lymph node dissection and vascular ligation were performed intraperitoneally by using Senhance robotic system as conventional laparoscopic surgery. We tried using fourth robotic arm to accomplish lymphadenectomies and middle colic artery dissection. A right hemicolectomy with D3 dissection using the Da Vinci surgical system was reported. Another report of a right hemicolectomy performed with the Senhance robotic system was identified; however, in that study, lymph node dissections were not performed intraperitoneally. CONCLUSIONS: Therefore, to our knowledge, this is the first report using the Senhance robotic system for right hemicolectomy with D3 dissection. We hope that our case report will assist in the establishment of this robotic procedure in surgical practice.

Prognostic Utility of Apical Lymph Node Metastasis in Patients With Left-sided Colorectal Cancer.

BACKGROUND: Unlike the tumor nodes metastasis (TNM) lymph node classification, based solely on counts of nodal metastases, the Japanese system of classifying colorectal carcinoma (CRC) focuses on regional lymph node spread. In this study, we explored the prognostic utility of inferior mesenteric artery (IMA) apical lymph node (APN) metastasis. PATIENTS AND METHODS: This was a retrospective study of patients with stage III left-sided CRC. All enrollees were subjected to D3 resection between April 2007 and December 2016 at the International Medical Center of Saitama Medical University and then stratified by histologic presence (APN+ group) or absence (APN- group) of tumor in APNs examined postoperatively. Ultimately, propensity score matching was invoked (1:2) and COX regression analysis was conducted, determining group rates of relapse-free survival (RFS) and cancer-specific survival (CSS). RESULTS: A total of 498 patients were studied, grouped as APN+ (19/498, 3.8%) or APN- (479/498, 96.2%). Prior to matching, the APN+ (vs. APN-) group showed significantly more lymphatic involvement (73.7% vs. 47.8%; p=0.023), deep (T3/T4) tumor infiltration (100% vs. 78.9%; p=0.024), and nodal metastasis (N2: 84.2% vs. 27.6%; p<0.001). In addition, para-aortic nodal recurrences were significantly increased (15.7% vs. 2.0%; p<0.001), conferring worse RFS (p<0.001) and CSS (p=0.014) rates. Once baseline factors were matched, the two groups appeared similar in RFS (p=0.415) and CSS (p=0.649). Multivariate regression analysis indicated that elevated carcinoembryonic antigen (CEA) level and deep tumor infiltration were independent risk factors for RFS, whereas postoperative complications and tumor-positive node counts were independent risk factors for CSS. APN+ status was not a significant risk factor for RFS or CSS. CONCLUSION: APN positivity may thus constitute a regional rather than systemic manifestation. The TNM staging based on the number of metastatic lymph nodes seems to be more reasonable than the regional lymph node classification method.

Laparoscopic right hemicolectomy for metastatic renal cell carcinoma in the ascending colon: A case report.

INTRODUCTION: Renal cell carcinoma (RCC) arises from the renal parenchyma and is the most common primary malignancy of the kidney. RCC frequently metastasizes to the lung, bone, lymph nodes, and other locations, but rarely to the colon. We report a case of metastatic RCC of the ascending colon that was successfully resected with laparoscopic right hemicolectomy. PRESENTATION OF CASE: The patient is a 65-year-old man who developed hip joint pain and was diagnosed with polymyalgia rheumatica during the first year after laparoscopic right nephrectomy for right RCC. A screening colonoscopy was performed and a tumor was found in the ascending colon. Biopsy strongly suggested metastatic RCC. No other distant metastases were found, and laparoscopic right hemicolectomy was performed. The tumor extended from the mucosa to the subserosa and was diagnosed histopathologically as colonic metastasis of RCC. There were no lymph node metastases in the simultaneously resected mesentery, but venous invasion was observed. DISCUSSION: RCC can metastasize to various organs, but metastasis to the colon is extremely rare. In cases of colon metastasis, abdominal symptoms, hematochezia, or anemia may occur, and their occurrence should be checked during follow-up. Based on past reports, resection of metastatic lesion is considered the most appropriate treatment. CONCLUSION: Although it is rare for RCC to metastasize to the colon, it is possible. Resection can be recommended for colon metastasis with no other metastases, and colectomy with R0, including the regional mesocolon, may provide a favorable long-term prognosis.